AUTHOR AND EDITOR INFORMATION

Section 1 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

INTRODUCTION

Section 2 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Background

Rhinoviruses (RVs) are small (30 nm), nonenveloped viruses that contain a single-strand RNA genome within an icosahedral (20-sided) capsid. RVs belong to the Picornaviridae family, which includes the genera Enterovirus (polioviruses, coxsackieviruses groups A and B, echoviruses, numbered enteroviruses, parechoviruses) and Hepatovirus (hepatitis A virus). Approximately 101 serotypes have been identified.

This article focuses on the common cold because it is most frequently associated with RV. Nasopharyngitis, croup, and pneumonia, which are uncommonly caused by RV, are also briefly discussed. RV plays a significant role in the pathogenesis of otitis media and asthma exacerbations. Although incidence and prevalence are high, most cases are mild and self-limited.

Pathophysiology

RV can be transmitted by aerosol or direct contact. The primary site of inoculation is the nasal mucosa, although the conjunctiva may be involved to a lesser extent. RV attaches to respiratory epithelium and locally spreads. The major human RV receptor is intercellular adhesion molecule-1 (ICAM-1). The natural response of the human defense system to injury involves ICAM-1, which aids the binding between endothelial cells and leukocytes. RV takes advantage of the ICAM-1 by using it as a receptor for attachment. In addition, RV uses ICAM-1 for subsequent viral uncoating during cell invasion. Some RV serotypes also up-regulate ICAM-1 expression on human epithelial cells to increase susceptibility to infection.

The optimal temperature for RV replication is 33-35°C. RV does not efficiently replicate at body temperature. This may explain why RV replicates well in the nasal passages and upper tracheobronchial tree but less well in the lower respiratory tract. The incubation period is approximately 2-3 days. Viremia is uncommon.

RV is shed in large amounts, with as many as 1 million infectious virions present per mL of nasal washings. Viral shedding can occur a few days before cold symptoms are recognized by the patient, peaks on days 2-7 of the illness, and may last as long as 3-4 weeks.

A local inflammatory response to the virus in the respiratory tract can lead to nasal discharge, nasal congestion, sneezing, and throat irritation. Damage to the nasal epithelium does not occur, and inflammation is mediated by the production of cytokines and other mediators.

Histamine concentrations in nasal secretions do not increase. By days 3-5 of the illness, nasal discharge can become mucopurulent from polymorphonuclear leukocytes that have migrated to the infection site in response to chemoattractants such as interleukin-8. Nasal mucociliary transport is markedly reduced during the illness and may be impaired for weeks. Both secretory immunoglobulin A and serum antibodies are involved in resolving the illness and protecting from reinfection.

Coronaviruses, reinfections with parainfluenza, and respiratory syncytial virus (RSV) are the most important of many other viruses that can cause common colds. Other viruses (eg, adenoviruses, influenza viruses) also can cause common colds but are more likely to cause acute nasopharyngitis and more severe respiratory infections.

Mycoplasma pneumoniae can occasionally present with common cold symptoms before developing into more extensive respiratory disease. Other pathogens include Coccidioides immitis, Histoplasma capsulatum, Bordetella pertussis, Chlamydia psittaci, and Coxiella burnetii.

Recent clinical studies indicate sinus involvement in common colds. Abnormalities on CT scan findings (eg, opacification, air-fluid levels, mucosal thickening) are present in adults with common colds that resolve over 1-2 weeks without antibiotic therapy.

Despite what is reported in folklore, no good clinical evidence reports that colds are acquired by exposure to cold weather, getting wet, or becoming chilled.

Frequency

United States

Common colds are most frequent from September to April in temperate climates. RV infections, which are present throughout the year, account for the initial increase in cold incidence during the fall and a second incidence peak at the end of the spring season. Colds that occur from October through March are caused by the successive appearance of numerous viruses, including parainfluenza, coronavirus, RSV, and influenza virus. Adenoviral infections occur at a constant rate throughout the season.

