Scant data are available on the clinical significance of rhinovirus infections in immunocompromised patients. We reviewed the clinical courses of and outcomes for 22 myelosuppressed adult blood and marrow transplant recipients with rhinovirus infections who were hospitalized at the M.D. Anderson Cancer Center (Houston) from January 1992 to January 1997. In 15 patients (68%), illnesses remained confined to the upper respiratory tract. Seven patients (32%) developed fatal pneumonia. These patients had profound respiratory failure a mean of 12 days (range, 3-21 days) after the onset of symptoms. In six of these seven cases, rhinovirus was isolated before death from a bronchoalveolar lavage fluid specimen and/or an endotracheal aspirate. Five patients underwent autopsies, one of which revealed disseminated aspergillosis and four of which revealed interstitial pneumonitis and/or acute respiratory distress syndrome and no other organisms. In conclusion, rhinovirus infections may be associated with considerable pulmonary-related morbidity and mortality in severely myelosuppressed immunocompromised patients.
Awareness of respiratory syncytial virus (RSV) as a serious pathogen in the child with congenital heart disease is increasing. We studied the impact of RSV lower respiratory tract disease on patients in a large academic pediatric cardiology practice. We found that RSV disease necessitating hospitalization occurs in congenital heart disease patients well into the second year of life. Although pulmonary hypertension remains a significant risk factor for morbidity in these patients, it does not appear to be as much of a factor as in the past. By implementing a nasopharyngeal RSV enzyme-linked immunoassay screening of young patients prior to cardiac surgery we found a reduction in community-acquired postoperative RSV disease. We postulate this will lead to a reduction in nosocomial disease in the postoperative care unit.
Respiratory syncytial virus (RSV) isolates obtained from nine infected immunocompromised adult patients hospitalized during two consecutive winters (January through April 1987 and 1988) were collected and analyzed against a panel of monoclonal antibodies by an enzyme immunoassay. The history of the patients' illness, onset of symptoms, and date of initial isolation of virus was correlated with the hospital ward and time of hospitalization. Three patients died of respiratory failure related to RSV infection acquired nosocomially. A cluster of RSV disease in four patients hospitalized simultaneously during the 1987 season was demonstrated to be caused by four antigenically distinct viruses; despite an epidemiologic link among the patients, each had been infected from a different source. The RSV disease in the five immunocompromised adults in 1988 was caused by two distinct strains; three patients were infected with RSV subgroup A/4, and two were infected with RSV subgroup B/2. Combining the epidemiologic and strain characterization studies, none of four patients in 1987 were infected from each other, and two of five patients in 1988 may have been infected, directly or indirectly, from one of the other five. The strain characterization studies demonstrated the potential complexity of RSV nosocomial transmission and the need to consider a number of sources for transmission in developing effective prevention strategies. The three deaths underscore the importance of nosocomial RSV disease and the importance of effective prevention strategies.
We determined the prevalence of antibody to cytomegalovirus (CMV) in the sera of non-homosexual hemophilia patients and homosexual men infected with the human immunodeficiency virus type 1 (HIV-1). CMV antibody testing by latex agglutination revealed 33 of 58 HIV-1 infected hemophiliacs (57%) were antibody-positive compared with 54 of 54 HIV-1 infected asymptomatic non-hemophiliac homosexuals (100%) (p less than .001). Nine of 15 hemophiliacs (60%) with symptomatic HIV-1 infection were CMV antibody-positive. We also tested 22 HIV-1 antibody-negative hemophiliacs who had received non-heat treated factor concentrates. 14 of these 22 (64%) were CMV antibody-positive compared with 57% of HIV-1 antibody-positive hemophiliacs. We conclude 1) there is little correlation between transmission of HIV-1 and CMV by factor concentrates, 2) the presence of CMV antibody does not appear to be associated with clinical stage of HIV-1 infection in hemophiliacs, and 3) there may be a significant number of CMV antibody-negative hemophiliacs with HIV-1 infection at risk for primary infection and subsequent disease if CMV seronegative blood products are not provided for future transfusions.
The incidence of cytomegalovirus disease, the most important infectious complication of renal transplantation, was reduced in renal allograft recipients by a regimen of prophylactic high-dose oral acyclovir. To analyze the pharmacologic aspects of our prophylactic approach, we evaluated safety, pharmacodynamics, and in vitro susceptibility data. One hundred four recipients of cadaveric renal allografts received either oral acyclovir (n = 53) in doses of up to 3,200 mg/day or a placebo (n = 51) for 12 weeks posttransplant. Leukocyte count and serum creatinine were selected as markers of laboratory safety and were evaluated pretransplant, at study midpoint (creatinine only), and at study completion. Concentrations of acyclovir in plasma were determined to verify the ability of the dosing strategy to achieve predicted values. Viral Cytomegalovirus is the single most important cause of infectious disease after renal transplantation (10, 14). Because cytomegalovirus disease occurs almost exclusively during the first 3 months after renal transplantation (16) and treatment has been difficult (1), we developed a prophylactic approach using the antiviral drug acyclovir. We demonstrated that high-dose oral acyclovir, given according to a scheme that adjusted for estimated creatinine clearance, reduced the incidence and severity of cytomegalovirus disease in recipients of cadaveric renal allografts (2). In addition to efficacy, comprehensive analyses of safety, pharmacodynamics, and in vitro susceptibilities of cytomegalovirus strains collected from the subjects were needed to evaluate the risk/benefit ratio of this prophylactic approach more thoroughly. These issues are addressed in the present report.( clovir was provided as 800-mg tablets; placebo tablets were identical in appearance and taste. All patients received a single tablet just prior to transplantation and again 24 h later. The subsequent dosing schedules for the remainder of the 12-week dosing period were based upon creatinine clearance (CLCR) estimated by the method of Jelliffe and Jelliffe for unstable serum creatinine (11). Patients with an estimated CLCR of <10 ml/min/1.73 m2 (<0.167 ml/s) received 800 mg daily; those with an estimated CLCR of between 10 and 25 ml/min/1.73 m2 (0.167 and 0.417 ml/s) received 800 mg three times daily; and those with an estimated CLCR of >25 ml/min/1.73 m2 (>0.417 ml/s) received 800 mg four times daily. Patients undergoing hemodialysis received 800 mg twice daily. All patients were cared for according to standard protocols at The University of Minnesota Hospital and Clinic and received our standard immunosuppressive regimen, which included quadruple therapy with antilymphoblast globulin, cyclosporine, prednisone, and azathioprine (9). Study participants received daily clinical and laboratory evaluations during the first week posttransplant and twice weekly thereafter until discharge. Thereafter, patients were seen in the outpatient clinic at 3 months and 1 year posttransplant.Clinical laboratory evaluation of drug safety. S...
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