Adenovirus pneumonia

Introduction to adenoviral pneumonia Adenovirus is one of the main pathogens of viral pneumonia. In older children or young people, adenovirus only causes upper respiratory tract disease, which can cause severe acute adenoviral pneumonia in infants and young children. Chang et al. First, a case of type 7A adenoviral pneumonia was reported, which was reported in various countries. In 1958, China began to study adenovirus infection, and found that the pathogens causing adenoviral pneumonia in infants and young children are mainly adenovirus type 3 and 7, and the prognosis of mild and older children is better. Severe infection and adenoviral pneumonia are Poor prognosis and high mortality. basic knowledge The proportion of illness: 0.89% Susceptible people: no specific population Mode of infection: droplet infection Complications: respiratory syncytial virus infection

Adenoviral pneumonia

(1) Causes of the disease

The adenovirus is a DNA virus. In 1953, Robwz et al. first isolated from human adenoid cells. The virus particles contained DNA and protein, which were propagated in the nucleus. The virus was observed by electron microscopy as a complete icosahedral structure. Core and capsid, non-encapsulated, outer capsid diameter of about 60 ~ 90nm capsid consists of 252 sub-particles, of which 240 sub-particles form a group of 6-sided body to form 20 triangular faces of 20-sided, 12 The granules are composed of 12 apexes, each of which has a "fibril" extending from the base of the pentad, making the virion resemble a communication satellite-like configuration, a double-stranded DNA genome, and a molecular weight (20 to 25) × 106 The ends are repeated, and the 5 ends are linked with protein, which is infectious and intranuclear.

The adenovirus is very stable in the infected cell homogenate, cold-resistant, can maintain its infectivity within a few weeks at 4 °C, -25 °C for several months, relatively heat-resistant, UV-irradiation for 30 min can inactivate its infectivity, The pH range and temperature tolerance are wide, and the highest infectivity can be maintained at room temperature of 6.0-9.5.

It is known that human adenovirus has 42 serotypes (named adenovirus H1H42), which can be divided into 6 subgenera (AF) according to genomic homology, group recombination potential and other criteria. There are 42 types and belong to 6 species. Adenoviruses in the same subgenus have common pathogenic mechanisms and epidemiological characteristics. Adenovirus can be divided into 4 according to its characteristics of red blood cell agglutination. Subgroups, most types do not cause serious illness, but some types can cause acute respiratory diseases in sensitive populations, <1% in adults, and 5% of children under 5 years of age are caused by adenovirus Involuntary infections are usually caused by Ad1, Ad2, Ad5. Most children have been infected with these types of adenoviruses in infants and young children. 50% of them have mild symptoms and are non-specific. Adenoviruses infected with Ad2. Afterwards, latent infections are often formed and viruses are transmitted for a long time. Most epidemic infections are caused by Ad3, Ad11, Ad7, and Ad8. The prevalence of acute respiratory infections caused by adenovirus in recruits is mostly caused by Ad4 and Ad7, and occasionally by Ad3, Ad11, Ad21 causes pharyngeal conjunctival heat mainly by Ad3 and Ad7 From the "pool conjunctivitis" of children's summer camps, it can be an outbreak. Epidemic keratoconjunctivitis is mainly caused by Ad8. Adenovirus is caused by clinical observation and laboratory access to Ad7 and Ad3 type 2 viruses in infants with viral pneumonia. The main pathogen of pneumonia, and often more serious, can be fatal, but in the past decade or so, the number of children with severe clinical disease has decreased, which may be related to the increase of Ad7 year by year. Some scholars have used restriction enzymes for adenovirus type 3 and 7 Viral nucleic acid genomic analysis showed that the virulence and pathogenicity of different genomic types were different. 7b led to severe pneumonia, and the clinical symptoms of pneumonia caused by 7d were mild. 7d and 7b appeared from common to individual, indicating that 7d may be The variant strain of 7b caused the virulence of the disease-causing gene fragment to weaken, which made the symptoms of Ad7 pneumonia moderate and light. In addition, some strains were found to cause genitourinary infections, and some adenoviruses such as Ad40 and Ad41 were associated with gastroenteritis. related.

