COVID-19 and influenza co-infection: Difference between revisions

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'''For COVID-19 frequently asked outpatient questions, click [[COVID-19 frequently asked outpatient questions|here]]'''
'''For COVID-19 frequently asked outpatient questions, click [[COVID-19 frequently asked outpatient questions|here]]'''


{{CMG}}; {{AE}}
{{CMG}}; {{AE}} [[User:Zaida Obeidat|Zaida Obeidat, M.D.]][mailto:dr.zaida88@gmail.com]


{{SK}}  
{{SK}}  


==Overview==
==Overview==
In December 2019, a novel [[coronavirus]], known as [[severe]] [[acute respiratory syndrome coronavirus]] 2 ([[SARS-CoV-2]]), was identified as the cause of an [[outbreak]] of [[acute]] [[respiratory]] [[illness]] in Wuhan, China. Since then, there has been a rapid spread of the [[virus]], leading to a global [[pandemic]] of [[coronavirus disease 2019]] (COVID-19). [[Influenza]], commonly known as [[flu]], is an [[infectious disease]] of birds and [[mammal]]s caused by  [[RNA virus]]es of the biological family [[Orthomyxoviridae]] (the influenza viruses). [[Coronavirus disease 2019]] ([[COVID-19]]) and [[Influenza]] share many characteristics, common [[symptoms]] of the co-[[infection]] are [[fever]], [[sore throat]], [[dyspnea]], [[myalgia]], [[cough]], [[headache]], [[fatigue]] and [[malaise]]. <ref name="Merck">{{cite web |author= Merck Manual Home Edition |title=Influenza: Viral Infections |url= http://www.merck.com/mmhe/sec17/ch198/ch198c.html?}}</ref> <ref name="pmid32160148">{{cite journal| author=Wu X, Cai Y, Huang X, Yu X, Zhao L, Wang F | display-authors=etal| title=Co-infection with SARS-CoV-2 and Influenza A Virus in Patient with Pneumonia, China. | journal=Emerg Infect Dis | year= 2020 | volume= 26 | issue= 6 | pages= 1324-1326 | pmid=32160148 | doi=10.3201/eid2606.200299 | pmc=7258479 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32160148  }} </ref> <ref name="pmid32611659">{{cite journal| author=Kondo Y, Miyazaki S, Yamashita R, Ikeda T| title=Coinfection with SARS-CoV-2 and influenza A virus. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 7 | pages=  | pmid=32611659 | doi=10.1136/bcr-2020-236812 | pmc=7358105 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32611659  }} </ref>


==Historical Perspective==
==Historical Perspective==


* COVID-19, also called Sever Acute Respiratory Distress Syndrome Coronavirus 2 (SARS-CoV-2) originated in Wuhan, China in late December 2019. It has caused a significant morbidity and mortality worldwide and has been declared a global pandemic by the WHO.
* [[COVID-19]], also called severe [[Acute Respiratory Distress Syndrome|acute respiratory distress syndrome]] [[coronavirus]] 2 ([[SARS-CoV-2]]) originated in Wuhan, China in late December 2019.
* Influenza occurs mainly during the winter, it is a highly contagious acute viral respiratory infection that causes significant morbidity and mortality worldwide.
* It has been declared a global [[pandemic]] by the [[WHO]] after being caused a significant [[morbidity]] and [[mortality]] worldwide.
* [[Influenza]] is a highly [[contagious]] respiratory [[virus]], it causes an  acute [[respiratory infection]], occurs mainly during the winter, it causes significant [[morbidity]] and [[mortality]] worldwide.
* It can be mild or sever, which may result in [[hospitalization]] or [[death]].
* People at high risk of serious [[complications]] are young children, [[elderly]], and people with [[underlying medical conditions]].
* The total number of [[morbidity]] and [[mortality]] has been declining significantly after the seasonal [[Influenza vaccine]]. <ref name="pmid32399452">{{cite journal| author=Konala VM, Adapa S, Gayam V, Naramala S, Daggubati SR, Kammari CB | display-authors=etal| title=Co-infection with Influenza A and COVID-19. | journal=Eur J Case Rep Intern Med | year= 2020 | volume= 7 | issue= 5 | pages= 001656 | pmid=32399452 | doi=10.12890/2020_001656 | pmc=7213830 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32399452  }} </ref>


==Classification==
==Classification==


* There is no established system for the classification of [[COVID-19]] and [[Influenza]] co-infection.


==Pathophysiology==
==Pathophysiology==


* The exact pathogenesis of co-infection with SARS-CoV-2 and Influenza viruses is not fully understood.


==Causes==
==Causes==


* Coronavirus disease 2019 (COVID-19) and Influenza co-infection are caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and influenza (A or B) virus.


==Differentiating COVID-19 and Influenza co-infection from other Diseases==
==Differentiating COVID-19 and Influenza co-infection from other Diseases==


* Influenza and COVID-19 are both contagious respiratory illnesses, but they are caused by different viruses.  Influenza is caused by infection with influenza viruses and COVID-19 is caused by infection with the coronavirus (SARS-CoV-2). Testing may be needed to help confirm a diagnosis because some of the symptoms of flu and COVID-19 are similar. Influenza and COVID-19 share many characteristics, but there are some key differences between the two.
* [[Influenza]] and [[COVID-19]] are both [[contagious]] [[respiratory]] illnesses, but they are caused by different viruses.   
*[[Influenza]] is caused by [[infection]] with [[influenza viruses]] and [[COVID-19]] is caused by [[infection]] with the [[coronavirus]]2 ([[SARS-CoV-2]]).  
*Testing may be needed to help confirm a [[diagnosis]] because some of the [[symptoms]] of [[flu]] and [[COVID-19]] are similar.  
*[[Influenza]] and [[COVID-19]] share many characteristics, but there are some key differences between the two.
 
