Influenza Signs and Symptoms

Influenza Signs and Symptoms and the Role of Laboratory Diagnostics

Signs and Symptoms

The signs and symptoms of influenza can vary by age, immune status, and presence of underlying medication conditions. Uncomplicated influenza can include any or all of these signs and symptoms: fever, muscle aches, headache, lack of energy, dry cough, sore throat, nasal congestion, and possibly runny nose. Fever is not always present in influenza patients, especially in elderly persons. The fever and body aches can last 3-5 days and the cough and lack of energy may last for 2 or more weeks, especially in the elderly. Influenza can be difficult to diagnose based on clinical signs and symptoms alone because the signs and symptoms of influenza can be similar to those caused by other infectious agents including, but not limited to, Mycoplasma pneumoniae, adenoviruses, respiratory syncytial viruses, rhinoviruses, parainfluenza viruses, and Legionella spp.

Complications associated with influenza can vary by age, immune status, and underlying medical conditions. Some examples include worsening of underlying chronic medical conditions (e.g. worsening of congestive cardiac failure; asthma exacerbation; exacerbation of chronic obstructive pulmonary disease); lower respiratory tract disease (pneumonia, bronchiolitis, croup, respiratory failure); invasive bacterial co-infection; cardiac (e.g. myocarditis); musculoskeletal (e.g. myositis, rhabdomyolysis); neurologic (e.g. encephalopathy, encephalitis); multi-organ failure (septic shock, renal failure, respiratory failure).

Appropriate treatment of patients with respiratory illness depends on accurate and timely diagnosis. Early diagnosis of influenza can reduce the inappropriate use of antibiotics and provide the option of using antiviral therapy. However, because certain bacterial infections can produce signs and symptoms similar to influenza, bacterial infections should be considered and appropriately treated, if suspected. In addition, bacterial co-infection can occur as a complication of influenza.

Influenza surveillance information about the prevalence of circulating influenza viruses and diagnostic testing can aid clinical judgment and help guide treatment decisions. The accuracy of clinical diagnosis of influenza on the basis of signs and symptoms alone is limited because symptoms from illness caused by other pathogens can overlap considerably with influenza. Influenza surveillance by state and local health departments and CDC can provide information regarding the prevalence of influenza A and B viruses in the community. Surveillance can also identify the predominant circulating types, influenza A virus subtypes, and strains of influenza viruses.

 

Laboratory Diagnostic Procedures

A number of tests can help in the diagnosis of influenza (see table). But, tests do not need to be done on all patients with suspected influenza. For individual patients, tests are most useful when they are likely to yield clinically useful results that will help with diagnosis and treatment decisions. During a respiratory illness outbreak in a closed setting (e.g., hospitals, long-term care facility,  cruise ship, boarding school, summer camp) testing for influenza can be very helpful in determining if influenza is the cause of the outbreak.

Diagnostic tests available for influenza include viral culture, serology, rapid antigen testing, reverse transcription polymerase chain reaction (RT-PCR), immunofluorescence assays, and rapid molecular assays. Sensitivity and specificity of any test for influenza might vary by the laboratory that performs the test, the type of test used, the time from illness onset to specimen collection, and the type of specimen tested. Among respiratory specimens for viral isolation or rapid detection of human influenza viruses, nasopharyngeal specimens typically have higher yield than nasal or throat swab specimens. As with any diagnostic test, results should be evaluated in the context of other clinical and epidemiologic information available to health care providers.

Preferred respiratory samples for influenza testing include nasopharyngeal or nasal swab, and nasal wash or aspirate, depending on which kind of test is used (see table). Samples should be collected within the first 3-4 days of illness. Rapid influenza diagnostic tests (RIDTs) provide results within approximately 15 minutes; viral culture provides results in 3-10 days. Most of the rapid influenza diagnostic tests that can be done in a physician’s office are approximately 50-70% sensitive for detecting influenza and approximately greater than 90% specific. Therefore, false negative results are more common than false positive results, especially during peak influenza activity in the community. Rapid molecular assays can produce results in approximately 20 minutes with high sensitivity and specificity. Other molecular assays are increasingly becoming available and can produce results in approximately 60-80 minutes with very high sensitivity and specificity.

