Scientific letter
Viral etiology of exacerbations of patients with chronic obstructive pulmonary disease during the winter season
Etiología viral de las exacerbaciones de los pacientes con enfermedad pulmonar obstructiva crónica en la época invernal
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It is estimated to be the fourth leading cause of death worldwide, affecting 2.4% of the population.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> COPD exacerbations (COPDE) constitute the main complications of this disease since they deteriorate lung function. These acute processes have multifactorial causes, including viral infections, especially during the winter season.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Chronic inflammation caused by viral infection and stimulation of IL-8 and other cytokines appear to be the cause of COPDE and lung lesions.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> The viral impact in these processes has been underestimated until now due to the detection techniques used; the current use of molecular techniques has demonstrated the leading role of viruses in these episodes. With this technology, different studies have demonstrated viral infection in between 30 and 40% of COPDE cases, primarily involving rhinovirus, influenza and respiratory syncytial virus (RSV).<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The incorporation of molecular techniques in the diagnosis of viral infections has allowed us to study their participation in acute COPDE cases.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We report a prospective study conducted during the period with the highest prevalence of this type of infection (from October 2018 to February 2019). One hundred and eighty-seven patients (79% men) who came to the emergency department with an exacerbation (cough, expectoration and respiratory distress) of their previously diagnosed COPD were analysed during the study period.</p><p id="par0025" class="elsevierStylePara elsevierViewall">A single throat swab culture was performed in each patient to detect bacteria and viruses. The viruses were studied using a commercial real-time RT-PCR (Allplex Respiratory Assay, Seegen, South Korea) that simultaneously and differentially detected 16 different viruses.</p><p id="par0030" class="elsevierStylePara elsevierViewall">One hundred and four (104) positive samples (55.6%) were detected in the 187 patients, of which 78 (41.7%) corresponded to viruses alone, 19 (10.1%) to bacteria alone, and 7 (3.7%) to viruses and bacteria together. That is, viruses represented 45.4% (85 cases) of all respiratory processes in these patients. Differences in viral aetiology were observed in each of the months studied: with 36.6% in November and 69.7% in December. Similarly, the percentage of viral infections as the sole cause of COPDE has also fluctuated: it was 60% in October and 94.4% in February.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The main viruses detected have been rhinovirus (30.5%), influenza A (H3N2) (28.2%), RSV-B (22.3%), coronavirus (16.4%), adenovirus (1.1%) and metapneumovirus (1.1%). The bacteria detected were mainly <span class="elsevierStyleItalic">P. aeruginosa</span> and <span class="elsevierStyleItalic">H. influenzae</span> and, of the 7 virus–bacteria associations, rhinovirus represented the majority of them (57%). Five patients (5.8%) with influenza A (H3N2) infection required admission to the ICU; no patient died as a result of viral infection.</p><p id="par0040" class="elsevierStylePara elsevierViewall">A recent meta-analysis on the prevalence of viral infections in COPDE showed that a virus can be detected in up to 50% of cases if molecular techniques are used.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1–4</span></a> In our study, positive results for viruses reached a total of 45.4%, a value that is within the range reported. Our study simultaneously analysed the presence of bacteria, although they have represented only 10.1% of the cases. Whether they are simple colonizers or true pathogens cannot be determined.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Rhinoviruses have been the most commonly detected viruses, which coincides with other studies that estimate them at up to 58%,<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a> although in the winter season there is a high circulation of these viruses associated with the common cold. As expected, influenza viruses, in this case circulating A (H3N2), and RSV have been the cause of 50.5% of COPDE cases. Viral aetiology distribution data similar to ours have already been described, although with variations depending on the type of influenza circulating in a given winter epidemic.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1–4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Rapid identification of the viral aetiology of COPDE cases avoids the unnecessary administration of antibiotics and anticipates a good prognosis. Of the main viruses involved, only influenza could be prevented by systematically vaccinating these patients each season.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Reina J, Sala E, Fraile P. Etiología viral de las exacerbaciones de los pacientes con enfermedad pulmonar obstructiva crónica en la época invernal. Med Clin (Barc). 2020;155:315–316.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Worldwide prevalence of viral infection in AECOPD patients: a meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "H. Jafarinejad" 1 => "M. Moghoofei" 2 => "S. Mostafaei" 3 => "J. Salimian" 4 => "S.A. Jamalkandi" 5 => "A. 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