{| class="wikitable"
|+
! colspan="3" |This table compares the Influenza and COVID-19: {{cite web|url=https://www.cdc.gov/flu/symptoms/flu-vs-covid19.htm|title=Similarities and Differences between Flu and COVID-19 &#124; CDC|format=|work=|accessdate=}}
|-
!
!Similarities between Covid-19 and Influenza infection
!Differences between Covid-19 and Influenza infection
|-
|'''[[Signs]] and [[symptoms]]'''
|
* Signs and symptoms can vary from [[asymptotic]] (subclinical) to severe symptoms.
 
* Common symptoms include:
** [[Fever]]/[[chills]], [[cough]]
** [[Shortness of breath]]
** F[[fatigue|atigue]]
** [[Sore throat]]
** [[Runny nose]]
** M[[muscle aches|uscle aches]]
** [[Headache]]
** [[Gastrointestinal]] symptoms ([[vomiting]] and [[diarrhea]]).
|
* Change in or loss of [[taste]] or [[smell]] can be a specific [[sign]] of '''[[COVID-19]]'''.
|-
|Incubation Period
|
* It takes one or more days for a person to get [[infected]] and develop symptoms after the exposure.
|
* It takes longer to develop [[symptoms]] in '''[[COVID-19]]''' than [[Influenza]].
* The time range can be vary in '''[[COVID-19]]''', symptoms can appear early in 2 days or late in 14 days.
* In '''[[Influenza]]''', symptoms may develop 2 to 4 days after [[infection]].
|-
|Period of [[Contagiousness]]
|
* A person can spread the [[virus]] for 1 day before the appearance of any [[symptoms]].
|
* The period of [[contagiousness]] is longer in '''[[COVID-19]]''', a person can spread the [[virus]] for about 2 days before having any [[symptoms]] and remain [[contagious]] for at least 10 days after experience any [[signs]] or [[symptoms]].
 
* [[Asymptotic]] or after the symptoms disappeared, It can be [[contagious]] for 10 days after testing positive for '''[[COVID-19]]'''.
* In '''[[Influenza]]''', it can be [[contagious]] for about 1 day before appearing any symptoms.
* Older children and adults can be most [[contagious]] during the first 3-4 days, but may remain [[contagious]] for 7 days of their [[illness]].
* Infants and [[immunocompromised]] patients can be [[contagious]] for longer.
|-
|'''How does it spread'''
|
* '''Both''' can spread from [[person-to-person]], people in [[close contact]] (within 6 feet) with one another.
* Mainly by [[droplets]] from [[sick]] people when [[cough]], [[sneeze]], or [[talk]].
* [[Physical contact]] or [[touching]] their own [[face]], [[mouth]], [[nose]] or [[eye]] after touching [[contaminated]] surfaces or objects.
* Asymptotic or people with very mild symptoms.
|
* '''[[COVID-19]]''' is very [[contagious]] among certain [[populations]] and age groups than [[Influenza]].
* The SARS-CoV-2 virus can quickly and easily spread to a lot of people, '''COVID-19''' has been observed to have more super spreading events than Influenza.
|-
|'''[[High risk]] groups'''
|
* Highest risk groups to develop [[severe illness]] and [[complications]] in '''both''' [[COVID-19]] and [[Influenza]] includes:
 
- [[Elderly]].
 
- People with underlying medical conditions.
 
- [[Pregnant]][ women. 
| - School-aged children infected with '''[[COVID-19]]''' are at higher risk of [[Multisystem Inflammatory Syndrome in Children]] ([[MIS-C]]) which is rare but sever complication.
 
-  The risk of [[complications]] in '''[[Influenza]]''' for [[young]] [[healthy]] [[children]] are higher compared to [[COVID-19]].
 
- [[Infants]] and children with underlying medical conditions are at the highest risk for '''both''' [[Influenza]] and [[COVID-19]].
|-
|'''[[Complications]]'''
|
*[[Complications]] in '''both''' can include:
** [[Pneumonia]]
** [[Respiratory failure]]
** [[Acute respiratory distress syndrome]] ([[ARDS]])
** [[Sepsis]]
** - [[Heart attacks]] or [[myocardial infarction]] ([[MI]])
** - [[Multiple organ failure]] ([[renal failure]], [[respiratory failure]], [[shock]])
** Worsening of [[chronic medical conditions]]
** [[Heart]], [[muscle]], or [[brain]] [[tissues]] [[inflammations]].
|
*'''[[COVID-19]]''' can associate with:
**[[Blood clots]] in [[heart|the heart]], [[lungs]], or[[brain|, brian]] [[blood vessels]].
** [[Multisystem Inflammatory Syndrome in Children]] ([[MIS-C]]).
|-
|'''[[Treatment]]'''
| - [[Supportive]] medical care to relieve [[symptoms]] and [[complications]].
|
*'''[[COVID-19]]''':
 
- [[The National Institute of Health]] ([[NIH]]) has developed guidance on treatment, which will be updated regularly as new evidence on [[safety]] and [[efficacy]] of drugs come out.
 
- There are no drugs approved by the FDA to prevent or treat COVID-19.
 
- [[Remdesivir]] ([[antiviral agent]]) is available under [[Emergency Use Authorization]] ([[EUA]]), and being explored as a treatment for COVID-19.
 
*'''[[Influenza]]''':
 
- Hospitalized patients with Influenza or high risk group are recommended to be treated with [[antiviral drugs]].
|-
|'''[[Vaccine]]'''
| - [[Vaccines]] for [[COVID-19]] and [[Influenza]] must be approved by the [[FDA]].
|<nowiki>- There are multiple </nowiki>[[vaccines]] to protect against 3 or 4 [[viruses]] that cause the '''[[Influenza]]''' produced annually and approved by the [[FDA]].
 
