In addition, he received a temporary two-tier ...

Respiratory syncytial virus (RSV) is an important community acquired pathogen that can cause significant morbidity and mortality in patients who have threatened pulmonary function, are elderly, or immunocompromised. This paper describes a 70-year-old man with remote history of heart transplantation, which came with signs and symptoms of pneumonia. Chest computed tomography (CT) images demonstrated new patchy infiltrates matte entire upper and lower lobes of left lung, and RSV direct fluorescent antibody (DFA) was positive. The patient received ribavirin aerosol, one dose of intravenous immunoglobulin, and one dose of palivizumab. After two months following, the patient improved infiltrates on chest CT, improved lung function and no evidence of rejection or dysfunction. There are some data about RSV infection in patients with heart transplants, but this case highlights the importance of considering this potentially serious infection and introduces a new method of treatment. A. Introduction >> << Respiratory syncytial virus (RSV) is a RNA virus belonging to the family of enveloped Paramyxoviridae and is known primarily as a common infection in children []. However, it is community acquired respiratory viral infection can lead to significant morbidity and mortality in patients who have threatened pulmonary function, are elderly, or immunocompromised [

]. Other respiratory viruses have been reported in adult heart recipients []. There is little data on natural history, treatment and prognosis of RSV pneumonia in adult recipients of heart. We considered two previous reports of the case in the literature [

]. The first report described a patient who became ill 60 days after transplantation and successfully treated with ribavirin aerosol. The second describes a patient with fever of uncertain origin, who was diagnosed with RSV pneumonia in gallium three years after transplantation. This article is not about treatment or outcome. Our patient is unique, since he was 10 years after transplantation and was weaned off prednisone. 2. Case

70-year old Caucasian man with a history of heart transplantation ortotopichnoyi (ONT) in 1999 ischemic cardiomyopathy presented a five-day history of rhinorrhea, mylagias, and subjective fever. In addition, he noted worsening orthopnea and inability to sleep without the use of continuous positive airway pressure devices. Subsequently, he developed dyspnea with productive cough gray / white phlegm. Routine computer tomogram after transplantation (CT) scan of the chest six months before admission showed large atelectasis in the basal segments of left lower lobe and uvula. Repeat CT scan two months before admission showed worsening of the left lower lobe atelectasis (Fig.

). Because he was transbronhyalnoy biopsy left lower lobe. Pathology was unremarkable. Bronchial fluid cultures grew normal respiratory flora and cytology was negative for malignant neoplasms. Pulmonary function tests (PFTS) at the time were in accordance with restrictive physiology (Table

). On the day of admission, the patient with symptoms of acute infection of the upper and lower respiratory processes and worsening orthopnea from baseline. Chest radiograph (not shown) and CT chest at that time revealed new patchy infiltrates matte entire upper and lower lobes of left lung (Fig.

). Postponed diseases including Type II diabetes with nephropathy, retinopathy and neuropathy, obesity (BMI 39 5 kg / m

), Non-alcoholic fatty liver disease, chronic peripheral edema and venous congestion, long-melanoma, basal cell carcinoma with person, hypertension, dyslipidemia. He was a former smoker dedicated to his heart transplant, rarely consumed alcohol, denies any prior or illegal intravenous drugs, and could not recall any recent sick contacts. Medications on admission were cyclosporine (100 mg orally twice a day), mikofenolyatmofetil (250 mg orally twice daily), insulin hlarhin, furosemide, simvastatin, enalapril, trimethoprim-sulfamethoxazole, diltiazem, acetaminophen, aspirin, fenofibrate and vitamin E and vitamin C . Physical examination showed obese people in light of respiratory failure. He had a fever with a temperature of 36. 7 degrees Celsius. Pulse 118 and regular, blood pressure 148/74, blood oxygen saturation 88 air in the room improved to 94 for 3 liters of oxygen and the weight 118kh. He was breathing about 24 times per minute and held bilateral rales at the base of the lungs. Besides tachycardia, his cardiovascular examination was unremarkable. The rest of his examination was remarkable for 3 + fossa swelling of lower extremities with venous stasis changes to the top of his calves. Upon arrival in the intensive care unit, arterial blood gases showed pH 7. 29 PCO

to 74mmHg and software

to 48mmHg. Results of multiple serologies and cultures were negative, except positive RSV direct fluorescent antibody (DFA). Given the severity of his symptoms to be treated with 5-day aerosol ribavirin (Virazole 2GM inhaled every 8:00), a dose immunoglobulin IV (Gamunex 400mg/kg = 50000 mg), and due to financial difficulties, a 1 / 2 dose of palivizumab (Synagis 7. 5mh/kh = 900mg) [

]. In addition, he received a temporary two-level ventilation with positive airway pressure (BiPAP) and 3 days of intravenous methylprednisolone (40 mg per day). After five days of treatment, re-RSV DFA was negative. Later he was weaned off of BiPAP and was discharged from hospital. Three months later, subsequent CT chest showed authorized its frosted glass infiltrates (Fig.

), and improving its PFTS from baseline (see table). He had no evidence of rejection or dysfunction. 3. Discussion

In strattera online the United States, most RSV infections occur all over for about 22 weeks from late autumn to late spring [

]. Peak activity occurs in January and February. Syndrome RSV infection in adults include mild upper respiratory tract, bronchitis / bronchiolitis, pneumonia and fulminant respiratory failure [

]. We believe this document is clinically important because there is lack of information on treatment of SARS pneumonia in OHT recipients and lower doses of palivizumab may not be enough. We treated our patient based on the experience reported in the bone marrow and lung transplant literature [

]. Aerosol ribavirin reduces viral load in adults after bone marrow transplantation, but may have little effectiveness on mortality [

]. In patients with lung transplantation, aerosol ribavirin increases the likelihood of improving forced expiratory volume in one second, reduces the rate of obliterative bronchiolitis, and may lead to full recovery [

]. Experience shows that the addition of palivizumab (humanized anti-RSV antibody) or intravenous immunoglobulin (VVIH) may improve survival of patients after bone marrow transplantation and decrease the incidence obliterating bronchiolitis and rejection in patients after lung transplantation [

]. However, the recommended dose (Table

) [], palivizumab treatment in adults may cost more than 10,000 [

]. New experimental treatments were considered in [

]. To date there is no consensus on treatment of pneumonia, RSV, but it was suggested that the use of ribavirin aerosol and antibody therapy should be considered in patients with upper respiratory tract symptoms and other risk factors (eg, immunosuppression after transplantation) [

] . 4. Conclusion

In general, little is known about RSV infection in recipients of heart ortotopichnoyi. Given the serious consequences of RSV pneumonia after bone marrow transplantation or lung, pneumonia, SARS should be included in the differential diagnosis in patients after ONT, representing the viral introductory and abnormal pulmonary images. Despite the lack of data on treatment and results of RSV infection in recipients of heart transplantation, our patient seems to have a good clinical response to the approach of bone marrow and lung transplant literature with lower doses of palivizumab. Further investigation on the frequency and optimal therapeutic approach for RSV infection in heart transplant recipients do not need. The authors of this paper have no conflict of interest to disclose. All authors contributed to the development, a critical review and approval of this document. .