What is the diagnosis and treatment for a patient with symptoms of fever, chills, and rhinorrhea?

Diagnosis and Treatment of Acute Rhinosinusitis

Diagnosis

The patient with fever, chills, and rhinorrhea most likely has acute viral rhinosinusitis (AVRS), which should be treated symptomatically unless symptoms persist beyond 10 days or worsen after 5-7 days, indicating possible bacterial infection. 1

Acute rhinosinusitis typically presents with the following symptoms:

• Nasal congestion/obstruction
• Rhinorrhea (anterior or posterior)
• Facial pain/pressure/fullness
• Fever (more common in viral phase)
• Chills
• Hyposmia/anosmia (reduced sense of smell)

Differentiating Viral vs. Bacterial Rhinosinusitis

The diagnosis of acute bacterial rhinosinusitis (ABRS) should be considered when:

1. Symptoms persist ≥10 days beyond the onset of upper respiratory symptoms without improvement 1
2. Symptoms worsen within 10 days after initial improvement (double worsening) 1
3. Symptoms are particularly severe in the first 3-4 days of illness (high fever, unilateral facial/tooth pain) 1

The presence of purulent nasal discharge accompanied by nasal obstruction and/or facial pain/pressure is the cornerstone of diagnosis for ABRS 1. However, nasal purulence alone cannot distinguish between viral and bacterial infection.

Treatment Algorithm

1. Acute Viral Rhinosinusitis (Initial Presentation with Fever, Chills, Rhinorrhea)

For symptoms present <10 days without worsening (presumed viral):

• Symptomatic treatment only:
  • Analgesics/antipyretics: Acetaminophen or NSAIDs for fever, pain relief 2
  • Saline nasal irrigation 1, 2
  • Adequate hydration
  • Rest
  • Avoid antibiotics as they are not justified for viral infections 3

2. Acute Bacterial Rhinosinusitis (If Symptoms Persist ≥10 Days or Worsen)

If symptoms persist ≥10 days, worsen after initial improvement, or are unusually severe:

• First-line antibiotic therapy:

  • Amoxicillin with or without clavulanate for 5-10 days 1, 2
  • For penicillin allergy: Second or third-generation cephalosporins (if no anaphylaxis history) or fluoroquinolones (for severe cases) 2

• Adjunctive therapy:

  • Intranasal corticosteroids 1, 2
  • Saline nasal irrigation 1, 2
  • Analgesics/antipyretics for symptomatic relief 2

Pathophysiology

The most common cause of acute rhinosinusitis is viral infection, with rhinoviruses being the predominant pathogens 4. Viral deposition in the nose initiates infection by attaching to host cell receptors, leading to inflammatory mediator release and symptom development within 10-16 hours after viral entry 4.

In cases that progress to bacterial infection, the most common bacterial pathogens include:

• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis (more common in children) 1

Important Clinical Considerations

• Imaging is not necessary for uncomplicated cases of acute rhinosinusitis 1
• Nasal cultures are not routinely indicated 1
• Color of nasal discharge alone is not a reliable indicator to differentiate viral from bacterial infection 1
• Hand hygiene is important to prevent transmission of respiratory viruses 1
• Warning signs requiring immediate medical attention include:
  • Orbital swelling/pain
  • Visual changes
  • Severe headache
  • Mental status changes
  • High, persistent fever 2

Prognosis

Most cases of viral rhinosinusitis are self-limiting and resolve within 7-10 days 1, 4. However, approximately 0.5-2% of viral upper respiratory infections may be complicated by bacterial infection 1. Early treatment of bacterial rhinosinusitis can prevent complications such as orbital cellulitis, meningitis, or intracranial abscess.