- There is no [[Vaccine]] to [[COVID-19]] yet but researchers and vaccine developers are working on developing a [[vaccine]] to prevent '''[[COVID-19]]'''.
|}
 
 
 
 
* [[Coronavirus disease 2019]] ([[COVID-19]]) and [[Influenza]] co-infection, must be differentiated from other diseases that may cause [[fever]], [[cough]], [[shortness of breath]] and [[tachypnea]]. The table below, summarizes the differential diagnosis:
{|
! rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Diseases
! rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Past medical history
! colspan="7" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Symptoms
! colspan="3" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Physical Examination
! colspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Diagnostic tests
! rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Other Findings
|-
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Headache
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Chest pain
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Wheezing
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Dyspnea
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Chest Tenderness
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Cough
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Hemoptysis
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Fever
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Tachypnea
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Tachycardia
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |CT/MRI
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Chest X-ray
|-
! style="background: #DCDCDC; padding: 5px; text-align: center;" | [[COVID-19]] and [[Influenza]] co-[[infection]]
| align="left" style="background:#F5F5F5;" |
* Possible exposure to infected individuals.
| align="center" style="background:#F5F5F5;" | +/-
| align="center" style="background:#F5F5F5;" | +/-
| align="center" style="background:#F5F5F5;" | -
| align="center" style="background:#F5F5F5;" | +
| align="center" style="background:#F5F5F5;" | +/-
| align="center" style="background:#F5F5F5;" | +
| align="center" style="background:#F5F5F5;" | +/-
| align="center" style="background:#F5F5F5;" | +
| align="center" style="background:#F5F5F5;" | +
| align="center" style="background:#F5F5F5;" | +
| align="center" style="background:#F5F5F5;" |
* Chest CT findings: bilateral ground glass consolidations.
| align="center" style="background:#F5F5F5;" |
* Chest X-ray: consolidation, peripheral ground glass opacity.
| align="left" style="background:#F5F5F5;"  | 
|-
 
 
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Pneumonia]]
| align="left" style="background:#F5F5F5;" |
* [[Ill contact]]
* [[Travel]]
* [[Smoke]]
* [[Diabetic]]
* Recent [[hospitalization]]
* [[COPD]]
| align="center" style="background:#F5F5F5;" | +/-
| align="center" style="background:#F5F5F5;" | +
| align="center" style="background:#F5F5F5;" | -
| align="center" style="background:#F5F5F5;" | +
| align="center" style="background:#F5F5F5;" | -
| align="center" style="background:#F5F5F5;" | +
| align="center" style="background:#F5F5F5;" | -
| align="center" style="background:#F5F5F5;" | +
| align="center" style="background:#F5F5F5;" | +
| align="center" style="background:#F5F5F5;" | +
| align="center" style="background:#F5F5F5;" |
* Chest CT findings: [[Consolidation]] ([[alveolar]]/[[lobar]] [[pneumonia]]), [[Peribronchial]] [[nodules]] ([[bronchopneumonia]])
* [[Ground-glass]] [[opacity]]
| align="center" style="background:#F5F5F5;" |
* Chest X-ray: [[Consolidation]] ([[alveolar]]/[[lobar]] [[pneumonia]]), [[Peribronchial]] [[nodules]] ([[bronchopneumonia]], [[Ground-glass]] [[opacity]], [[Abscess]], [[Pleural effusion]]
| align="left" style="background:#F5F5F5;" |
|-
! style="background: #DCDCDC; padding: 5px; text-align: center;" | [[Chronic obstructive pulmonary disease]] ([[COPD]])
| align="left" style="background:#F5F5F5;" |
* [[Smoking]]
* [[Alpha-1 antitrypsin deficiency]]
* Increased [[sputum]] production ([[chronic bronchitis]])
* [[Cough]]
| align="center" style="background:#F5F5F5;" | -
| align="center" style="background:#F5F5F5;" | -
| align="center" style="background:#F5F5F5;" | +
| align="center" style="background:#F5F5F5;" | +
| align="center" style="background:#F5F5F5;" | -
| align="center" style="background:#F5F5F5;" | +
| align="center" style="background:#F5F5F5;" | -
| align="center" style="background:#F5F5F5;" | -
| align="center" style="background:#F5F5F5;" | +
| align="center" style="background:#F5F5F5;" | +
| align="center" style="background:#F5F5F5;" |
* Chest CT findings: [[Chronic bronchitis]] may show [[bronchial wall thickening]], [[scarring]] with [[bronchovascular]] [[irregularity]], [[fibrosis]]
[[Emphysema]] may show [[alveolar septal destruction]] and [[airspace enlargement]] ([[Centrilobular]]- [[upper lobe]], [[panlobular]]- [[lower lobe]])
[[Giant bubbles]]
* On MRI: Increased diameter of [[pulmonary arteries]], [[Peripheral pulmonary vasculature attentuation]], [[Loss of retrosternal airspace due to right ventricular enlargement]]
[[Hyperpolarized Helium MRI may show progressively poor ventilation and destruction of lung]]
| align="center" style="background:#F5F5F5;" |
* Chest X-ray: [[Enlarged]] [[lung]] shadows ([[emphysema]]), [[Flattening of diaphragm]] ([[emphysema]])
| align="left" style="background:#F5F5F5;" |
* [[Alpha 1 antitrypsin deficiency]] may be associated with [[hepatomegaly]]
|-
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Tuberculosis]]
| align="left" style="background:#F5F5F5;" |
* [[Immunocompromised host]] e.g. [[HIV]] [[infection]]
* [[malnutrition]]
* [[smoking]]
* [[diabetes]]
* [[alcohol abuse]]
* indoor [[air pollution]] <ref name="pmid19394122">{{cite journal| author=Lönnroth K, Jaramillo E, Williams BG, Dye C, Raviglione M| title=Drivers of tuberculosis epidemics: the role of risk factors and social determinants. | journal=Soc Sci Med | year= 2009 | volume= 68 | issue= 12 | pages= 2240-6 | pmid=19394122 | doi=10.1016/j.socscimed.2009.03.041 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19394122  }} </ref>
| align="center" style="background:#F5F5F5;" | +
| align="center" style="background:#F5F5F5;" | +
| align="center" style="background:#F5F5F5;" | -
| align="center" style="background:#F5F5F5;" | +
| align="center" style="background:#F5F5F5;" | -
| align="center" style="background:#F5F5F5;" | +
| align="center" style="background:#F5F5F5;" | +
| align="center" style="background:#F5F5F5;" | +
| align="center" style="background:#F5F5F5;" | +
| align="center" style="background:#F5F5F5;" | +
| align="center" style="background:#F5F5F5;" |
*[[CT scan]] findings:
**[[Primary]] [[tuberculousis]]: [[lobar]] [[consolidation]] ([[well defined]], [[dense]], [[homogenous]], and confined to a [[segment]] or [[lobe]]), [[middle]] or [[lower]] [[lobe]] involvement is very common, small [[cavities]], with [[mediastinal]] or [[hilar]] [[adenopathy]].
**Reactivation tuberculosis:  most commonly involved [[segments]] are the [[upper]] [[posterior]] [[segment]] of [[upper lobe]] and the [[superior segment]] of the [[lower lobe]]. [[Cavitation]] is associated with [[bronchogenic]] spread of the disease. seen in more than 50% of cases, usually [[multiple]] and involves [[thick]] [[wall]]s without an [[air fluid level]] (seen as multiple [[ill-defined]] 5- to 10-mm [[nodules]] that usually involve the dependent [[lung]] zone).  <ref name="pmid28185620">{{cite journal| author=Lyon SM, Rossman MD| title=Pulmonary Tuberculosis. | journal=Microbiol Spectr | year= 2017 | volume= 5 | issue= 1 | pages=  | pmid=28185620 | doi=10.1128/microbiolspec.TNMI7-0032-2016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28185620  }} </ref>
| align="center" style="background:#F5F5F5;" |
*[[Chest]] [[X-ray]]: [[lobular]] [[infiltrate]] with [[bilateral]] [[hilar]] [[adenopathy]]. <ref name="pmid28185620">{{cite journal| author=Lyon SM, Rossman MD| title=Pulmonary Tuberculosis. | journal=Microbiol Spectr | year= 2017 | volume= 5 | issue= 1 | pages=  | pmid=28185620 | doi=10.1128/microbiolspec.TNMI7-0032-2016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28185620  }} </ref>
| align="left" style="background:#F5F5F5;" |
* [[Fever]] usually develops during sleep, accompanied with [[night sweats]].
* [[Malaise]], [[irritability]], [[weakness]], unusual [[fatigue]], and [[weight loss]], may be present.
* [[Chest pain]] may be localized and [[pleuritic]]. <ref name="pmid28185620">{{cite journal| author=Lyon SM, Rossman MD| title=Pulmonary Tuberculosis. | journal=Microbiol Spectr | year= 2017 | volume= 5 | issue= 1 | pages=  | pmid=28185620 | doi=10.1128/microbiolspec.TNMI7-0032-2016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28185620  }} </ref>
|-
|}