Several studies demonstrate the incidence of the common cold to be highest in preschool and elementary school-aged children. An average of 3-8 colds per year is observed in this age group, with an even higher incidence in children who attend daycare and preschool. Because of the numerous viral agents involved and the many serotypes of several viruses (especially RV), younger children having new colds each month during the winter season is not unusual. Adults and adolescents typically have 2-4 colds per year.

International

A seasonal increase in incidence during the winter months is observed worldwide.

Mortality/Morbidity

The most common manifestation of RV, the common cold, is mild and self-limited. However, severe respiratory disease, including bronchiolitis and pneumonia, can rarely occur in infants.

Race

Native Americans and Eskimos are more likely to develop the common cold and appear to have more frequent complications such as otitis media. These findings may be explained as much by environmental conditions (eg, poverty, overcrowding) as by ethnicity.

Age

Because antibodies to viral serotypes develop over time, the highest incidence is found in infants and young children. In addition, young children are more likely to have the frequent, close, personal contact necessary to transmit RV. Contrary to the experience of adults, children may also be more contagious due to having higher virus concentrations in secretions and longer duration of viral shedding.

CLINICAL

Section 3 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

History

Rhinoviruses (RVs) cause or predispose to various upper respiratory infections (URIs) and lower respiratory infections (LRI), which are less common.

• Common cold
• • Nose dryness or irritation is often the first symptom and is followed within hours by profuse watery rhinorrhea, nasal congestion, and sneezing.
  • A sore throat or throat irritation is common.
  • Malaise, headache, and cough are also common symptoms of the common cold.
  • Fever is absent or low grade. Infants and preschoolers are more likely to experience fevers, which are often 38-39°C.
  • Nasal secretions typically become thicker and colored after the first few days of illness.
  • Irritability or restlessness is common.
  • Nasal obstruction can interfere with sleep and feeding.
  • Posttussive vomiting can occur.
  • Symptoms in adults and adolescents usually resolve by day 7; however, symptoms often last 10-14 days in younger children.
• Acute otitis media
• • Viral URIs are common precipitating factors for acute otitis media (AOM). This is likely because they cause respiratory mucosal inflammation that leads to eustachian tube obstruction.
  • Respiratory viruses are found in either the middle ear fluid or nasopharynx in approximately 40% of patients with AOM.
  • As many as 24% of patients with AOM have RV present in nasopharyngeal secretions. RV has also been obtained from middle ear fluid.
  • Patients whose symptoms are refractory to treatment with antibiotics are more likely to have positive viral cultures from the middle ear.
• Sinusitis: Preceding RV infection can lead to bacterial superinfection.
• Asthma exacerbations
• • Viral URI is a common trigger for asthma exacerbations in children of all ages.
  • In children younger than 5 years, RV and RSV are the most commonly implicated pathogens. RV is the most commonly implicated pathogen in older children.
• LRI: RV may cause both pneumonia and bronchiolitis in infants.
• Croup: RV may cause laryngotracheobronchitis in infants.
• Acute nasopharyngitis
• • Acute nasopharyngitis is most commonly caused by adenovirus, enteroviruses, influenza, and parainfluenza.
  • RV is an uncommon cause of acute nasopharyngitis.
  • Common colds, by definition, do not have objective evidence of pharyngeal irritation.
• Cystic fibrosis: RV is the implicated virus in as many as 57% of respiratory exacerbations.
• Transmission modes
• • RV possesses various transmission modes and can infect a huge population at any given time.
  • Aerosol transmission is the most common transmission mode for respiratory tract infections (RTIs). Transmission occurs when small airborne particles are inhaled or large droplets are directly touched.
  • Direct hand contact with infected secretions or indirect contact with fomites is also important. Patients then infect themselves by touching their noses or conjunctivae.
  • Highly contagious behavior includes nose blowing, sneezing, and physically transferring infected secretions onto environmental surfaces or paper tissue.
  • Contrary to popular belief, behaviors such as kissing, talking, coughing, or even drooling do not contribute highly to the spread of disease.
  • Infection rates approximate 50% within the household and range from 0-50% within schools, which indicates that transmission requires long-term contact with infected individuals. Brief exposures to others in places such as movie theaters, shopping malls, friends' houses, or doctors' offices incur low risk of transmission.
  • The incubation period is approximately 2-4 days.
  • Because children carry the fewest antibodies, children who attend school are the most common reservoirs of RV infection.

