The outcome of 26 patients with respiratory syncytial virus infection following allogeneic stem cell transplantation

Abstract

Summary:Respiratory syncytial virus (RSV) is known to cause acute lung injury in the immunocompromised host, especially recipients of bone marrow allografts. Specific prognostic factors for the development of severe lifethreatening disease remain to be identified as does the optimum treatment of established disease. Over a 5-year period the incidence and outcome of RSV in BMT recipients was analysed retrospectively. Prognostic factors assessed included type of transplant, engraftment status at the time of infection, the presence of lower respiratory tract disease, viral genotype and treatment received. During the study period, 26 of 336 (6.3%) allogeneic stem-cell recipients were identified as having RSV. Five patients (19.2%) died as a direct result of RSV. One patient died secondary to an intracranial bleed with concomitant RSV. There were four patients with graft failure (two primary and two secondary) attributable to the presence of RSV, two of whom subsequently died of infections related to prolonged myelosuppression. The presence of lower respiratory tract infection and a poor overall outcome was the only statistically significant association. Unrelated donor transplants and AML as the underlying disease appeared to be associated with a poorer outcome. Engraftment status, viral genotype and RSV treatment received did not correlate with outcome. We conclude that future studies are required to identify early sensitive and reproducible prognostic factors of RSV in the immunocompromised host. The roles of intravenous and nebulised ribavirin need to be clarified by prospective controlled trials.

Pre-emptive oral ribavirin therapy of paramyxovirus infections after haematopoietic stem cell transplantation: a pilot study

“…2,3,[6][7][8] This involves hospital admission of fairly well patients and significant discomfort associated with prolonged periods of isolation and use of masks or tents. In addition, there is concern about healthrisks to the medical and nursing staff with environmental exposure to inhaled ribavirin.…”

“…[1][2][3][4][5] Considering the poor prognosis of established paramyxovirus pneumonia, the emphasis has shifted to a preemptive approach with early initiation of treatment at the stage of upper respiratory tract (URI) infection or even at an asymptomatic stage. [6][7][8][9] Small, uncontrolled studies suggest an improvement in the outcome of these infections with this pre-emptive approach. The difficulty in delivering aerosolised ribavirin, compounded by patient discomfort and the financial burden, makes widespread acceptance of this approach unlikely.…”

Palivizumab is highly effective in suppressing respiratory syncytial virus in an immunosuppressed animal model

“…[1][2][3] A recent case review reported three deaths among seven patients who developed RSV infections in the post-engraftment period, suggesting a continued significant impact of this pathogen. 4 Those authors also reported an association between RSV infection and both primary and secondary graft failure in four patients. The opinions or assertions contained herein are those of the author(s) and are not to be construed as official or reflecting the views of the Department of Defense, the United States Air Force, or the Uniformed Services University.…”

Intravenous ribavirin for respiratory syncytial viral infections in pediatric hematopoietic SCT recipients

“…Consequently, no international consensus has been reached and pediatric patients still remain understudied. In this regard, some studies suggest improved outcomes with the addition of high-dose Ig, 18,19 RSV-IVIG 20 or MoAb (palivizumab) 21 in children undergoing HSCT, but clear evidence of efficacy is lacking. Prophylaxis with palivizumab has been approved by the FDA in prematurity or in bronchopulmonary dysplasia, 22 but is still limited by its high cost.…”

“…No RSV-specific gamma globulin or humanized MoAb (palivizumab) was administered. All four LRTI patients showed a favorable clinical response, with 100% survival after a mean follow-up of 17 months (range [13][14][15][16][17][18][19][20][21][22][23][24]. With regard to IVIG, our guideline was not adhered to in two patients with severe LRTI-RSV who did not receive combined therapy with IVIG (episodes 1 and 6).…”