To maximize detection of influenza viruses, respiratory specimens should be collected as close to illness onset as possible (ideally < 3-4 days after onset; molecular assays may detect influenza viral RNA in respiratory tract specimens for longer periods after illness onset than antigen detection assays). For hospitalized patients with lower respiratory tract disease and suspected influenza, lower respiratory tract specimens should be collected and tested for influenza viruses by RT-PCR because influenza viral shedding in the lower respiratory tract may be detectable for longer periods than in the upper respiratory tract. If the patient is critically ill on invasive mechanical ventilation, and has tested negative on an upper respiratory tract specimen, including by a molecular assay, a lower respiratory tract specimen (endotracheal aspirate or bronchioalveolar lavage fluid) should be collected for influenza testing by RT-PCR or other molecular assays.

 

Viral Culture

During outbreaks of respiratory illness when influenza is suspected, some respiratory samples should be tested by molecular assays and both rapid influenza diagnostic tests and by viral culture. The collection of some respiratory samples for viral culture is essential for determining the influenza A virus subtypes and influenza A and B virus strains causing illness, and for surveillance of new virus strains that may need to be included in the next year’s influenza vaccine. During outbreaks of influenza-like illness, viral culture also can help identify other causes of illness.

During outbreaks of respiratory illness when influenza is suspected, some respiratory samples should be tested by molecular assays and viral culture. The collection of some respiratory samples for viral culture is essential for determining the influenza A virus subtypes and influenza A and B virus strains causing illness, and for surveillance of new virus strains that may need to be included in the next year’s influenza vaccine. During outbreaks of influenza-like illness, viral culture also can help identify other causes of illness.

 

RIDTS

Commercial rapid influenza diagnostic tests (RIDTs) are antigen detection assays that can detect influenza viruses within 15 minutes with low to moderate sensitivity and high specificity. Some tests are CLIA-waived and approved for use in any outpatient setting, whereas others must be used in a moderately complex clinical laboratory. These rapid influenza diagnostic tests differ in the types of influenza viruses they can detect and whether they can distinguish between influenza virus types. Different tests can detect 1) only influenza A viruses; 2) both influenza A and B viruses, but not distinguish between the two types; or 3) both influenza A and B viruses and distinguish between the two. Some RIDTs utilize an analyzer reader device to standardize results to and improve sensitivity.

None of the rapid influenza diagnostic tests provide any information about influenza A virus subtypes. The types of specimens acceptable for use (i.e., throat, nasopharyngeal, or nasal aspirates, swabs, or washes) also vary by test. The specificity and, in particular, the sensitivity of rapid influenza diagnostic tests are lower than for viral culture and RT-PCR and vary by test. Because of the lower sensitivity of the rapid influenza diagnostic tests, physicians should consider confirming negative test results with RT-PCR, viral culture or other means, especially in hospitalized patients or during suspected institutional influenza outbreaks because of the possibility of false-negative RIDT results, especially during periods of peak community influenza activity. In contrast, false-positive RIDT results are less likely, but can occur during periods of low influenza activity. Therefore, when interpreting results of a rapid influenza diagnostic test, physicians should consider the positive and negative predictive values of the test in the context of the level of influenza activity in their community. Package inserts and the laboratory performing the test should be consulted for more details regarding use of rapid influenza diagnostic tests.

 

Immunofluorescence

Immunofluorescence assays are antigen detection assays that generally require use of a fluorescent microscope to produce results in approximately 2-4 hours with moderate sensitivity and high specificity. Both direct (DFA) and indirect fluorescent antibody (IFA) staining assays are available to detect influenza A and B viral antigens in respiratory tract specimens. Subtyping or further identification of influenza A viruses is not possible by immunofluorescent assays. One rapid immunofluorescence assay is an RIDT and utilizes an analyzer device to produce results in approximately 15 minutes.

