Respiratory syncytial virus infection in the late bone marrow transplant period: report of three cases and review

Abstract

Summary:Respiratory syncytial virus (RSV) infection is an important cause of respiratory mortality in immunosuppressed patients, including bone marrow transplant (BMT) recipients. The presence of lower respiratory tract infection and infection in the pre-engraftment phase of BMT is believed to confer a poor prognosis. Three patients who underwent allogeneic BMT at our institution developed RSV pneumonia over 1 year post BMT, with the underlying disease in remission. All three were hypoxic with extensive pulmonary disease at presentation. Treatment consisted of aerosolized ribavirin and intravenous immune globulin with successful clearing of viral shedding and excellent clinical outcomes. RSV infection is probably less severe in the late post-BMT period, but needs to be considered early in the differential diagnosis of pulmonary infiltrates in this patient population. Bone Marrow Transplantation (2001) 27, 1071-1073. Keywords: RSV infection; late; BMT; ribavirin Respiratory syncytial virus (RSV) is a common pediatric pathogen with a predilection for winter outbreaks. In the adult population, RSV infections are increasingly recognized as important causes of respiratory mortality, primarily in immunosuppressed patients, including allogeneic bone marrow transplant (BMT) recipients. The clinical presentation in these sub-groups is frequently as an upper respiratory tract infection (URTI) that can rapidly progress to viral pneumonia if untreated. This progression from URTI to pneumonia is much higher in the immediate posttransplant period.1,2 RSV pneumonia in allogeneic BMT patients has been associated with mortality rates between 60% and 80%, despite aggressive treatment. Negative predictors of outcome following RSV infection in BMT recipients remain ill-defined, but include infection in the pre- There are few data regarding RSV infections in adult BMT recipients 1 year or more after transplant. We report three such cases of RSV infection at the Roswell Park Cancer Institute (Buffalo, NY) treated successfully with aerosolized ribavirin and intravenous immune globulin (IVIG) during the winter of 1999-2000. The absolute neutrophil count was normal and the underlying disease was in complete remission in all three patients. Case reportsPatient 1 is a 24-year-old female, who was 384 days following an allogeneic BMT for chronic myelogenous leukemia from an HLA-matched sibling donor. The conditioning regimen used for BMT was busulfan and cyclophosphamide. The post-BMT course was complicated by acute and chronic graft-versus-host disease (GVHD) requiring methyprednisolone, cyclosporine and tacrolimus therapy. She had completed a course of immunosuppressive therapy 2 weeks prior to detection of RSV infection. The patient was receiving trimethoprim/sulfamethoxazole, penicillin and acyclovir prophylaxis. Presenting symptoms included sinus congestion, cough with mucopurulent expectoration and dyspnea on exertion. Her 15-month-old infant had had symptoms of URTI within the preceding weeks. She was afebrile and hemodynamically sta...

Intravenous ribavirin for eradication of respiratory syncytial virus (RSV) and adenovirus isolates from the respiratory and/or gastrointestinal tract in recipients of allogeneic hematopoietic stem cell transplants

“…In children as well as in adults, for RSV infections most groups used aerosolized ribavirin with fairly good success, especially if applied early during infection in a pre-emptive manner to prevent progression to lower respiratory tract infection and pneumonia. 7,[17][18][19][20][21][22][23][24] However, since the clinical use of aerosolized ribavirin has been limited by caregivers' concerns about drug exposure and potential teratogenic effects, it seems to be of great importance to search for safer and similar effective routes of administration. For this purpose, either the oral or the intravenous formulation of ribavirin may be used.…”

Respiratory syncytial virus infection following hematopoietic stem cell transplantation

“…Our data demonstrate that recipients of unrelated or mismatched related transplants who develop RSV pneumonia more than 1 month post HSCT can be successfully treated, despite the presence of hypoxemia. Khushalani and colleagues 21 have also reported the successful treatment of three adult patients with hypoxia and extensive pulmonary disease due to RSV, with aerosolized ribavirin and conventional intravenous gammaglobulin. The optimal therapy for this transplant group will require prospective randomized trials.…”

Active surveillance for respiratory virus infections in adults who have undergone bone marrow and peripheral blood stem cell transplantation

“…In contrast, RSV has been reported to cause pneumonia in patients with allogeneic transplant greater than 1 year after transplantation, although the mortality in these patients appear to be lower than in those in the first month after transplantation. 16,17 Our study combines the strengths of a prospective cohort study design with the use of highly sensitive RT-PCR assays for RV detection. Most (six of seven) of the hospitalizations for lower respiratory tract infection in our study were due to RSV and influenza infection; however, only two of the six were detected by viral culture.…”