Treatment of Respiratory Syncytial Virus Pneumonia in a Lung Transplant Recipient: Case Report and Review of Literature

Jeremy D. Flynn, Pharm.D.; Wendell S. Akers, Pharm.D., Ph.D.; Mikael Jones, Pharm.D.; Natasa Stevkovic, Pharm.D.; Thomas Waid, M.D.; Timothy Mullett, M.D.; Salik Jahania, M.D.

Disclosures

Pharmacotherapy. 2004;24(7) 

In This Article

Abstract and Introduction

A 61-year-old woman who underwent lung transplantation developed severe respiratory syncytial virus (RSV) pneumonia and experienced respiratory failure requiring mechanical ventilation. She was treated initially with aerosolized ribavirin monotherapy; RSV hyperimmune globulin was later added to her regimen. Lung transplant recipients are acutely susceptible to respiratory infections, including community-acquired respiratory viruses. Respiratory syncytial virus is particularly difficult to treat in immunocompromised patients because of the lack of proved pharmaceutical agents and solid scientific evidence by which to guide therapy. The most important factor appears to be the early start of therapy; immunocompromised patients who develop RSV pneumonia and subsequent respiratory failure requiring mechanical ventilation have a mortality rate approaching 100%. This case report demonstrates the successful treatment of RSV pneumonia with the combination of aerosolized ribavirin and RSV hyperimmune globulin in a severely ill lung transplant recipient who required mechanical ventilation.

Since the first successful human lung transplantation was performed, the demand for this lifesaving treatment for end-stage lung disease of multiple etiologies has increased considerably. Survival rates continue to increase due to better patient selection and improved diagnosis and treatment of both acute and chronic rejection. However, a considerable impact of opportunistic and nonopportunistic infection on postoperative morbidity and mortality after lung transplantation still remains.[1] Respiratory infections, which are common after lung transplantation, can be caused by a variety of pathogens, such as bacteria, fungi, and viruses. Respiratory infections lead to increased morbidity and mortality both directly through infectious complications, and indirectly by predisposing the patient to development of bronchiolitis obliterans or bronchiolitis obliterans organizing pneumonia.[1,2,3,4]

After bacteria, viruses are the second most common cause of infection in lung transplant recipients. Community-acquired respiratory viruses, particularly respiratory syncytial virus (RSV), are increasingly recognized as important pathogens in this patient population.[1,2] Most cases of RSV in immunocompromised hosts have occurred in hematopoietic stem cell transplant recipients. These patients have RSV in various degrees of severity and outcomes, ranging from full recovery to progressive respiratory failure and death.

The most common therapies for RSV in immunocompromised patients are aerosolized ribavirin and immunoglobulin products. The effectiveness of aerosolized ribavirin monotherapy in immunocompromised adults is controversial, and reports of its effectiveness in a variety of patient populations are conflicting.[5,6,7] Thus, combination therapy with ribavirin and an immunoglobulin product is now considered by many practitioners to be the standard of care in immunocompromised patients.[8,9]

Several uncontrolled studies in immunocompromised patients or animal models have suggested a benefit of ribavirin in combination with RSV hyperimmune globulin to treat RSV upper and lower respiratory tract infections.[10,11,12] However, some reports refute those findings and suggest that addition of intravenous immunoglobulin or RSV hyperimmune globulin to ribavirin therapy results in no additional benefit when compared with ribavirin monotherapy or supportive care with no pharmacologic therapy.[6,13,14]

The most important factor in the success of any treatment appears to be the early start of therapy; mortality rates are greatly increased when therapy is delayed.[6,11,15,16,17,18] We report a case of RSV pneumonia in a single lung transplant recipient who was treated with aerosolized ribavirin and intravenous RSV hyperimmune globulin.

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