==Epidemiology and Demographics==
==Epidemiology and Demographics==


* Patients of all age groups may develop COVID-19 and influenza co-infection.
* The countries that got affected by the pandemic are:
** China
** Italy
** India
** The United States
** Brazil


==Risk Factors==
==Risk Factors==


* Common risk factors in the development of  COVID-19 and influenza infection include:
**[[Immunocompromised]] ( e.g. [[chronic infections]] or [[cancer patients]]).
** It's more common among the workers who works in [[close contact]].
** It's common among the [[population]] who doesn't maintain proper [[social distancing]].
* To view the COVID-19 risk factors, [[COVID-19 risk factors|click here]].


==Screening==
==Screening==


* There is [[insufficient]] evidence to recommend routine [[screening]] for [[COVID-19]] and [[Influenza]] [[co-infection]].
* For the [[prevention]] and control of [[infection]], on January 24th 2020 Taiwan Centers for Disease Control started testing of [[SARS-CoV-2]] for people suspected with COVID-19. Until February 28th, 2015 cases were screened and 34 of them were diagnosed of COVID-19. During this time, 43 [[flu-like]] [[symptomatic]] patients were screened in China Medical University Hospital and 2 of them were confirmed to be positive for [[SARS-CoV-2]]. <ref name="pmid2220574">{{cite journal| author=Sevilla DC, Wagner NB, Anderson WD, Ideker RE, Reimer KA, Mikat EM | display-authors=etal| title=Sensitivity of a set of myocardial infarction screening criteria in patients with anatomically documented single and multiple infarcts. | journal=Am J Cardiol | year= 1990 | volume= 66 | issue= 10 | pages= 792-5 | pmid=2220574 | doi=10.1016/0002-9149(90)90353-3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2220574  }} </ref>
* To establish the [[diagnostic]] protocol for the co-infection of [[COVID-19]] and other [[respiratory infections]] like [[Influenza A]] and B, they comparatively analyzed the clinical presentations, laboratory data, radiologic findings, and travel and exposure contact histories, of COVID-19 patients who suspected to have other respiratory infections.
* [[SARS-CoV-2]] detection by real-time reverse transcription [[polymerase chain reaction]] (rRT-PCR) and Respiratory [[pathogens]] detection by FilmArray™ Respiratory Panel were used for [[screening]].


==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==


* [[SARS-CoV-2]] and [[Influenza]] co-infection has a wide range of clinical presentation, most of the [[symptoms]] are similar, the symptoms can be vary from [[asymptomatic]] to [[severe disease]] ([[ARDS]]) which require the [[ICU]] admission.