(two) pathogenesis

Adenovirus infection through the respiratory tract, first from the eyes, nose, pharyngeal mucosa invading the epithelial cells for 3 to 5 days after the acute inflammation of the upper respiratory tract, and can spread to nearby tissues causing top-down respiratory inflammation, 5 to 10 days later developed into pneumonia The virus can cause viremia through the blood circulation to cause systemic diseases, often damage the central nervous system and the heart and other important organs, and the serious symptoms of various systems appear. The adenovirus invades the cells and can lead to the following results: 1 breeding in the cells, causing Cytopathic, and release a large number of viruses from the cells and invade other cells, causing acute infection; 2 viruses (such as Ad1, Ad2, and Ad5) invade certain cells, such as tonsils, lymphocytes or monkey epithelial cells, sustainable After several years of asymptomatic, the release of the virus is also fluctuating, suggesting that it can cause latent or chronic infection; 3 virus (adenovirus A and B subgenus) when the cell proliferates, its DNA and intracellular DNA combine to promote Cell proliferation without the formation of infectious virus particles, can cause cancer in newborn rodents, but retrospective and prospective epidemiology, serology, virology And biochemical research has not yet produced evidence of human cancer.

Recently, Mistchenko and other studies reported that serum levels of interleukin-6,8 (IL-6,8), tumor necrosis factor (TNF) and immunoglobulin IgM increased during severe adenovirus infection, suggesting that the above cytokines and immunity Factors may play an important role in the development and progression of adenoviral pneumonia.

Focal or fusion necrotic lung infiltration and bronchitis and interstitial inflammation are the main pathological changes of the disease. The eyes of both lungs are involved in the naked eye. The margins of the lower and lower spine are severe. In severe cases, lesion fusion can be seen. Hard to touch, the cut surface is uniform and dense dark red, in which scattered or densely bronchial-centered miliary grayish yellow lesions, epithelial necrotic tissue and inflammatory exudate of trachea and bronchi fill the entire bronchial cavity, around the bronchi There are also exudates in the alveolar cavity, mostly lymph, monocytes, serum, cellulose, sometimes accompanied by bleeding, while neutrophils are rare, bronchial or alveolar epithelial cells can be seen at the edge of the inflammatory zone, epithelial nucleus Inside the nucleus inclusion body, its size is similar to normal red blood cells, the boundary is clear, dyeing eosinophilic or homozygous, there is a transparent circle around it, the nuclear membrane is clear, there is a small amount of chromatin accumulation inside the nuclear membrane, no inclusions in the cytoplasm There is also no multinucleated giant cell formation, which affects ventilation and gas exchange due to bronchial occlusion and severe inflammatory lesions of the lung parenchyma, which ultimately leads to low Hypertension and carbon dioxide retention increase the number of breaths and heart rate. Due to the increase of respiratory depth and the involvement of respiratory assisted muscles, there are nose flapping and dimples. Hypoxia and carbon dioxide retention and increased acid metabolites can cause metabolic acidosis and Respiratory acidosis, and can make small arteries reflex contraction, form pulmonary hypertension, increase the burden on the right heart, adenovirus and toxic metabolites in the body directly affect the myocardium, can cause toxic myocarditis, mild interstitial inflammation of the myocardium, The blood vessel wall proliferates, which in turn leads to heart failure.

Hypoxia and carbon dioxide retention can cause significant expansion of blood vessels in the brain. The endothelial cells, smooth muscle and outer membrane cells of the wall are hyperplastic and swollen. The brain tissue around the blood vessels is loose, showing mild demyelination. The nerve cells are acutely swollen. Proliferating cells, fibroids, arachnoid and subarachnoid vessels are highly dilated, blood-cerebrospinal fluid barrier permeability increases, and patients may experience convulsions, cerebral edema and cerebral palsy.

Hypoxemia and toxins can also cause gastrointestinal dysfunction. The main changes in the liver are interstitial inflammation and steatosis. The kidneys are turbid and swollen. Lymphoid tissue, spleen, lymph nodes, tonsils, etc. have significant acute inflammation. Reaction and hyperplasia.

Adenoviral pneumonia prevention

Strengthen nursing and physical exercise to prevent respiratory infections, prevent cross-infection during hospitalization during epidemics; when there is adenovirus infection in nursery and child care institutions, isolation measures should be taken to observe the positive duration of pharyngeal virus, and the isolation period should be more than 2 weeks. The oral live vaccine of adenovirus type 3,4,7 has a preventive effect, and the recombinant adenovirus live vaccine will be an ideal live vaccine, which will make the body produce immunity against adenovirus respiratory infection. Local immunity to rotavirus is produced in the intestine.

