A NEW longitudinal cohort study has highlighted the significant role of human rhinovirus (RV) in triggering acute wheeze episodes in children and adults which are often accompanied by bacterial coinfection. The research, led by W. Gerald Teague, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia, has suggested that 22% of children with recurrent wheezing have undetected “silent” lung infections that could be more effectively treated with antiviral medications rather than the commonly prescribed steroids used to combat wheezing.
The study screened a cohort of 805 children and young adults aged 2 months to 18 years and found that 22% had undetected lung infections without typical cold symptoms. As RV is the most prevalent pathogen associated with these episodes, its link to persistent wheeze and childhood asthma, particularly when contracted in early life, make it a key target for identifying and understanding these “silent” infections.
Researchers aimed to understand the lung inflammatory responses associated with RV infections in children with treatment-refractory wheeze. However, they faced challenges due to the invasive nature of bronchoalveolar lavage and the difficulty of obtaining lower respiratory samples from children. Despite these limitations, the study demonstrated that RV was the predominant virus in the bronchoalveolar lavage of children, particularly during preschool years. These results showed that RV alone, detected in 29.7% of cases, often led to “silent granulocytic bronchoalveolitis,” characterised by lung granulocytosis, elevated blood CRP, and higher total blood neutrophils.
The presence of RV in asymptomatic children with recurrent wheezing suggests a smouldering lung inflammation, which has not been thoroughly explored. This discovery challenges the current treatment paradigm in which, typically, corticosteroids are prescribed under the assumption of a corticosteroid-responsive inflammation. However, the results of this research suggested that corticosteroid treatment might not always be effective, especially in children without markers of type-2 inflammation, which was not prevalent in cases of silent RV infection.
Furthermore, high-dose daily corticosteroid treatment was associated with an increased prevalence of RV, raising concerns about its long-term use. Additional research will be crucial to changing the approach to managing recurrent wheeze in children, potentially reducing the reliance on corticosteroids and improving long-term outcomes for young patients.
Katie Wright, EMJ
Reference
Teague WG et al. A novel syndrome of silent rhinovirus-associated bronchoalveolitis in children with recurrent wheeze. J Allergy Clin Immunol. 2024;DOI:10.1016/j.jaci.2024.04.027.
