What are the typical symptoms and clinical presentation of respiratory syncytial virus infection in adults, including older adults and those with chronic cardiopulmonary disease, immunosuppression, or heart failure?

Symptoms of Adult RSV

Adult RSV infection presents with nonspecific upper and lower respiratory symptoms that are often clinically indistinguishable from influenza, with nasal congestion, cough, and wheezing being the most common manifestations, particularly in older adults and those with chronic cardiopulmonary disease. 1

Common Respiratory Symptoms

The typical symptom profile in hospitalized adults with RSV includes:

• Cough occurs in approximately 85% of hospitalized adults with RSV infection 2
• Shortness of breath develops in 79% of hospitalized cases 2
• Nasal congestion is a prominent feature across all adult age groups 1, 3
• Sputum production occurs in 63% of hospitalized patients 2
• Wheezing is noted in 38% of hospitalized adults, similar to the wheezing pattern seen in pediatric RSV 2

Systemic and Constitutional Symptoms

• Low-grade fever is present in approximately 48% of hospitalized adults, though fever may be less prominent than in influenza 1, 3, 2
• Weakness and fatigue occur in 50% of hospitalized cases 2
• Fever patterns tend to be less pronounced compared to influenza, which can make clinical differentiation challenging 1

Lower Respiratory Tract Manifestations

Lower respiratory tract complications develop in 52% of hospitalized adults with RSV, with pneumonia being the most common serious complication. 2

• Pneumonia occurs in 42.3% of adults hospitalized for RSV infection and represents the direct cause of death in 66.7% of patients who die within 60 days of admission 1
• Acute bronchitis develops in 21.9% of hospitalized RSV cases 1
• Chest radiographs may appear normal despite significant lower respiratory symptoms and hypoxia, making clinical diagnosis challenging 4

Disease Exacerbations in High-Risk Populations

COPD and Asthma Exacerbations

• COPD exacerbation occurs in 80.4% of patients with underlying COPD, chronic bronchitis, or emphysema who are hospitalized with RSV 1
• Asthma exacerbation develops in 49.5% of patients with underlying asthma during RSV hospitalization 1
• Combined COPD/asthma exacerbations account for 27.3% of RSV-related hospitalizations in adults 1

Cardiovascular Complications

Acute cardiac events occur in 22.4% of adults aged ≥50 years hospitalized with RSV, with rates reaching 33.0% in those with pre-existing cardiovascular disease. 1

• Acute heart failure develops in 15.8% of hospitalized RSV patients 1
• Acute ischemic heart disease occurs in 7.5% of cases 1
• Heart failure exacerbation during RSV hospitalization independently increases mid- to long-term mortality (adjusted HR = 1.86) 1
• Atrial fibrillation during hospitalization increases short-term mortality (adjusted HR = 1.66) 1

Clinical Presentation by Population

Older Adults (≥60 years)

• Older adults experience higher rates of consolidative pneumonia, ICU admissions, and extended hospital stays compared to younger adults 1
• The 30-day mortality hazard ratio is 2.85 for patients aged ≥75 years compared to younger adults 5
• Functional decline can be significant and prolonged, particularly in frail elderly patients from skilled nursing facilities 6

Immunocompromised Patients

• Immunocompromised adults may present with more severe lower respiratory tract disease and higher rates of progression to pneumonia 6, 4
• Viral shedding may be prolonged in immunosuppressed patients, making early bronchoscopy valuable for diagnosis 3, 7

Patients with Chronic Cardiopulmonary Disease

• Adults with COPD or asthma are at 3.2 to 13.4 times higher risk of hospitalization compared to those without these conditions 1
• Wheezing is particularly common in patients with underlying reactive airway disease 2

Important Clinical Caveats

• Symptoms are nonspecific and difficult to distinguish from influenza or other respiratory viruses without laboratory testing 1, 3, 2
• Co-infections occur in approximately 13% of hospitalized adults, complicating the clinical picture 2
• Patients often receive empiric antibiotics (78% in one study) and anti-influenza therapy (36%) due to diagnostic uncertainty 2
• Diagnosis requires molecular testing (RT-PCR) because viral culture and antigen detection are insensitive in adults due to low viral titers 6, 3, 7