The Use of Intravenous Palivizumab for Treatment of Persistent RSV Infection in Children With Leukemia

Abstract

Palivizumab is a humanized monoclonal antibody used to decrease the threat of respiratory syncytial virus (RSV) infection among children at high risk. There are no standard guidelines due to conflicting data on palivizumab's use in the treatment of RSV lower respiratory tract infections. Intravenous (IV) palivizumab was shown to be well tolerated and associated with decreased mortality in high-risk children who have RSV disease. However, it did not prevent lower respiratory tract infections and did not affect the survival rate of allogeneic stem cell transplant recipients who had RSV infection. We present 2 children with acute lymphocytic leukemia (ALL) and persistent RSV infection while receiving chemotherapy. Patient A is a 4-year-old male with Down syndrome, ALL, and persistent RSV infection for at least 3 months. Patient B is a 3-year-old female with pre-B cell ALL whose chemotherapy intensification phase was delayed due to a month-long RSV infection. RSV infections were determined by using real-time polymerase chain reaction assays from nasopharyngeal swabs before IV palivizumab therapy; patient A was positive for RSV at 36 cycles and patient B was positive for RSV at 29 cycles. RSV infection was cleared in both patients within 72 hours after receiving IV palivizumab (patient A: 16 mg/kg; patient B: 15 mg/kg). IV palivizumab may be a treatment option for persistent RSV infection among immunocompromised patients.

Improving the prescribing of palivizumab

“…Six patients across the hospitals were given palivizumab to treat acute severe RSV infection. There is limited evidence to support use of palivizumab as treatment for RSV infection . There are case reports and case series that suggest intravenous palivizumab may be a treatment option for persistent RSV infection among immunocompromised patients …”

“…There is limited evidence to support use of palivizumab as treatment for RSV infection. 5,6 There are case reports and case series that suggest intravenous palivizumab may be a treatment option for persistent RSV infection among immunocompromised patients. 6 In 2015, fewer children (36%) received the full course of palivizumab, compared to 2014 (74%).…”

“…5,6 There are case reports and case series that suggest intravenous palivizumab may be a treatment option for persistent RSV infection among immunocompromised patients. 6 In 2015, fewer children (36%) received the full course of palivizumab, compared to 2014 (74%). While this is a contributing factor to overall cost reduction for the hospitals between the 2 years, it raises significant concern about breakthrough RSV infections that are more likely to occur if the interval between doses is greater than 30 days.…”

Presentation of Severe Combined Immunodeficiency with Respiratory Syncytial Virus and Pneumocystis Co-infection

“…Half the patients with SCID show a lymphocyte phenotype T−B+NK−, which is associated with defects in gamma-common chain or JAK3. [10][11][12][13] Oral RBV is equally efficacious as aerosolized RBV in the treatment of RSV infection in immunocompromised hosts. 5,6 The most common cause of acute bronchiolitis in infants, RSV, can be fatal in infants with SCID, as lymphopenia has been related to adverse outcome in viral infections in immunocompromised host.…”

Intravenous palivizumab in respiratory syncytial virus infection after hematopoietic stem cell transplant in children

“…Uncontrolled studies have shown that combined therapy with ribavirin and polyclonal or monoclonal antibodies is associated with decreased mortality, and a lower effect when monoclonal antibodies are administered alone . A report of two children with leukemia suggested that intravenous (IV) palivizumab, a monoclonal antibody against the RSV‐F protein, may be a treatment option for persistent RSV infection . The impact of IV palivizumab on respiratory or systemic viral loads and clinical outcomes in immunocompromised children has not been defined.…”