===Natural History===
* The main [[complications]] for the patients according to a study conducted in Wuhan, China, were [[acute respiratory distress syndrome]], [[acute]] [[liver]] [[injury]], and [[diarrhea]]. <ref name="pmid32196707">{{cite journal| author=Ding Q, Lu P, Fan Y, Xia Y, Liu M| title=The clinical characteristics of pneumonia patients coinfected with 2019 novel coronavirus and influenza virus in Wuhan, China. | journal=J Med Virol | year= 2020 | volume= | issue=  | pages=  | pmid=32196707 | doi=10.1002/jmv.25781 | pmc=7228290 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32196707  }} </ref>


* [[SARS-CoV-2]] and [[Influenza]] co-infection did not significantly worsen the symptoms and outcomes. <ref name="pmid32522037">{{cite journal| author=Konala VM, Adapa S, Naramala S, Chenna A, Lamichhane S, Garlapati PR | display-authors=etal| title=A Case Series of Patients Coinfected With Influenza and COVID-19. | journal=J Investig Med High Impact Case Rep | year= 2020 | volume= 8 | issue=  | pages= 2324709620934674 | pmid=32522037 | doi=10.1177/2324709620934674 | pmc=7290261 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32522037  }} </ref>


===Complications===
==Diagnosis==
===Diagnostic Study of Choice===


* The [[diagnosis]] of [[COVID-19]] and [[Influenza]] co-infection can be established by the following investigations: <ref name="pmid32522037">{{cite journal| author=Konala VM, Adapa S, Naramala S, Chenna A, Lamichhane S, Garlapati PR | display-authors=etal| title=A Case Series of Patients Coinfected With Influenza and COVID-19. | journal=J Investig Med High Impact Case Rep | year= 2020 | volume= 8 | issue=  | pages= 2324709620934674 | pmid=32522037 | doi=10.1177/2324709620934674 | pmc=7290261 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32522037  }} </ref>
**[[SARS-CoV-2]] detection by real-time reverse transcription [[polymerase chain reaction]] (rRT-PCR) from nasopharyngeal swab sample or bronchoalveolar lavage fluid.
**[[Respiratory]] [[pathogens]] detection by [[FilmArray™ Respiratory Panel]]. <ref name="pmid: 32220574">{{cite journal| author=Hsih WH, Cheng MY, Ho MW, Chou CH, Lin PC, Chi CY | display-authors=etal| title=Featuring COVID-19 cases via screening symptomatic patients with epidemiologic link during flu season in a medical center of central Taiwan. | journal=J Microbiol Immunol Infect | year= 2020 | volume= 53 | issue= 3 | pages= 459-466 | pmid=: 32220574 | doi=10.1016/j.jmii.2020.03.008 | pmc=7102665 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32220574  }} </ref>
**[[Rapid nucleic acid amplification test]] for [[influenza A]] and B.<ref name="pmid32423586">{{cite journal| author=Cuadrado-Payán E, Montagud-Marrahi E, Torres-Elorza M, Bodro M, Blasco M, Poch E | display-authors=etal| title=SARS-CoV-2 and influenza virus co-infection. | journal=Lancet | year= 2020 | volume= 395 | issue= 10236 | pages= e84 | pmid=32423586 | doi=10.1016/S0140-6736(20)31052-7 | pmc=7200126 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32423586  }} </ref>
**[[Chest Tomography]] images showing peripheral and bilateral multiple [[plaques]] or [[nodular]] ground-glass opacities.<ref name="pmid32388472">{{cite journal| author=Yin S, Peng Y, Ren Y, Hu M, Tang L, Xiang Z | display-authors=etal| title=The implications of preliminary screening and diagnosis: Clinical characteristics of 33 mild patients with SARS-CoV-2 infection in Hunan, China. | journal=J Clin Virol | year= 2020 | volume= 128 | issue=  | pages= 104397 | pmid=32388472 | doi=10.1016/j.jcv.2020.104397 | pmc=7192082 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32388472  }} </ref>


===Prognosis===
===Symptoms===


* According to a study conducted in Wuhan, China, common symptoms at onset of illness included: <ref name="pmid32196707">{{cite journal| author=Ding Q, Lu P, Fan Y, Xia Y, Liu M| title=The clinical characteristics of pneumonia patients coinfected with 2019 novel coronavirus and influenza virus in Wuhan, China. | journal=J Med Virol | year= 2020 | volume=  | issue=  | pages=  | pmid=32196707 | doi=10.1002/jmv.25781 | pmc=7228290 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32196707  }} </ref> <ref name="pmid32565366">{{cite journal| author=D'Abramo A, Lepore L, Palazzolo C, Barreca F, Liuzzi G, Lalle E | display-authors=etal| title=Acute respiratory distress syndrome due to SARS-CoV-2 and Influenza A co-infection in an Italian patient: Mini-review of the literature. | journal=Int J Infect Dis | year= 2020 | volume= 97 | issue=  | pages= 236-239 | pmid=32565366 | doi=10.1016/j.ijid.2020.06.056 | pmc=7301795 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32565366  }} </ref>  <ref name="pmid32398954">{{cite journal| author=Awadasseid A, Wu Y, Tanaka Y, Zhang W| title=Initial success in the identification and management of the coronavirus disease 2019 (COVID-19) indicates human-to-human transmission in Wuhan, China. | journal=Int J Biol Sci | year= 2020 | volume= 16 | issue= 11 | pages= 1846-1860 | pmid=32398954 | doi=10.7150/ijbs.45018 | pmc=7211182 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32398954  }} </ref>
**[[Fever]]
**[[Cough]]
**[[Shortness of breath]]
**[[Sore throat]]
**[[Myalgia]]
**[[Fatigue]]
**[[Headache]]
**[[Expectoration]]


==Diagnosis==
===Physical Examination===
===Diagnostic Study of Choice===


* Common physical examination findings of the co-infection with COVID-19 and Influenza include: [[fever]], [[dry cough]], [[tachypnea]], and [[tachycardia]].
* Decrease in [[oxygen saturation]] [[SpO2]](< 93%), the first [[manifestation]] of [[deterioration]] of [[inflammatory]] [[lung]] [[injury]].