Physical

Physical characteristics of the common cold include the following:

• The common cold is usually afebrile, although temperatures of 38-39°C are possible in younger children.
• Profuse nasal discharge can be clear and watery or mucopurulent. Purulent secretions are common after the first few days of illness and do not imply bacterial sinusitis unless secretions persist for more than 10-14 days.
• Edema and erythema of nasal mucosae may be present.
• Despite sore throat, the pharynx has a normal appearance, without any erythema, exudate, or ulceration.
• Mildly enlarged nontender cervical lymph nodes are present.

Causes

Factors that increase infection risk and severity are as follows:

• Smoking increases risk of respiratory infection by approximately 50%.
• Very young or old individuals are at greater risk, possibly due to decreased immunity.
• Exposure to infected contacts increases infection risk.
• Touching the conjunctivae or nose with contaminated fingers and/or objects increases infection risk.
• Crowding leads to increased transmission.
• Men may have a slightly, probably insignificant, higher risk.
• Breastfeeding has little effect on the incidence of the common cold.
• Underlying chronic medical conditions, including anatomic, metabolic, genetic, or immunologic disorders (ie, tracheoesophageal fistula, congenital heart disease, cystic fibrosis, immunodeficiency) increase infection risk and severity.

DIFFERENTIALS

Section 4 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Other Problems to be Considered

Acute nasopharyngitis

WORKUP

Section 5 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Lab Studies

• Diagnostic studies are generally unnecessary for patients with the common cold.
• • Clinical signs and symptoms of the common cold, by definition, are similar regardless of the infectious etiology.
  • In addition, with approximately 100 different serotypes of rhinovirus (RV) alone, assisting the diagnosis by serologic methods is economically impractical.
  • WBC count has little value in the diagnosis of the common cold.
• If a specific viral diagnosis is desired, the virus can be cultured from nasal secretions.
• • Nasal washings are more sensitive than throat specimens.
  • Direct antigen tests are routinely available for influenza and RSV. Some centers offer direct antigen tests for parainfluenza and adenovirus.

Imaging Studies

• Routine use of imaging studies is unnecessary.
• More than 85% of patients with the common cold have sinus abnormalities on CT scan. A diagnosis of bacterial sinusitis is unlikely if symptom duration is fewer than 10-14 days.

TREATMENT

Section 6 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Medical Care

• The following treatment options are still experimental and not proven:
• • Developing a vaccine: Development of a vaccine is nearly impossible because of the numerous serotypes. No antiviral agents are available to treat infections.
  • Accelerating nasal drainage: Hot chicken soup causes a temperature increase that accelerates nasal drainage. Be aware of possible hypernatremia.
  • Providing inhaled, warm, humidified air: Nasal hyperthermia is based on the fact that increased temperatures inhibit RV replication in vitro. Inhaled, warm, humidified air (40 L/min at 40-44°C in nostrils) has produced inconsistent findings in several studies.
  • Using aroma rubs, homeopathic and/or herbal remedies, and ultrafine high-volume filtration systems: These treatment options have yet to be studied.
  • Using experimental drugs: Many experimental drugs are currently in trials or have not been approved for consumer use. These include capsid-binding agents, pirodavir, WIN 54954, intranasal interferon (IF), virus receptor blockers, antireceptor antibodies, and soluble ICAM-1.
• Most treatment provides supportive measures for respiratory illness symptoms. Conventional treatments for the common cold include the following:
• • Using phenol-alcohol–based compounds (Lysol) to disinfect the environment
  • Washing hands
  • Obtaining rest, plenty of fluids, and reassurance that the usual viral course is 6-10 days
  • Positioning mattress at a 45° angle
  • Providing comfortable surrounding temperature and adequate humidity (This treatment method soothes irritated nasopharyngeal mucosae and helps eliminate nasal secretions by preventing dryness.)
  • Using decongestants (Decongestants and antihistamines are not recommended for children younger than 6 mo and have not been shown to be efficacious at any age.)
  • Using nasal saline drops with bulb syringe nostril aspiration (This treatment can help infants with congestion and obstruction.)
  • Discontinuing smoking or using alcohol

