Rhinovirus/Enterovirus Association with ARDS
The available evidence indicates that rhinovirus/enterovirus (RV/EV) is infrequently but consistently associated with ARDS, with rates ranging from approximately 6-14% in pediatric intensive care populations and scattered case reports in adults.
Frequency in Pediatric Populations
In children admitted to pediatric intensive care units with RV/EV infections, approximately 14% meet criteria for pediatric ARDS 1. This study of 155 children found that 62% required positive pressure respiratory support ≥5 cm H₂O within 24 hours of admission, and among these, 34% had SaO₂/FiO₂ ratios ≤264, with 22 patients (14%) meeting full pediatric ARDS criteria 1.
A more recent multicenter study found a lower frequency, with pediatric ARDS occurring in 6.67% of RV/EV-positive PICU admissions 2. This study of 75 cases showed that RV/EV infections primarily manifested as bronchopneumonia/pneumonia (42.67%), acute bronchiolitis/bronchitis (32%), and sepsis/septic shock (9.33%), with 16% requiring invasive mechanical ventilation 2.
Frequency in Adult Populations
ARDS from RV/EV in adults appears rare and is documented primarily through case reports 3, 4. The literature contains only scattered reports of RV/EV-induced ARDS in immunocompetent adults, though the condition may be underrecognized given that molecular diagnostic testing has only recently become widespread 4.
Global Burden and Risk Factors
A large multicountry analysis from the Global Influenza Hospital Surveillance Network (2017-2024) provides important context: among 7,929 RV/EV-positive hospitalized patients, in-hospital mortality was 6.3% in adults aged 65-74 years and 9.2% in those ≥75 years 5. While this study didn't specifically quantify ARDS rates, it demonstrates that RV/EV causes substantial severe respiratory disease requiring mechanical ventilation across age groups 5.
Key Risk Factors for Severe Disease:
- Children <5 years with ≥2 comorbidities: 4.62-fold increased odds of mechanical ventilation 5
- Adults ≥75 years: 2.66-fold increased odds of death 5
- Lower-middle-income countries: 10-fold higher mortality in children <5 years and 7-fold higher in older adults compared to high-income countries 5
- Immunosuppression: JAK inhibitor therapy and other immunomodulatory treatments increase risk 3
Clinical Context and Caveats
Important considerations when interpreting RV/EV detection in ARDS patients:
Coinfection is common: RV/EV is frequently codetected with other pathogens (bacteria, fungi, other viruses), making attribution of causality challenging 6, 7
Asymptomatic shedding: Up to 41% of immunocompromised patients may shed RV/EV asymptomatically, and prolonged shedding >4 weeks is frequent 6
Diagnostic limitations: Commercial multiplex panels cannot distinguish enteroviruses from rhinoviruses, and some emerging strains (like enterovirus D68) may be missed 7
Underrecognition in adults: The advent of RT-PCR has only recently facilitated diagnosis, suggesting historical underreporting 4
Bottom Line
RV/EV accounts for ARDS in approximately 6-14% of pediatric ICU admissions with documented RV/EV infection, while adult ARDS from RV/EV remains rare but likely underrecognized. The true burden is probably higher than reported due to diagnostic limitations, asymptomatic shedding confounding attribution, and frequent coinfections. Clinicians should maintain heightened suspicion in young children with comorbidities, elderly adults, immunocompromised patients, and those from resource-limited settings, where outcomes are substantially worse 1, 2, 5, 3.