===Physical Examination===
===Laboratory Findings===
Common laboratory findings associated with covid-19 and influenza coinfection are:


*[[Lymphocytopenia]] (80% of patients)
*[[Thrombocytopenia]]
* Elevated [[liver functions]] [[AST]], [[ALT]] (40%)
* Elevated [[CRP]] (80%)
* Elevated [[ESR]] (30%)
* Elevated [[BUN]] (30%)
* Elevated [[Creatinine]] (70%)
* Elevated [[ferritin]] (70%)
* Elevated [[fibrinogen]]
* Elevated [[D-dimer]]
* Elevated [[interleukin-6]]
* Elevated [[lactic acid]]
* Elevated [[LDH]]
* Elevated [[creatine kinase]] <ref name="pmid32196707">{{cite journal| author=Ding Q, Lu P, Fan Y, Xia Y, Liu M| title=The clinical characteristics of pneumonia patients coinfected with 2019 novel coronavirus and influenza virus in Wuhan, China. | journal=J Med Virol | year= 2020 | volume=  | issue=  | pages=  | pmid=32196707 | doi=10.1002/jmv.25781 | pmc=7228290 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32196707  }} </ref> <ref name="pmid32399452">{{cite journal| author=Konala VM, Adapa S, Gayam V, Naramala S, Daggubati SR, Kammari CB | display-authors=etal| title=Co-infection with Influenza A and COVID-19. | journal=Eur J Case Rep Intern Med | year= 2020 | volume= 7 | issue= 5 | pages= 001656 | pmid=32399452 | doi=10.12890/2020_001656 | pmc=7213830 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32399452  }} </ref> <ref name="pmid32522037">{{cite journal| author=Konala VM, Adapa S, Naramala S, Chenna A, Lamichhane S, Garlapati PR | display-authors=etal| title=A Case Series of Patients Coinfected With Influenza and COVID-19. | journal=J Investig Med High Impact Case Rep | year= 2020 | volume= 8 | issue=  | pages= 2324709620934674 | pmid=32522037 | doi=10.1177/2324709620934674 | pmc=7290261 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32522037  }} </ref> <ref name="pmid32565366">{{cite journal| author=D'Abramo A, Lepore L, Palazzolo C, Barreca F, Liuzzi G, Lalle E | display-authors=etal| title=Acute respiratory distress syndrome due to SARS-CoV-2 and Influenza A co-infection in an Italian patient: Mini-review of the literature. | journal=Int J Infect Dis | year= 2020 | volume= 97 | issue=  | pages= 236-239 | pmid=32565366 | doi=10.1016/j.ijid.2020.06.056 | pmc=7301795 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32565366  }} </ref>


===Laboratory Findings===
===Imaging studies===


* [[Chest]] [[X-ray]] images showing [[bilateral]]/[[peripheral]] [[opacities]] with [[lower]] [[lobes]] [[predominant]].


* Chest Tomography images showing [[peripheral]] and [[bilateral]] ground-glass consolidation peripherally. <ref name="pmid32565366">{{cite journal| author=D'Abramo A, Lepore L, Palazzolo C, Barreca F, Liuzzi G, Lalle E | display-authors=etal| title=Acute respiratory distress syndrome due to SARS-CoV-2 and Influenza A co-infection in an Italian patient: Mini-review of the literature. | journal=Int J Infect Dis | year= 2020 | volume= 97 | issue=  | pages= 236-239 | pmid=32565366 | doi=10.1016/j.ijid.2020.06.056 | pmc=7301795 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32565366  }} </ref> <ref name="pmid32398954">{{cite journal| author=Awadasseid A, Wu Y, Tanaka Y, Zhang W| title=Initial success in the identification and management of the coronavirus disease 2019 (COVID-19) indicates human-to-human transmission in Wuhan, China. | journal=Int J Biol Sci | year= 2020 | volume= 16 | issue= 11 | pages= 1846-1860 | pmid=32398954 | doi=10.7150/ijbs.45018 | pmc=7211182 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32398954  }} </ref> <ref name="pmid32611659">{{cite journal| author=Kondo Y, Miyazaki S, Yamashita R, Ikeda T| title=Coinfection with SARS-CoV-2 and influenza A virus. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 7 | pages=  | pmid=32611659 | doi=10.1136/bcr-2020-236812 | pmc=7358105 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32611659  }} </ref> <ref name="pmid32368495">{{cite journal| author=Azekawa S, Namkoong H, Mitamura K, Kawaoka Y, Saito F| title=Co-infection with SARS-CoV-2 and influenza A virus. | journal=IDCases | year= 2020 | volume= 20 | issue=  | pages= e00775 | pmid=32368495 | doi=10.1016/j.idcr.2020.e00775 | pmc=7184249 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32368495  }} </ref>


==Treatment==
==Treatment==
===Medical Therapy===
===Medical Therapy===


* There is no [[treatment]] available for [[COVID-19]], the mainstay of therapy is [[supportive]] care.
* [[Hydroxychloroquine]], [[azithromycin]], [[Interferon-l]], [[glucocorticoids]], [[interleukin antagonists]], [[Ulinastatin]], [[intravenous immunoglobulins]], and [[plasmapheresis]] are already used in clinical practice for [[COVID-19]] and showed initial positive outcomes. <ref name="pmid32196707">{{cite journal| author=Ding Q, Lu P, Fan Y, Xia Y, Liu M| title=The clinical characteristics of pneumonia patients coinfected with 2019 novel coronavirus and influenza virus in Wuhan, China. | journal=J Med Virol | year= 2020 | volume=  | issue=  | pages=  | pmid=32196707 | doi=10.1002/jmv.25781 | pmc=7228290 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32196707  }} </ref>
* The National Institutes of Health (NIH) [[COVID-19]] treatment guidelines recommend [[Remdesivir]] for [[hospitalised]] patients with severe [[COVID-19]]. <ref name="pmid2611659">{{cite journal| author=Schwartz L, Atlas D| title=Synergy between membrane depolarization and muscarinic receptor activation leads to potentiation of neurotransmitter release (II) | journal=Brain Res | year= 1989 | volume= 503 | issue= 1 | pages= 62-7 | pmid=2611659 | doi=10.1016/0006-8993(89)91704-6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2611659  }} </ref>
* Severe disease require [[intubation]] and [[mechanical ventilation]].
* [[Dexamthasone]] is helpful in [[hospitalized]] and [[oxygen dependent]] patients with [[COVID-19]].
* [[Antiviral]] agents ([[Oseltamivir]], [[Zanamivir]], [[Peramivir]], and [[Baloxavir]]) are recommended by the [[CDC]] for all [[hospitalized]] and [[high risk]] [[patient]]s with [[Influenza]].
===Surgery===
* Surgical intervention is not recommended for the management of [[COVID-19]] and [[Influenza]] co-infection.
===Primary Prevention===
* The [[CDC]] recommends getting the [[Influenza vaccine]], there are multiple [[FDA]]-licensed [[influenza]] vaccines produced annually to protect against the 3 or 4 [[influenza]] viruses.
* There is currently no vaccine to prevent [[COVID-19]]. The best way to prevent [[infection]] is to avoid being exposed to the [[virus]] by:
** Washing [[hands]] regularly with soap and water for at least 20 seconds or using a [[hand sanitizer]] with 60% [[alcohol]].
** Wearing a cloth [[face mask]] and avoid touching [[eyes]], [[nose]], and [[mouth]] with unwashed [[hands]].
** Covering [[mouth]] and [[nose]] when [[cough]] or [[sneeze]].
** Maintaining 6 feet distance from other people and avoiding [[close contact]].
** Refraining [[smoking]] and other activities that weaken the [[lungs]].
** Clean and disinfect frequently touched surfaces and objects.
===Secondary prevention===


