The Science Journal of the American Association for Respiratory Care

2001 OPEN FORUM Abstracts

Nosocomial RespiratorySyncytial Virus Infection in an Adult Renal Transplant Patient

RodrigoMorales, MD, Michael Kirkpatrick, MD, Barry Browne, MD and Osemwegie Emovon,MD University of South Alabama, Mobile, Alabama

Introduction: Respiratorysyncytial virus (RSV) is an important cause of severe lower respiratory tractinfection in immunocompromised hosts. This repor tdescribes an unexpected caseof nosocomial RSV pneumonia after kidney transplantation.

Case Presentation: A 58year old male who was discharged five days after receiving a cadaver renal allograftpresented the following day with dyspnea and productive cough. The immunosuppressivetherapy consisted of Cyclosporine-microemulsion, prednisone and mycophenolatemoefetil. The patient was only prophylaxis with TMP-SMX and acyclovir. On physicalexaminatio, the patient was inmild respiratory distress at rest, blood pressure134/72 mmHG, pulse of 72 per minute and a temperature of 98.0F. Ausculationof his lungs revealed bilateral diffuse expiratory wheezes and crakles on theleft side. Puls oximeter reading was 92% while he breathed supplemental O2 at2 I/min via nasal prongs. Initial chest radiograph shoed a new patchy left upperlobe infiltrate. The serum sodium was 124 mEq/L, potassium 4.8mEq/L, chloride93mE/L, carbon dioxide 25 mEq/L, nitrogen urea 62 mg/dL and creatinine 3.8/dl.White blood cell wcount was 10,600/cc ad hemoglobin 10.4g/dl. Initial empiricantibiotic therapy consisted of levofloxacin and ceftriaxone. The patient deteriorated,and repeat chest radiograph shoed worsening of the upper lobe infiltrate. Theantibiotic coverage was changed to fluconozole, ceftazidime and vamcomycin,and the patient was transferred to the intensive care unit. A bronchoalveolarlavage (BAL) initially yielded no organizsms. RSV was isolated verom the BALfluid by immunofluoresence at 48 hours. Therapy with nebulized ribiravin wasconsidered but not administered because the patient was clinically improving.The patient was subsequently discharged and at 6 weeks follow up a chest radiographshowed resolution of theinfiltrate and his renal graft was functioning. Retrospectiveinvestigation revealed that at least three health care workers directly involvedin the care of the patient during the initial hospitalization had experiencednon-specific upper respiratory symptoms. No other contact was identified onthe transplant ward.

Discussion: In a patientreceiving immunosuppresive therapy, the onset of dyspnea suggests a pulmonaryinfection. The incidence of bacterial pneumonia in the first three months afterrenal transplantation has been described to be in the range of 1 to 2%. Nosocomialpneumonia was considered hence the sequence of antimicrobial agents. The timeof hospitalization of our patient corresponded with an upward trend in the percentof antigen detection and isolation of RSV in the Southern United States. Outbreaksof RSV occur during late fall, winter or spring. Rapid antigen detection methodsfor diagnosing RSV are more sensitive in samples from the lower airways. Inour case a rapid test was not requested because the possibility of RSV was notentertained. Nosocomial transmission of RSV usually starts after the indadvertentintroduction of the irus by family member of a health worker, as was suspectedin our case. The transmission of jRSV can occur by droplets, at a distance ofless than 0.9m, or by self-inoculation of the respiratory tract after acquiringthe virus from a fomite. The role of precautions including hand-washing, andthe use of gloves and gowns is recommended. Althourgh response to aerosolizedrivavirin has been described, supportive care is the mainstay of treatment asprovided in the present case.


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