Adenoviral pneumonia complications Complications, respiratory syncytial virus infection

Combined with respiratory syncytial virus (RSV) or parainfluenza virus infection.

Adenoviral pneumonia symptoms common symptoms wheezing nose wing fan hair pharynx throat congestion pale pale bloating diarrhea dyspnea convulsions coma

Acute respiratory diseases caused by adenovirus, fever pharyngitis and pharyngeal conjunctival fever are the most common in children, infants and young children with pneumonia, incubation period of 3 to 8 days, followed by upper respiratory tract infection, pharyngeal conjunctival fever or other respiratory infections After the onset, high fever, long course of disease is characterized by general fever, the first 1-3 days, the body temperature is more than 38 ~ 39 ° C, and then gradually increase, 4 to 5 days, half of the cases can reach 40 ° C or more, showing heat Or irregular heat type, high fever lasts 7 to 10 days, severe 2 weeks is the fever after the extreme period, individual cases have a fever time of up to 20 days, the symptoms of poisoning are heavy, the spirit is wilting, pale and gray, which may be caused by poisoning Peripheral vasoconstriction and viremia are associated with systemic disease.

According to performance, clinical can be divided into mild and severe.

Mild disease: more preschool and school-age children, early symptoms of conjunctivitis, pharyngitis and rash, adenovirus infection, short heat, lasting 7 to 14 days, mild symptoms of poisoning, general heartless, brain and other complications, lung The signs and X-rays are similar to the general bronchial pneumonia. The course of disease is 10 to 14 days, and the high fever suddenly drops. The general symptoms will improve soon, and the shadow of the lungs will disappear completely within 2 to 4 weeks.

Severe symptoms: severe symptoms of poisoning, high fever can last up to 3 to 4 weeks, most of them have comorbidities such as circulation and central nervous system and DIC. The lung lesions last for 1 to 4 months, and the lungs are not wet for a long time. Disappeared, DIC can occur with extreme gravity.

Adenoviral pneumonia, if the high fever lasts for 10 to 14 days or more after the onset, but does not improve, or the fever has decreased, and then rises again, or the condition is once reduced and worsened, you should pay attention to the possibility of secondary bacterial infection. Korppi observation reports that in the case of respiratory adenovirus infection involving the lower respiratory tract, especially pneumonia, bacterial infection is common. At this time, the sputum is yellow, and the sputum or throat swab is positive for bacterial culture. The common pathogen is golden yellow grape. Cocci, pneumococcal, Escherichia coli, etc. At this time, if X-ray examination shows an increase in lung lesions or new lesions, peripheral white blood cells and neutrophils are elevated, nuclear left shift or granulocytes appear poisonous particles, the condition is more general Adenoviral pneumonia is more serious.

In addition, children with adenoviral pneumonia can also be infected with respiratory syncytial virus (RSV) or parainfluenza virus, at which time the condition of the child is also more serious than simple adenoviral pneumonia.

The severity and prognosis of the disease are related to age, viral virulence, immune function, secondary bacterial or other viral infections. For example, young children with adenovirus infection are heavier than older children; type 7 is heavier than type 3; 21 Type can leave long-term lung damage, such as atelectasis, pulmonary fibrosis, which may be caused by occlusive bronchiolitis.

The clinical features of measles complicated with adenoviral pneumonia, in addition to the general characteristics of adenoviral pneumonia, the condition is heavier, the course of disease is prolonged, the recovery is slower, more serious complications, especially myocarditis, laryngitis is the main cause of death, small In the age group, the mortality rate is high. In some cases, the rash is not typical, and the pneumonia is the main cause, which should be paid attention to.

Respiratory symptoms

Most children have frequent coughs from the onset of illness, and the secretions of the respiratory tract are sticky and difficult to cough up. After 4 to 6 days, wheezing, cyanosis, nasal fan, three concave signs, obstructive dyspnea or respiratory failure, lung physics Late appearance is characterized by adenoviral pneumonia. In the early stage of the onset, the breath sounds are thick. After 4 to 5 days of fever, lung signs may appear. The sputum is voiced, the breath sound is reduced or the dry snoring sounds, and the lungs can be smelled when the lungs are solid. The sound is gradually audible and wet, or sputum, and it is increasing, and there are signs of emphysema. In some severe cases, the pleural reaction or a small amount of pleural effusion is combined in the second week, and the pleural effusion can separate the adenovirus.