 

Rapid Molecular Assays

Rapid molecular assays are a new kind of molecular influenza diagnostic test for upper respiratory tract specimens with high sensitivity and specificity.1 One platform uses isothermal nucleic acid amplification and has high sensitivity and yields results in 15 minutes or less. Another platform uses RT-PCR and has high sensitivity and produces results in approximately 20 minutes. See Rapid Diagnostic Testing for Influenza: Information for Health Care Professionals for more information.

1 Two FDA-cleared rapid molecular assays are available in the United States. Rapid molecular assays can provide results in approximately 20 minutes. Alere i Influenza A&B was FDA cleared for use with both nasal swabs (direct) and NP or nasal swabs in VTM. It was CLIA-waived for use with nasal swabs (direct) only. Roche Cobas Influenza A/B was cleared and CLIA-waived by FDA for use with nasopharyngeal swabs only.

 

Other Molecular Assays

Reverse Transcription-Polymerase Chain Reaction (RT-PCR) and other molecular assays can identify the presence of influenza viral RNA in respiratory specimens with very high sensitivity and specificity. Some molecular assays are able to detect and discriminate between infections with influenza A and B viruses; other tests can identify specific seasonal influenza A virus subtypes [A(H1N1)pdm09, or A(H3N2)]. These assays can yield results in approximately 1-8 hours depending upon the assay. Notably, the detection of influenza viral RNA by these assays does not necessarily indicate detection of viable infectious virus or on-going influenza viral replication. It is important to note that not all assays have been cleared by the FDA for diagnostic use. See Influenza Virus Testing Methods for more information.

 

Serologic Testing

Routine serological testing for influenza requires paired acute and convalescent sera, does not provide results to help with clinical decision-making, is only available at a limited number of public health or research laboratories and is not generally recommended, except for research and public health investigations. Serological testing results for antibodies to human influenza viruses on a single serum specimen is not interpretable and is not recommended.

Influenza Diagnostic Table

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What Are Palliative Care and Hospice Care?

 

Many Americans die in facilities such as hospitals or nursing homes receiving care that is not consistent with their wishes. To make sure that doesn’t happen, older people need to know what their end-of-life care options are and state their preferences to their caregivers in advance. For example, if an older person wants to die at home, receiving end-of-life care for pain and other symptoms, and makes this known to healthcare providers and family, it is less likely he or she will die in a hospital receiving unwanted treatments.Vase of flowers in a hospital room

Learn more about advance care planning.

Caregivers have several factors to consider when choosing end-of-life care, including the older person’s desire to pursue life-extending or curative treatments, how long he or she has left to live, and the preferred setting for care.

Read more about where end-of-life care is given.

Palliative Care

Doctors can provide treatment to seriously ill patients in the hopes of a cure for as long as possible. These patients may also receive medical care for their symptoms, or palliative care, along with curative treatment.

A palliative care consultation team is a multidisciplinary team that works with the patient, family, and the patient’s other doctors to provide medical, social, emotional, and practical support. The team is made of palliative care specialist doctors and nurses, and includes others such as social workers, nutritionists, and chaplains.

Palliative care can be provided in hospitals, nursing homes, outpatient palliative care clinics and certain other specialized clinics, or at home. Medicare, Medicaid, and insurance policies may cover palliative care. Veterans may be eligible for palliative care through the Department of Veterans Affairs. Private health insurance might pay for some services. Health insurance providers can answer questions about what they will cover. Check to see if insurance will cover your particular situation.

In palliative care, you do not have to give up treatment that might cure a serious illness. Palliative care can be provided along with curative treatment and may begin at the time of diagnosis. Over time, if the doctor or the palliative care team believes ongoing treatment is no longer helping, there are two possibilities. Palliative care could transition to hospice care if the doctor believes the person is likely to die within 6 months (see What does the hospice 6-month requirement mean?). Or, the palliative care team could continue to help with increasing emphasis on comfort care.

