Atypical Presentations of Respiratory Syncytial Virus Infection: Case series

he respiratory syncytial virus (rsv) belongs to the Paramyxoviridae family and, along with the recently identified human metapneumovirus, belongs to the Pneumovirinae subfamily.RSV is further classified into subtypes A and B; subtype A usually causes a more severe form of the disease. 1 Both subtypes occur more commonly in cold weather and rainy seasons. 2 Around the world, it has been noted that RSV is highly prevalent in fiveyear-old children. 3 In the United States, 4-5 million children younger than four years of age annually contract RSV infections and 125,000 require hospital admission.4 In most cases, the virus is not fatal; however, in certain groups of high-risk patients, an RSV infection can lead to a more severe morbidity or result in death.5 In order to manage affected patients appropriately, clinicians need to be aware of severe intrapulmonary and extrapulmonary manifestations of RSV infections.6 RSV mainly causes lower respiratory tract infections in children younger than two years of age or upper respiratory tract infections in older children and adults.5,6 RSV rarely causes severe extrapulmonary manifestations like cerebellitis, encephalitis, fatal interstitial myocarditis, hepatitis or Reye's syndrome.[6][7][8][9] This case series reports four children admitted to the critical care area of the Royal Hospital, Muscat, Oman, in December 2013 with severe and rare manifestations of RSV.All patients had a positive outcome and made a full recovery. Case OneA previously healthy 11-month-old female infant was admitted to the Royal Hospital in December 2013 with a three-day history of fever, a runny nose and cough followed by drowsiness and respiratory distress.She had been in contact with her sibling who had an upper respiratory tract infection.A physical examination revealed fever, drowsiness and response only to painful stimuli.She was tachypnoeic, had marked hepatomegaly (8 cm below the costal margin with a liver span of 13 cm) and her spleen was not palpable.Investigations showed a normal complete blood count (CBC), high aspartate transaminase (AST)