Transplant infection
Clinical features and outcomes of paramyxoviral infection in lung transplant recipients treated with ribavirin

https://doi.org/10.1016/S1053-2498(02)00569-7Get rights and content

Abstract

Background:

Paramyxoviral infections are reported in 6% to 21% of lung transplant recipients. Aerosolized ribavirin is used to treat paramyoxviral infections, but data on outcomes of this treatment in lung transplant patients are limited.

Methods:

Lung recipients treated with aerosolized ribavirin from 1992 through 2000 for pulmonary respiratory syncytial virus (RSV) or parainfluenza virus (PIV) infection were assessed for the following variables: age; gender; underlying diagnosis; time from transplantation; duration of illness; clinical symptoms; and change from baseline FEV1 (forced expiratory volume in 1 second). Outcomes included FEV1 values at 30 and 90 days, need for intubation, development of acute rejection or obliterative bronchiolitis (OB) in the year after treatment; and 90-day and overall mortality.

Results:

Fifteen patients received ribavirin for a median of 5 days (range 3 to 7) for 17 episodes of RSV (n = 12) or PIV (n = 5) infection. The clinical presentations of RSV and PIV infection were similar. Infection occurred a median of 520 days (range 7 to 1,700) after transplantation. Three episodes required intubation; 2 episodes were fatal accounting for a 90-day mortality per episode of 12%. The FEV1 at presentation declined by 25% (range 4% to 44%) from baseline. In 3 patients the FEV1 did not return to baseline by 90 days or thereafter. All 3 patients had underlying pulmonary fibrosis (IPF) vs no IPF in 0 of 9 evaluable patients who recovered (p = 0.009). There was no correlation between response to ribavirin and subsequent development of OB.

Conclusions:

About 33% of lung transplant patients with lower respiratory tract paramyxoviral infections who were treated with inhaled ribavirin died or did not return to baseline FEV1. This effect was acute and not associated with later complications, including OB. Underlying IPF may be a risk factor for failure to return to baseline. Larger, prospective, multicenter studies are required to confirm these findings.

Section snippets

Patients and ribavirin treatment

After institutional review board approval, a review was undertaken of all lung or heart–lung transplant recipients at Vanderbilt University Medical Center who had received aerosolized ribavirin to treat either RSV or PIV infection. Fifteen patients received 17 courses of aerosolized ribavirin therapy between April 1992 and December 2000. Methods of viral identification included BD-Directigen RSV rapid antigen (EIA; BD Diagnostic Systems, Sparks, MD), viral culture, Hexaplex polymerase chain

Results

During the 9-year study period, 15 lung transplant recipients received aerosolized ribavirin for 17 episodes of paramyxoviral respiratory illness, including 12 (71%) cases of RSV and 5 (29%) cases of PIV infection. Two patients had episodes of both RSV and PIV on separate occasions. The median duration of ribavirin therapy was 5 days (range 3 to 7). Ribavirin was well tolerated. The most common side effect was headache, observed in only 2 patients. One intubated patient required discontinuation

Discussion

Viral infections are a major cause of community-acquired respiratory illness in the general population. Paramyxoviruses account for up to 10% of lower respiratory tract disease and can produce dyspnea and wheezing in immunocompetent adults.2, 16, 17 Reports of paramyxoviral infection in kidney and liver transplant recipients have described similar symptoms and morbidity.18, 19 Lung transplant patients with lower respiratory paramyxoviral infection may suffer a significant and sometimes

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    Dr McCurdy is currently a research fellow at the Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland.

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