Hospice

Increasingly, people are choosing hospice care at the end of life. Hospice can be provided in any setting—home, nursing home, assisted living facility, or inpatient hospital.

At some point, it may not be possible to cure a serious illness, or a patient may choose not to undergo certain treatments. Hospice is designed for this situation. The patient beginning hospice care understands that his or her illness is not responding to medical attempts to cure it or to slow the disease’s progress.

Like palliative care, hospice provides comprehensive comfort care as well as support for the family, but, in hospice, attempts to cure the person’s illness are stopped. Hospice is provided for a person with a terminal illness whose doctor believes he or she has 6 months or less to live if the illness runs its natural course.

Hospice is an approach to care, so it is not tied to a specific place. It can be offered in two types of settings—at home or in a facility such as a nursing home, hospital, or even in a separate hospice center.

Read more about where end-of-life care can be provided.

Hospice care brings together a team of people with special skills—among them nurses, doctors, social workers, spiritual advisors, and trained volunteers. Everyone works together with the person who is dying, the caregiver, and/or the family to provide the medical, emotional, and spiritual support needed.

A member of the hospice team visits regularly, and someone is always available by phone—24 hours a day, 7 days a week. Hospice may be covered by Medicare and other insurance companies; check to see if insurance will cover your particular situation.

It is important to remember that stopping treatment aimed at curing an illness does not mean discontinuing all treatment. A good example is an older person with cancer. If the doctor determines that the cancer is not responding to chemotherapy and the patient chooses to enter into hospice care, then the chemotherapy will stop. Other medical care may continue as long as it is helpful. For example, if the person has high blood pressure, he or she will still get medicine for that.

Some Differences Between Palliative Care and Hospice
Palliative Care Hospice
Who can be treated? Anyone with a serious illness Anyone with a serious illness whom doctors think has only a short time to live, often less than 6 months
Will my symptoms be relieved? Yes, as much as possible Yes, as much as possible
Can I continue to receive treatments to cure my illness? Yes, if you wish No, only symptom relief will be provided
Will Medicare pay? It depends on your benefits and treatment plan Yes, it pays all hospice charges
Does private insurance pay? It depends on the plan It depends on the plan
How long will I be cared for? This depends on what care you need and your insurance plan As long as you meet the hospice’s criteria of an illness with a life expectancy of months, not years
Where will I receive this care?
  • Home
  • Assisted living facility
  • Nursing home
  • Hospital
  • Home
  • Assisted living facility
  • Nursing home
  • Hospice facility
  • Hospital

Copyright © National Hospice and Palliative Care Organization. All rights reserved. Reproduction and distribution by an organization or organized group without the written permission of the National Hospice and Palliative Care Organization are expressly forbidden.

Although hospice provides a lot of support, the day-to-day care of a person dying at home is provided by family and friends. The hospice team coaches family members on how to care for the dying person and even provides respite care when caregivers need a break. Respite care can be for as short as a few hours or for as long as several weeks.

Families of people who received care through a hospice program are more satisfied with end-of-life care than are those of people who did not have hospice services. Also, hospice recipients are more likely to have their pain controlled and less likely to undergo tests or be given medicines they don’t need, compared with people who don’t use hospice care.

For More Information About Hospice and Palliative Care

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Countdown to Baby: What Happens During Delivery

When you’re in the second stage of labor, called delivery, you are mere minutes to a couple of hours away from meeting your newborn.

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What’s Normal and What’s Not?

 

Many older people worry about their memory and other thinking abilities. For example, they might be concerned about taking longer than before to learn new things, or they might sometimes forget to pay a bill. These changes are usually signs of mild forgetfulness—often a normal part of aging—not serious memory problems.Older woman talking to her doctor about memory problems

Talk with your doctor to determine if memory and other thinking problems are normal or not, and what is causing them.

What’s Normal and What’s Not?