Consultations

Refer to an allergist if patient has chronic rhinitis that is unresponsive to environmental and pharmacologic intervention.

MEDICATION

Section 7 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Symptomatic treatment with analgesics, decongestants, antihistamines, and antitussives is currently the mainstay of therapy. Some clinicians advocate supplementation with vitamin C; however, high doses in children are not recommended. Zinc lozenges are not practical because of the metallic taste. Other drugs that are currently experimental or not approved for rhinovirus include the following:

• Interferon alpha: Most effective for cold prevention, interferon alpha is ineffective for established colds. When administered through nasal spray, 80% of secondary rhinovirus (RV) colds were prevented. Interferon alpha is not cost-effective. Significant adverse effects have been reported.
• Pirodavir: A substituted phenoxy-pyridazinamine, pirodavir, possesses broad antipicornavirus activity. Clinical studies demonstrate no decrease in viral shedding or symptoms.
• WIN 54954: A methylisoxazole derivative, WIN 54954, has no significant antiviral or clinical effects.
• Virus receptor blockers: These drugs are hypothesized to block virus internalization to prevent replication.
• Antireceptor antibody: Tests demonstrate no decrease in infection frequency.
• Soluble ICAM-1: This drug consists of a molecule that blocks replication by binding receptor sites and inhibiting viral attachment and internalization. Currently, no clinical trials have been performed.

Remind parents that treatment of children younger than 2 years should be supervised by a physician. Doses for analgesics, cough suppressants, decongestants, and antihistamines should only be given upon the advice of a physician for children younger than 2 years. Emphasize that although OTC medications can be bought without a prescription that does not mean that they are harmless. Adverse effects, including deaths have occurred when unintentional overdose has occurred, or when given in addition to prescription or additional OTC medications that contain the same ingredients. For more information see CDC MMWR: Infant Deaths Associated with Cough and Cold Medications.

Drug Category: Analgesic and antipyretic agents

These agents are used for relief of pain, discomfort, or fever. They inhibit central synthesis and release of prostaglandins that mediate effect of endogenous pyrogens in hypothalamus; thus, they promote return of set-point temperature to within the reference range. Ibuprofen also possesses anti-inflammatory properties.

Drug Name	Acetaminophen (Tylenol, Feverall, Tempra)
Description	Reduces fever by directly acting on hypothalamic heat-regulating centers, which increases dissipation of body heat via vasodilation and sweating.
Adult Dose	325-650 mg PO q4-6h or 1000 mg tid/qid, not to exceed 4 g/d
Pediatric Dose	10-15 mg/kg/dose PO/PR q4-6h, not to exceed 2.6 g/d
Contraindications	Documented hypersensitivity; known G-6-PD deficiency
Interactions	Rifampin can reduce acetaminophen analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Pregnancy	B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions	Contained in many OTC products, and combined use with these products may result in cumulative doses exceeding recommended maximum dose; caution parents regarding varying concentrations of OTC products

Drug Category: Antihistamines

These agents relieve runny nose, watery eyes, or other allergylike symptoms. They act by competitive inhibition of histamine at H1 receptor. This mediates wheal and flare reactions, bronchial constriction, mucous secretions, smooth muscle contraction, edema, hypotension, CNS depression, and cardiac arrhythmias.

