on january 2 , 2011 , an 8-month - old girl with acute respiratory distress was seen in the emergency department of the children s hospital of the university of cologne . the girl s parents had noticed labored breathing , intercostal retractions , and fever for 1 day . no one else who had contact with the girl was sick . at admission , the girl was lethargic and inappetent with a fever of 38.3c and oxygen saturation of 86% . the patient had submandibular lymphadenopathy and mild pharyngitis but no rash or abnormalities of the heart or abdomen . the clinical signs were typical of an upper respiratory tract infection combined with severe obstructive bronchitis . chest radiographs showed diffuse bilateral infiltrates and total atelectasis of the right upper lung lobe . blood analysis indicated partial co2 concentration within normal limits and slightly elevated c - reactive protein level ( 10 mg / l ) . electrolytes and renal and hepatic markers were within reference ranges , as was complete blood count except for thrombocytosis ( 744,000 platelets/l ) . treatment with prednisolone and inhalation therapy delivering albuterol and ipratropium by vaporizor was initiated . because of the lung atelectasis , the child received cefuroxime as prophylaxis for 2 weeks . oxygen saturation could be restored to within reference limits with nasal cannula oxygen delivery at 4 l / min . during the next 2 days , the patient s body temperature was 38.0c39.0c , and she remained lethargic . a nasopharyngeal aspirate was obtained 4 days after symptom onset and screened for respiratory viruses by real - time pcr ( 2 ) and luminex xtag rvp panel ( abbott , wiesbaden , germany ) . each assay had positive results for hbov dna and negative results for influenza a virus ; influenza a virus subtype h1n1 ; influenza b virus ; parainfluenza viruses types 14 ; adenovirus ; human metapneumovirus ; coronaviruses nl63 , hku1 , 229e , and oc43 ; respiratory syncytial virus ( rsv ) ; rhinovirus ; and enterovirus . cultures of blood collected on the day of admission , before antimicrobial drug treatment was started , were negative . a second chest radiograph showed partial atelectasis of the left upper lung lobe , a retrocardial infiltrate , and pneumomediastinum . on hospitalization day 5 , oxygen saturation could be maintained at a lower flow rate . on day 6 , chest radiograph showed regression of atelectasis in both lobes and of the pneumomediastinum . temperature dropped to subfebrile levels , and the child s general condition was improving . on day 9 , no additional oxygen was needed . on day 10 , chest radiograph showed residual atelectasis in both upper lobes and residual infiltrates in both lungs , and the patient was discharged . two weeks later , at follow - up examination , the child was doing well , breath sounds were unremarkable , and the pathologic radiographic findings had resolved completely . to verify that the disease was caused by an hbov infection , we performed a real - time pcr targeting the nonstructural protein 1 region of hbov ; we detected 5,819 copies / ml hbov dna in the patient s serum 30 days after symptom onset ( 3 ) . the pcr was conducted with primers os1 and os2 as described ( 4 ) , and an hbov subtype 2 plasmid dilution series ( kindly provided by tobias allander , karolinska institute , stockholm , sweden ) was used as a quantitative control . sequencing was performed by an external sequencing service ( eurofins mwg , munich , germany ) ; the same primers from both directions were used . sequencing and blast analysis ( http://blast.ncbi.nlm.nih.gov/blast.cgi ) confirmed the virus to be hbov1 , not hbov24 . additionally , hbov - specific igm and igg and avidity of igg were measured by sensitive and specific enzyme immunoassays ( 5,6 ) . results were clearly positive for both : igm absorbance 0.385 and cutoff 0.167 ; igg absorbance 2.971 and cutoff 0.188 . igg was of low avidity ( 4% , cutoff 15% ) , indicating acute primary hbov infection . large - scale studies showed that hbov can be detected in children with signs and symptoms of respiratory tract infection . studies have detected hbov in 9% and 19.3% of all samples , indicating that it is the second or third most commonly detected virus , after rsv and rhinovirus ( 2,10 ) . thus , the overall contribution of hbov to all detected respiratory viruses lies well below that of rsv . high prevalence does not necessarily mean high clinical relevance , and proving its causative role has been difficult because the virus is often detected along with other viruses ; co - detection rates are as high as 75% ( 11,12 ) . hbov can also persist for months in the respiratory tract after resolution of disease , further complicating diagnosis ( 12 ) , which therefore should be based on detection of hbov dna in blood and measurement of hbov - specific antibodies . hbov is the most probable cause of respiratory tract disease if the patient has a high viral load in nasopharyngeal aspirates accompanied by viremia , if hbov is the only pathogen detected , and if an acute primary hbov infection is diagnosed by serologic testing ( 5,11,13 ) . the serologic assay developed earlier was validated in a series of studies and shown to reliably measure serologic response against hbov ( 58 ) . however , the contribution of bacteria to the course of the disease can not be completely ruled out . signs and symptoms for the patient reported here have been described as the most common signs and symptoms of hbov - infected children ( 14 ) and are typical of lower respiratory tract viral infections in general . in 1 study ( 14 ) , 18 patients had an hbov single infection and 2 had lobar atelectasis , as did the patient reported here . similarly , another case report described hbov infection that resulted in pneumomediastinum ( 15 ) . the age of the patient reported here is also typical of hbov , which mostly infects children 6 months to 3 years of age , but it does not usually infect young infants , as rsv does ( 14 ) . the case reported here shows that a lower respiratory tract infection caused by hbov can lead to severe and life - threatening disease .