Acute Viral Upper Respiratory Infection (Common Cold)
Diagnosis
This patient has an acute viral upper respiratory infection (common cold), characterized by the classic triad of fever, cough, and nasal congestion present for only 2 days. 1
The presentation is typical for viral rhinosinusitis:
- Symptoms lasting < 10 days without worsening indicate viral—not bacterial—infection. 1, 2
- Fever, cough, and nasal congestion together within 48 hours of onset are the hallmark features of viral respiratory infection. 3, 4
- The 2-day duration is far too short to diagnose bacterial rhinosinusitis, which requires either ≥10 days of persistent symptoms or a "double worsening" pattern (initial improvement followed by deterioration within 10 days). 1, 2
Critical pitfall to avoid: Do not prescribe antibiotics based on purulent nasal discharge alone—98–99.5% of acute rhinosinusitis cases are viral, and purulent color reflects neutrophil content, not bacterial infection. 1, 2
Immediate Management
Symptomatic Treatment (Start Now)
Intranasal corticosteroid spray (mometasone furoate 200 µg twice daily) should be started immediately—it significantly improves total symptom scores, headache, facial pain, and congestion compared to placebo, and there is no need to wait until day 10. 1
High-volume nasal saline irrigation is strongly recommended to enhance mucociliary clearance and reduce congestion. 1, 2
Analgesics (acetaminophen or NSAIDs) for fever, headache, and facial discomfort. 1
Supportive measures:
- Adequate hydration and rest 1
- Warm facial compresses 1
- Steamy showers 1
- Sleep with head of bed elevated 30–45° to improve sinus drainage 1
Short-term topical or oral decongestants may be used for 3–5 days maximum to avoid rebound congestion. 1
Influenza Consideration
If influenza is circulating in the community, the simultaneous presence of cough and fever within 48 hours of symptom onset is highly predictive of influenza infection. 3, 5, 4
If influenza is suspected and the patient presents within 48 hours of symptom onset, consider oseltamivir (Tamiflu) 75 mg twice daily for 5 days—treatment must begin within 48 hours to be effective. 6
The decision to treat empirically for influenza depends on:
- Local influenza activity (check CDC surveillance data) 5
- High-risk features (age ≥65, chronic medical conditions, immunosuppression) 6
- Severity of symptoms 6
When Antibiotics Are Indicated
Reassess at day 10–14 if symptoms persist without improvement, or immediately if symptoms worsen at any time ("double worsening"). 1, 2
If bacterial rhinosinusitis is diagnosed (symptoms ≥10 days or double worsening), start amoxicillin 500 mg three times daily for 10–14 days. 1, 2
If no improvement after 3–5 days of amoxicillin, switch to high-dose amoxicillin-clavulanate (2000 mg/125 mg twice daily) to cover β-lactamase-producing organisms (H. influenzae, M. catarrhalis). 1, 2
Imaging
No imaging (CT, MRI, or plain X-ray) is indicated for uncomplicated acute viral rhinosinusitis—imaging cannot differentiate viral from bacterial infection, and up to 40% of asymptomatic adults show sinus abnormalities on CT. 1, 2
Reserve CT only for suspected complications: orbital involvement (periorbital edema, proptosis, vision changes) or intracranial extension (severe headache with altered mental status, neck stiffness, cranial nerve deficits). 1, 2
Red-Flag Symptoms Requiring Urgent Evaluation
Send immediately to the emergency department if any of the following develop: 1, 2
- Periorbital edema, erythema, swelling, proptosis, or abnormal eye movements (orbital complications)
- Vision changes or ocular pain
- Severe headache with altered mental status, neck stiffness, or cranial nerve deficits (intracranial extension)
- Facial swelling or erythema over the involved sinus
- High fever >39°C with severe unilateral facial pain
- Signs of sepsis (tachycardia, hypotension)
Patient Education & Follow-Up
Viral rhinosinusitis typically resolves within 7–10 days with symptomatic care; complete resolution may take up to 2 weeks. 1
Instruct the patient to return if:
- Symptoms persist beyond 10 days without improvement 1
- Symptoms worsen at any time (double worsening) 1
- Any red-flag symptoms develop 1
Emphasize that antibiotics are ineffective for viral illness and contribute to antimicrobial resistance. 1
Counsel on smoking cessation if applicable—cigarette smoke impairs mucociliary clearance, prolongs viral illness, and markedly increases the risk of bacterial superinfection and recurrent sinusitis. 1, 2
Continue intranasal corticosteroids and supportive measures for an additional week if symptoms are improving but not fully resolved at day 10–14. 1