What’s the difference between normal, age-related forgetfulness and a serious memory problem? Serious memory problems make it hard to do everyday things like driving and shopping. Signs may include:

  • Asking the same questions over and over again
  • Getting lost in familiar places
  • Not being able to follow instructions
  • Becoming confused about time, people, and places

Mild Cognitive Impairment

Some older adults have a condition called mild cognitive impairment, or MCI, in which they have more memory or other thinking problems than other people their age. People with MCI can take care of themselves and do their normal activities. MCI may be an early sign of Alzheimer’s, but not everyone with MCI will develop Alzheimer’s disease.

Signs of MCI include:

  • Losing things often
  • Forgetting to go to important events or appointments
  • Having more trouble coming up with desired words than other people of the same age

If you have MCI, visit your doctor every 6 to 12 months to see if you have any changes in memory and other thinking skills over time. There may be things you can do to maintain your memory and mental skills. No medications have been approved to treat MCI.

Dementia

Dementia is the loss of cognitive functioning—thinking, remembering, learning and reasoning—and behavioral abilities to such an extent that it interferes with daily life and activities. Memory loss, though common, is not the only sign. A person may also have problems with language skills, visual perception, or paying attention. Some people have personality changes. Dementia is not a normal part of aging.

There are different forms of dementia. Alzheimer’s disease is the most common form in people over age 65. The chart below explains some differences between normal signs of aging and Alzheimer’s disease.

Differences Between Normal Aging and Alzheimer’s Disease
Normal Aging Alzheimer’s Disease
Making a bad decision once in a while Making poor judgments and decisions a lot of the time
Missing a monthly payment Problems taking care of monthly bills
Forgetting which day it is and remembering it later Losing track of the date or time of year
Sometimes forgetting which word to use Trouble having a conversation
Losing things from time to time Misplacing things often and being unable to find them

When to Visit the Doctor

If you, a family member, or friend has problems remembering recent events or thinking clearly, talk with a doctor. He or she may suggest a thorough checkup to see what might be causing the symptoms

The annual Medicare wellness visit includes an assessment for cognitive impairment. This visit is covered by Medicare for patients who have had Medicare Part B insurance for at least 1 year.

Memory and other thinking problems have many possible causes, including depression, an infection, or a medication side effect. Sometimes, the problem can be treated, and the thinking problems disappear. Other times, the problem is a brain disorder, such as Alzheimer’s disease, which cannot be reversed. Finding the cause of the problems is important to determine the best course of action.

A note about unproven treatments: Some people are tempted by untried or unproven “cures” that claim to make the brain sharper or prevent dementia. Check with your doctor before trying pills, supplements or other products that promise to improve memory or prevent brain disorders. These “treatments” might be unsafe, a waste of money, or both. They might even interfere with other medical treatments. Currently there is no drug or treatment that prevents Alzheimer’s disease or other dementias.

See more resources about cognitive health.

For More Information About Memory Loss and Forgetfulness

NIA Alzheimer’s and related Dementias Education and Referral (ADEAR) Center
1-800-438-4380 (toll-free)
adear@nia.nih.gov
www.nia.nih.gov/alzheimers
The National Institute on Aging’s ADEAR Center offers information and free print publications about Alzheimer’s disease and related dementias for families, caregivers, and health professionals. ADEAR Center staff answer telephone, email, and written requests and make referrals to local and national resources.

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New drug for MS is milestone for patients and research

A new drug, Ocrevus (ocrelizumab), has been approved by the U.S. Food and Drug Administration (FDA) to treat multiple sclerosis (MS). The National Multiple Sclerosis Society says it’s a “game changer” and Mayo Clinic neurologist Dr. Dean Wingerchuk says, “The approval of ocrelizumab is an important milestone both for people with MS and MS research.”

In a news statement released Wed. March 29, Dr. Billy Dunn, director of the Division of Neurology Products in the FDA’s Center for Drug Evaluation and Research says, “This therapy not only provides another treatment option for those with relapsing MS, but for the first time provides an approved therapy for those with primary progressive MS.”

More health and medical news on the Mayo Clinic News Network http://newsnetwork.mayoclinic.org/

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