Drug Category: Decongestants

These agents relieve congestion of nasal passages or sinuses.

Drug Name	Phenylephrine nasal (Neo-Synephrine)
Description	Strong postsynaptic alpha-receptor stimulant with little beta-adrenergic activity; produces vasoconstriction of arterioles, which decreases congestion.
Adult Dose	2-3 gtt or 1-2 sprays intranasally of 0.5% solution q4h
Pediatric Dose	6-12 months: 1-2 gtt intranasally of 0.16% solution q3h prn 1-6 years: 2-3 gtt intranasally of 0.125% solution q4h prn 6-12 years: 2-3 gtt intranasally or 1-2 sprays of 0.25% solution q4h prn >12 years: 2-3 gtt intranasally or 1-2 sprays of 0.5% solution q4h
Contraindications	Documented hypersensitivity; pheochromocytoma and severe hypertension; acute pancreatitis; hepatitis; myocardial disease; severe coronary disease; peripheral or mesenteric vascular thrombosis
Interactions	Bretylium may potentiate action of vasopressors on adrenergic receptors, possibly resulting in arrhythmias; MAOIs may significantly enhance adrenergic effects, and pressor response may be increased 2- to 3-fold; guanethidine may increase pressor response of direct-acting vasopressors, possibly resulting in severe hypertension
Pregnancy	C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions	Arrhythmia; hyperthyroidism; hyperglycemia

Drug Category: Antitussive agents

These agents centrally or peripherally act (or combination of both) on cough reflex. Central-acting agents increase threshold of cough center in brain to incoming stimuli, whereas those acting peripherally decrease sensitivity of receptors in respiratory tract.

Drug Name	Codeine
Description	For symptomatic relief of cough. Helpful for pain of intercostal muscle strain associated with cough. Binds to opiate receptors in CNS, causing inhibition of ascending pain pathways, altering perception and response to pain.
Adult Dose	10-20 mg/dose PO q4-6h prn for cough, not to exceed 120 mg/d
Pediatric Dose	1-1.5 mg/kg/d PO divided q4-6h prn
Contraindications	Documented hypersensitivity; children <2 y
Interactions	CNS depressants; TCAs may potentiate codeine effects; phenothiazine may antagonize analgesic effect; dextromethorphan may enhance analgesic effect
Pregnancy	D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions	Hypersensitivity reactions to other phenanthrene-derivative opioid agonists; respiratory diseases; severe liver and/or renal insufficiency

Drug Category: Vitamin C

These agents may decrease severity and duration (large doses not recommended for children).

FOLLOW-UP

Section 8 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Further Outpatient Care

• Advocate supportive measures such as rest, analgesics, and adequate hydration.
• Instruct per Patient Education.

Deterrence/Prevention

• Avoid aspirin administration if a child has a viral illness to prevent Reye syndrome (although this is rare).

Prognosis

• Complete recovery is usually observed within 7 days for adolescents and adults and within 10-14 days for children. Occasionally, a child's cough and congestion linger for 2-3 weeks.

Patient Education

• Reassure family and patient that frequent colds are common at certain times of the year.
• • Advising parents that 6-12 colds per year can be normal for young children, especially if they attend daycare or preschool, is helpful.
  • Frequent self-limited colds do not indicate a problem with the child's immune system and do not require antibiotic treatment.
• Because spread of secretions by contact with hands is a major route of transmission, encourage parents and patient to frequently wash their hands.
• Advise patient to return if fever exceeds 102°F, significant respiratory distress develops, or symptoms do not resolve in 10-14 days.
• Advise patient that purulent nasal discharge is commonly observed after the first few days of the infection and does not indicate a bacterial infection or the need for antibiotics.
• Patients with common colds do not need to be excluded from daycare or preschool settings.
• For excellent patient education resources, visit eMedicine's Cold and Flu Center. Also, see eMedicine's patient education article Colds.

REFERENCES

Section 9 of 9

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

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Article Last Updated: Oct 10, 2007