* There are no [[secondary prevention]] measures of [[COVID-19]] and [[Influenza]] co-infection.
* The [[secondary prevention]] measures of [[COVID-19]] include measures to make sure that an [[infected]] individual does not transfer the [[disease]] to others.
* [[WHO]] recommends for patients with suspected or confirmed COVID-19 with mild [[symptoms]] to stay home and self [[isolation]] from other family members at home.
* To read more about [[COVID-19 secondary prevention]], [[COVID-19 secondary prevention|Click here]].


==References==
==References==
{{reflist|2}}

Latest revision as of 16:29, 5 August 2020

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For COVID-19 frequently asked inpatient questions, click here

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Zaida Obeidat, M.D.[2]

Synonyms and keywords:

Overview

In December 2019, a novel coronavirus, known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was identified as the cause of an outbreak of acute respiratory illness in Wuhan, China. Since then, there has been a rapid spread of the virus, leading to a global pandemic of coronavirus disease 2019 (COVID-19). Influenza, commonly known as flu, is an infectious disease of birds and mammals caused by RNA viruses of the biological family Orthomyxoviridae (the influenza viruses). Coronavirus disease 2019 (COVID-19) and Influenza share many characteristics, common symptoms of the co-infection are fever, sore throat, dyspnea, myalgia, cough, headache, fatigue and malaise. [1] [2] [3]

Historical Perspective

Classification

  • There is no established system for the classification of COVID-19 and Influenza co-infection.

Pathophysiology

  • The exact pathogenesis of co-infection with SARS-CoV-2 and Influenza viruses is not fully understood.

Causes

  • Coronavirus disease 2019 (COVID-19) and Influenza co-infection are caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and influenza (A or B) virus.

Differentiating COVID-19 and Influenza co-infection from other Diseases

This table compares the Influenza and COVID-19: "Similarities and Differences between Flu and COVID-19 | CDC".
Similarities between Covid-19 and Influenza infection Differences between Covid-19 and Influenza infection
Signs and symptoms
  • Signs and symptoms can vary from asymptotic (subclinical) to severe symptoms.
Incubation Period
  • It takes one or more days for a person to get infected and develop symptoms after the exposure.
Period of Contagiousness
  • A person can spread the virus for 1 day before the appearance of any symptoms.
How does it spread
  • COVID-19 is very contagious among certain populations and age groups than Influenza.
  • The SARS-CoV-2 virus can quickly and easily spread to a lot of people, COVID-19 has been observed to have more super spreading events than Influenza.
High risk groups

- Elderly.

- People with underlying medical conditions.

- Pregnant[ women.

- School-aged children infected with COVID-19 are at higher risk of Multisystem Inflammatory Syndrome in Children (MIS-C) which is rare but sever complication.

- The risk of complications in Influenza for young healthy children are higher compared to COVID-19.

- Infants and children with underlying medical conditions are at the highest risk for both Influenza and COVID-19.

Complications
Treatment - Supportive medical care to relieve symptoms and complications.

- The National Institute of Health (NIH) has developed guidance on treatment, which will be updated regularly as new evidence on safety and efficacy of drugs come out.

- There are no drugs approved by the FDA to prevent or treat COVID-19.

- Remdesivir (antiviral agent) is available under Emergency Use Authorization (EUA), and being explored as a treatment for COVID-19.

- Hospitalized patients with Influenza or high risk group are recommended to be treated with antiviral drugs.

Vaccine - Vaccines for COVID-19 and Influenza must be approved by the FDA. - There are multiple vaccines to protect against 3 or 4 viruses that cause the Influenza produced annually and approved by the FDA.

- There is no Vaccine to COVID-19 yet but researchers and vaccine developers are working on developing a vaccine to prevent COVID-19.



Diseases Past medical history Symptoms Physical Examination Diagnostic tests Other Findings
Headache Chest pain Wheezing Dyspnea Chest Tenderness Cough Hemoptysis Fever Tachypnea Tachycardia CT/MRI Chest X-ray
COVID-19 and Influenza co-infection
  • Possible exposure to infected individuals.
+/- +/- - + +/- + +/- + + +
  • Chest CT findings: bilateral ground glass consolidations.
  • Chest X-ray: consolidation, peripheral ground glass opacity.
Pneumonia +/- + - + - + - + + +
Chronic obstructive pulmonary disease (COPD) - - + + - + - - + +

Emphysema may show alveolar septal destruction and airspace enlargement (Centrilobular- upper lobe, panlobular- lower lobe) Giant bubbles

Hyperpolarized Helium MRI may show progressively poor ventilation and destruction of lung

Tuberculosis + + - + - + + + + +

Epidemiology and Demographics

  • Patients of all age groups may develop COVID-19 and influenza co-infection.
  • The countries that got affected by the pandemic are:
    • China
    • Italy
    • India
    • The United States
    • Brazil

Risk Factors

Screening

Natural History, Complications, and Prognosis

Diagnosis

Diagnostic Study of Choice

Symptoms

Physical Examination

Laboratory Findings

Common laboratory findings associated with covid-19 and influenza coinfection are:

Imaging studies

Treatment

Medical Therapy

Surgery

  • Surgical intervention is not recommended for the management of COVID-19 and Influenza co-infection.

