Is Rhinovirus More Aggressive in Children This Season?

To the Editors: Rhinovirus is widely recognized as a common cause of upper respiratory tract infections in children.1 However, its potential to cause severe complications is gaining increasing attention. Even sudden infant deaths have been linked to rhinovirus infections.1,2 Here, we present 4 pediatric cases diagnosed with rhinovirus during November 2024, all of which presented with severe clinical conditions requiring hospitalization. These cases raise important questions about whether severe rhinovirus-associated illnesses are becoming more frequent and underscore the need for heightened awareness and further investigation in such cases. CASE 1 A 3-year-old male presented with a 6-day history of fever, rash and cervical lymphadenopathy. Laboratory findings included leukocytosis [white blood cell (WBC): 17,700/µL], thrombocytosis (platelet count: 517,000/µL), elevated erythrocyte sedimentation rate (70 mm/h) and elevated C-reactive protein (CRP: 118 mg/L). Echocardiography revealed tubular dilation (3–3.5 mm) of the proximal left coronary artery, consistent with Kawasaki disease. Comprehensive viral testing, including nasopharyngeal polymerase chain reaction (PCR) and serology, identified rhinovirus as the sole positive result. The patient was treated with intravenous immunoglobulin and aspirin, resulting in symptom resolution. Cardiology follow-ups are ongoing. CASE 2 A 3-year-old male presented with fever, cervical swelling and restricted neck movements. Clinical evaluation suggested a deep neck infection. Nasopharyngeal PCR testing identified rhinovirus as the only pathogen. Laboratory findings included leukocytosis (WBC: 15,000/µL, absolute neutrophil count: 7000/µL) and CRP (15 mg/L). The cultures were sterile, and other laboratory findings were negative. Despite treatment with ampicillin-sulbactam, persistent symptoms prompted a contrast-enhanced CT scan. Deep neck infection was confirmed with tomography, but no drainage was performed by the otolaryngology (ear, nose, and throat) team. The patient completed a 21-day antibiotic course and fully recovered. CASE 3 An 8-year-old male presented with respiratory distress following a 3-day history of nasal discharge. Physical examination revealed decreased breath sounds and crackles over the right basal lung fields. Laboratory findings included leukocytosis (WBC: 20,000/µL, absolute neutrophil count: 16,000/µL) and CRP (45 mg/L). The chest radiograph revealed a basal opacity in the right lung; however, the thoracic ultrasound performed for further evaluation was reported as normal. The patient required high-flow nasal cannula oxygen support and was treated with ampicillin-sulbactam for pneumonia. Rhinovirus was identified as the sole pathogen via nasopharyngeal PCR. The cultures obtained were sterile. After seven days, his condition improved, and he was discharged in good health (Fig. 1).FIGURE 1.: Case 3: right basal opacity observed on chest radiograph.CASE 4 A 1-year-old male presented to the emergency department with fever, vomiting and recurrent convulsions. Physical examination revealed tonsillar hypertrophy as the only abnormal finding. Due to recurrent seizures during observation in the emergency department, a lumbar puncture was performed. Given the patient’s deteriorating clinical condition, he was intubated and admitted to the intensive care unit for further management. Empirical treatment with vancomycin and ceftriaxone was initiated. Laboratory results showed leukocytosis (WBC: 14,500/µL, absolute neutrophil count: 9940/µL), with negative CRP and procalcitonin levels and biochemical parameters within normal limits. Cerebrospinal fluid analysis showed no biochemical abnormalities, with negative PCR testing and sterile culture results. Blood and urine cultures were also negative. However, nasal PCR testing confirmed rhinovirus as the causative agent. Brain magnetic resonance imaging and electroencephalogram were found to be normal. The patient remains under follow-up, and treatment is ongoing. These cases highlight the potential of rhinovirus to cause severe complications, including Kawasaki disease, deep neck infections, pneumonia and convulsions. All 4 cases were confirmed through comprehensive nasopharyngeal PCR testing, with no other pathogens identified. Emerging evidence supports an association between rhinovirus and severe outcomes, particularly in vulnerable pediatric populations.1,3 Several factors, including viral evolution, host immune responses and post-pandemic changes in viral epidemiology, may contribute to this observation.4,5 Through the presentation of these cases, we aim to emphasize the importance of considering rhinovirus in the differential diagnosis of severe pediatric infections. The consecutive occurrence of these cases suggests an increasing trend in severe complications associated with rhinovirus and underscores its potential to present with such serious manifestations.