2. Nervous system symptoms

After 3 to 5 days of onset, there may be impotence, alternating irritability and lethargy. As the disease progresses, convulsions, coma, toxic encephalopathy, sometimes meningeal irritation, adenovirus meningoencephalitis, or bilateral pupils may occur. When the size is large, the respiratory rhythm changes, cerebral edema, cerebral palsy, and cerebrospinal fluid are generally not abnormal.

3. Circulatory system symptoms

After onset, often pale, gray or blemishes, skin spots, cold limbs, heart rate increased, heart sounds are low and blunt, can be combined with myocarditis, about 30% to 50% of severe pneumonia appeared 6 to 14 days after onset Heart failure: oliguria, edema, increased heart rate, hepatosplenomegaly, electrocardiogram: generally sinus tachycardia, T wave or ST segment changes and low voltage, individual may have 1 or 2 degrees atrioventricular block, Occasionally pulmonary P wave.

4. Digestive system

Adenovirus breeds in the intestine, and persistent high fever and hypoxia affect digestive system function. In severe cases, gastrointestinal capillary permeability increases. More than half of patients with adenoviral pneumonia have mild vomiting, diarrhea, loss of appetite, and severe cases. Have abdominal distension, toxic intestinal paralysis or gastrointestinal bleeding, vomiting coffee-like substance, positive fecal occult blood test.

5. Urinary system

It has been reported that type 11 adenoviral pneumonia can have mild proteinuria in the acute phase, a small number of cells, severe cases can cause acute hemorrhagic cystitis, frequent urination, dysuria, hematuria and other symptoms, urine can be isolated from adenovirus.

6. Reticuloendothelial system symptoms

In the early stage of pneumonia, the liver and spleen can be enlarged and the lymph nodes of the whole body can be increased to different degrees and the regression is slow. In some cases, serum protein is decreased and transaminase is elevated, suggesting that the liver is damaged.

7. Other

In some cases, red papules, maculopapular rash and scarlet fever-like rash may appear in the early stage. It is easily misdiagnosed as measles and scarlet fever in the early stage. Although the appearance rate of lime-like white spots on the tonsils is not high, it is also a special sign in the early stage of the disease.

Beijing Children's Hospital proposed clinical classification in 1985 as follows: 1 light type: fever around 38 °C for 5 to 7 days; slight sleepiness, irritability and other neurological symptoms; no obvious comorbidities, 2 heavy: fever 39 ~ 40 ° C, continued 7 to 10 days; have irritability or alternating with lethargy, disturbance of consciousness, slow response and increased heart rate, liver enlargement, abdominal distension, etc.; different degrees of dyspnea symptoms and hypoxia; there are intrapulmonary and extrapulmonary complications, such as Pleuritis, toxic myocarditis, etc., 3 extremely heavy: sustained high fever for 11 to 14 days or more; severe dyspnea and cyanosis.

Examination of adenoviral pneumonia

Blood picture

About 62% of the total number of white blood cells are below 10.0×10 ⁹ /L, 36% are between (10-15)×10 ⁹ /L, and lymphocytes are mainly classified. The total number of white blood cells and neutrophils in secondary infection. Can be elevated, blood smear examination: neutrophil alkaline phosphatase and tetrazolium blue staining is generally lower than normal children or bacterial pneumonia.

2. Virological examination

Because adenovirus infection is common, and the clinical features are very similar to other viral infections, it is difficult to make a final diagnosis of adenovirus infection based on clinical manifestations. Therefore, the following specific diagnostic methods are needed.

(1) Virus isolation: It is the earliest method to study viruses. The success rate depends on whether a sufficient amount of live virus samples can be collected and sensitive tissues are found. The time for collecting specimens is preferably on the day of onset, and the positive rate is 86%. The positive rate of 6 to 10 days decreased to 15%. The specimens were throat, nose, throat swab or nasal wash. The collected specimens were quickly inoculated with sensitive cells. Primary or passaged epithelial cells such as human embryo kidney, Hela, KB Or HEp-2 is sensitive to adenovirus, and characteristic cytopathic lesions appear after a few days to several weeks of viral infection. The appearance of the lesion varies depending on the type of virus and the amount of infection of the virus. The lesion is characterized by the first rounding of the cell. Further spherical and enhanced by the refraction of light, many of the diseased cells come together like a bunch of grapes.

(2) Double serum hemagglutination inhibition test: Neutralization test in acute phase and recovery phase serum, the antibody titer increased more than 4 times has diagnostic significance, although only provides a retrospective diagnosis, but still valuable.