Primary Prevention

Secondary prevention

References

  1. Merck Manual Home Edition. "Influenza: Viral Infections".
  2. Wu X, Cai Y, Huang X, Yu X, Zhao L, Wang F; et al. (2020). "Co-infection with SARS-CoV-2 and Influenza A Virus in Patient with Pneumonia, China". Emerg Infect Dis. 26 (6): 1324–1326. doi:10.3201/eid2606.200299. PMC 7258479 Check |pmc= value (help). PMID 32160148 Check |pmid= value (help).
  3. 3.0 3.1 Kondo Y, Miyazaki S, Yamashita R, Ikeda T (2020). "Coinfection with SARS-CoV-2 and influenza A virus". BMJ Case Rep. 13 (7). doi:10.1136/bcr-2020-236812. PMC 7358105 Check |pmc= value (help). PMID 32611659 Check |pmid= value (help).
  4. 4.0 4.1 Konala VM, Adapa S, Gayam V, Naramala S, Daggubati SR, Kammari CB; et al. (2020). "Co-infection with Influenza A and COVID-19". Eur J Case Rep Intern Med. 7 (5): 001656. doi:10.12890/2020_001656. PMC 7213830 Check |pmc= value (help). PMID 32399452 Check |pmid= value (help).
  5. Lönnroth K, Jaramillo E, Williams BG, Dye C, Raviglione M (2009). "Drivers of tuberculosis epidemics: the role of risk factors and social determinants". Soc Sci Med. 68 (12): 2240–6. doi:10.1016/j.socscimed.2009.03.041. PMID 19394122.
  6. 6.0 6.1 6.2 Lyon SM, Rossman MD (2017). "Pulmonary Tuberculosis". Microbiol Spectr. 5 (1). doi:10.1128/microbiolspec.TNMI7-0032-2016. PMID 28185620.
  7. Sevilla DC, Wagner NB, Anderson WD, Ideker RE, Reimer KA, Mikat EM; et al. (1990). "Sensitivity of a set of myocardial infarction screening criteria in patients with anatomically documented single and multiple infarcts". Am J Cardiol. 66 (10): 792–5. doi:10.1016/0002-9149(90)90353-3. PMID 2220574.
  8. 8.0 8.1 8.2 8.3 Ding Q, Lu P, Fan Y, Xia Y, Liu M (2020). "The clinical characteristics of pneumonia patients coinfected with 2019 novel coronavirus and influenza virus in Wuhan, China". J Med Virol. doi:10.1002/jmv.25781. PMC 7228290 Check |pmc= value (help). PMID 32196707 Check |pmid= value (help).
  9. 9.0 9.1 9.2 Konala VM, Adapa S, Naramala S, Chenna A, Lamichhane S, Garlapati PR; et al. (2020). "A Case Series of Patients Coinfected With Influenza and COVID-19". J Investig Med High Impact Case Rep. 8: 2324709620934674. doi:10.1177/2324709620934674. PMC 7290261 Check |pmc= value (help). PMID 32522037 Check |pmid= value (help).
  10. Hsih WH, Cheng MY, Ho MW, Chou CH, Lin PC, Chi CY; et al. (2020). "Featuring COVID-19 cases via screening symptomatic patients with epidemiologic link during flu season in a medical center of central Taiwan". J Microbiol Immunol Infect. 53 (3): 459–466. doi:10.1016/j.jmii.2020.03.008. PMC 7102665 Check |pmc= value (help). PMID 32220574 : 32220574 Check |pmid= value (help).
  11. Cuadrado-Payán E, Montagud-Marrahi E, Torres-Elorza M, Bodro M, Blasco M, Poch E; et al. (2020). "SARS-CoV-2 and influenza virus co-infection". Lancet. 395 (10236): e84. doi:10.1016/S0140-6736(20)31052-7. PMC 7200126 Check |pmc= value (help). PMID 32423586 Check |pmid= value (help).
  12. Yin S, Peng Y, Ren Y, Hu M, Tang L, Xiang Z; et al. (2020). "The implications of preliminary screening and diagnosis: Clinical characteristics of 33 mild patients with SARS-CoV-2 infection in Hunan, China". J Clin Virol. 128: 104397. doi:10.1016/j.jcv.2020.104397. PMC 7192082 Check |pmc= value (help). PMID 32388472 Check |pmid= value (help).
  13. 13.0 13.1 13.2 D'Abramo A, Lepore L, Palazzolo C, Barreca F, Liuzzi G, Lalle E; et al. (2020). "Acute respiratory distress syndrome due to SARS-CoV-2 and Influenza A co-infection in an Italian patient: Mini-review of the literature". Int J Infect Dis. 97: 236–239. doi:10.1016/j.ijid.2020.06.056. PMC 7301795 Check |pmc= value (help). PMID 32565366 Check |pmid= value (help).
  14. 14.0 14.1 Awadasseid A, Wu Y, Tanaka Y, Zhang W (2020). "Initial success in the identification and management of the coronavirus disease 2019 (COVID-19) indicates human-to-human transmission in Wuhan, China". Int J Biol Sci. 16 (11): 1846–1860. doi:10.7150/ijbs.45018. PMC 7211182 Check |pmc= value (help). PMID 32398954 Check |pmid= value (help).
  15. Azekawa S, Namkoong H, Mitamura K, Kawaoka Y, Saito F (2020). "Co-infection with SARS-CoV-2 and influenza A virus". IDCases. 20: e00775. doi:10.1016/j.idcr.2020.e00775. PMC 7184249 Check |pmc= value (help). PMID 32368495 Check |pmid= value (help).
  16. Schwartz L, Atlas D (1989). "Synergy between membrane depolarization and muscarinic receptor activation leads to potentiation of neurotransmitter release (II)". Brain Res. 503 (1): 62–7. doi:10.1016/0006-8993(89)91704-6. PMID 2611659.