(3) Rapid diagnosis method: virus isolation and serological examination. After decades of research and application, the results are more reliable, but it takes a long time and can only be used as a retrospective diagnosis. Therefore, rapid diagnosis methods have been carried out at home and abroad.

1 Immunofluorescence technique: direct pharyngeal exfoliated cells in children with early adenoviral pneumonia, indirect immunofluorescence-labeled antibody detection technology is one of the early rapid diagnosis methods, taking nasopharynx exfoliated cells into smear, each piece The smear should have more than 50 scattered and intact cells. The direct method is to combine the anti-viral specific antibody globulin-labeled fluorescein directly with the viral antigen in the specimen, and observe under the special fluorescence microscope of 20W high-pressure mercury lamp. The specific antigen-antibody binds to the site where yellow-green fluorescence occurs. Indirect method is to label fluorescein isothiocyanate (FITC) on the anti-viral antibody globulin 2 antibody, and detect the combination of anti-viral antibody and viral antigen antibody. The direct method is simple and specific, but it is not as sensitive as the indirect method. The indirect method only needs to label a second antibody to detect a variety of viral antigens, and its sensitivity is higher than that of the direct method. After 1979, the immunization was carried out in Changchun. Fluorescence technique for the diagnosis of adenoviral pneumonia virus antigens reported a direct positive rate of 74.4% and an indirect positive rate of 88.6%.

2Immunase technology: In order to improve sensitivity, foreign anti-viral antibodies labeled with fluorescein are combined with isotope 125I or enzyme to form radioimmunofluorescence technology and immunofluorescence enzyme technology, which is a new immunological technology developed in recent years. The basic principle is the same as the immunofluorescence technique, except that the enzyme is used instead of fluorescein to label the viral antibody globulin or the second antibody globulin of the anti-viral antibody, which maintains the activity of the enzyme and the enzymatic activity. Under the premise, it can specifically bind to the corresponding antibody or antigen to form an enzyme-labeled immune complex, and the enzyme bound to the immune complex catalyzes the colorless substrate to hydrolyze when it encounters the corresponding substrate. Oxidation or reduction to form a soluble or insoluble colored product. The appearance of this product reflects the presence of an enzyme, which in turn indicates the occurrence of an antigen-antibody specific reaction, thereby making a diagnosis, and an immunoenzymatic technique to detect antigenic antibodies in tissue cells or body fluids. Divided into: A. Immunoenzymatic staining or immunohistochemistry: for detecting antigens and antibodies in biological tissues or cells And other components, B. Immunoenzyme assay: for detecting antigenic antibodies and other components in biological fluids and tissue culture fluids, a, enzyme-labeled antibody method: using this method to detect adenoviral antigens in pharyngeal exfoliated cells of children The whole operation process only takes 2~4h. According to Changchun's report, compared with the traditional laboratory method virus separation and double serum hemagglutination inhibition test, the direct method is 83%, the indirect method is 89.7%, b, enzyme Combined immunosorbent assay (ELISA): This method is more reliable than the enzyme-labeled antibody method using a spectrophotometer. Its sensitivity is similar to that of radioimmunoassay.

Salomon et al. performed immunofluorescence, immunoenzyme association and tissue culture three diagnostic techniques. The results showed that two rapid diagnostic techniques, immunoenzymatic and immunofluorescence, are reliable methods for diagnosing most respiratory viruses, but the diagnosis of adenovirus is better. Tissue culture is less sensitive.

3 Polymerase chain reaction (PCR): It is the most sensitive and specific molecular biology technology in the world. It can be used to detect adenoviral DNA. It is sensitive and rapid than isolated virus, whether it is adenovirus causing pneumonia or intestine that is difficult to culture. Adenovirus, as long as there is an adenovirus in the specimen, whether it is infectious or not, can be detected by PCR, and can also be used to study the molecular biological characteristics of the adenovirus and the relationship between its genetic variation and pathogenicity.

3. Determination of immune function

Adenoviral pneumonia has different degrees of influence on cellular immunity and humoral immunity of the body, and the degree of cellular immunosuppression is obvious in patients with severe disease.

(1) Decreased phagocytic function of leukocytes: the degree of reduction is related to the degree of disease, and the recovery period is significantly increased. The decrease of phagocytic function of leukocytes is a temporary inhibition related to infection.

(2) PHA skin test response is weakened: severely low responders are all children with severe disease. As the condition recovers, the PHA skin test response may also increase to some extent.

(3) Radioisotope infiltration: The lymphocyte transformation test has a low infiltration rate of 3H-TdR in the acute phase, and a significant decrease in the severity of the disease. The low infiltration rate of 3H-TdR reflects the weakening of the proliferative response of T cells to PHA.

(4) IgM increased in the acute phase, IgG and IgA decreased, and the recovery gradually became normal.

(5) Serum complement C3: The condition is mild and the condition is severe.

(6) The serum lysozyme level is significantly increased: in the infected state, the neutrophil renewal rate in the blood circulation is increased and the metabolic activity of monocytes is enhanced, which has certain significance in the body's defense mechanism.

4. Blood gas analysis and blood lactate determination

For patients with severe adenoviral pneumonia who have respiratory failure, it is helpful to judge the prognosis. According to the observation of Beijing Children's Hospital, the blood gas analysis pH is less than 7.25, the carbon dioxide partial pressure is greater than 9.0 kPa and severe hypoxemia (inhalation of more than 40% oxygen). At the concentration, the oxygen partial pressure is lower than 7.0 kPa) and/or there is a high lactateemia (the blood lactate detection value is greater than the normal value + 2 standard deviations), and the mortality rate is higher.

X-ray chest X-ray changes earlier than lung signs, early lung texture increased, blurred, followed by the inner zone of the two lungs and the lower part of the two sides of the flaky lesions of varying sizes, with the development of the disease, the lesion density increased, the lesions increased , the distribution is wider, and some merge into a large lesion, the right side is more than the left side, the lung shadows mostly disappear in 2 weeks, only 3 to 6 weeks to fully absorb, some cases may have pleural reaction or a small amount of pleural cavity Fluid and emphysema.

Diagnosis and identification of adenoviral pneumonia

diagnosis

Main basis: 16 months to 2 years old infants; 2 continuous high fever, missed heat or relaxation heat type, angina, conjunctivitis and measles-like rash; 3 poisoning symptoms, early sleepiness; 4 lung signs It appears later, usually after 4 to 5 days of high fever, wet voice can be heard; 5 is not treated by antibiotics; 6 when the lung signs are not obvious, X-ray examination has flaky shadow; 7 the total number of white blood cells is low, absolutely Most cases never exceeded 12.0×109/L, and neutrophils were less than 0.7. The neutrophil alkaline phosphatase and tetrazolium blue staining were lower than those of purulent bacterial infection.

Suspected adenovirus infection in the above clinical manifestations, if necessary, should be used for throat swab virus isolation and double serum antibody test or immunofluorescence technology, various enzyme technologies, radioimmunoassay and hemagglutination and cell adsorption technology, etc. Diagnostic methods to determine the diagnosis, but the final diagnosis depends on a comprehensive analysis of clinical, virological and serological.

Differential diagnosis

1. Bronchial pneumonia: It can also be seen in infants and young children, but the heat type is uncertain. Generally, the condition is mild, the lungs are diffuse, the number of white blood cells is mostly increased, and antibiotic treatment is effective.

2. Lobar pneumonia: sudden onset of illness, persistent high fever (reserved heat), general illness, early signs are not obvious, but found in older children, X-ray examination is full leaf or segmental, antibiotic treatment is effective, It is different from adenoviral pneumonia.

3. Bronchiolitis: more common in small babies, only low fever or even high fever, heavy asthma, lung wheezing, extensive voice, X-ray examination for point film, can be identified.

4. Parainfluenza virus pneumonia: Although it can also be seen in infants and young children, moderate fever, a long course of disease, antibiotic treatment is not effective, but the general symptoms are mild, lung signs are diffuse, X-ray examination is a small shadow.

5. Measles: early symptoms with fever, conjunctivitis, measles-like rash should be identified with measles, if there is a history of measles exposure, Koplik plaques appear in the oral mucosa after 3 to 4 days of fever, pharyngeal mucosal cells immunofluorescein-labeled antibody test and immunoenzyme When the standard antibody is negative for adenovirus antigen, it is diagnosed as measles infection.

In addition, tuberculosis primary syndrome, miliary tuberculosis, caseous pneumonia, when high fever continues to retreat, dyspnea, cyanosis, antibiotic treatment is ineffective, need to be differentiated from adenoviral pneumonia, physical signs of tuberculosis are not as obvious as adenoviral pneumonia It can be combined with the history of tuberculosis exposure, tuberculosis test and tuberculin test.

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