Correspondence
Respiratory Syncytial Virus
N Engl J Med 2001; 345:1132-1133October 11, 2001
- Article
To the Editor:
In the review of respiratory syncytial virus (RSV) and parainfluenza virus by Hall (June 21 issue),1 there is a detailed discussion of non–respiratory tract complications, including otitis media and relapses in children with the nephrotic syndrome. However, there is no mention of encephalopathy associated with RSV infection.
We recently reported on a study involving 487 children with RSV bronchiolitis, in which the incidence of encephalopathy, manifested as seizures (not febrile convulsions), was 1.8 percent.2 This is likely to be an underestimate, because we have observed and treated a number of children with encephalopathy and RSV infection since our study was completed. In previous studies that were not formal investigations of this issue, the incidence of seizures in association with RSV infection was 7 percent in children and 12.9 percent in neonates.3,4 The incidence of encephalopathy in association with parainfluenza virus infection is unclear.
The magnitude of RSV infection is enormous, not only in terms of morbidity and mortality among affected patients but also in terms of the financial cost to society. Encephalopathy is a further serious complication with resultant costs, since most of our affected patients had to be hospitalized, and brain magnetic resonance imaging, spinal-fluid analyses, and electroencephalographic studies were required.2 There remains a need for safer and more effective vaccination and therapy.
4 ReferencesYu-tze Ng, M.D.
Ian J. Butler, M.D.
University of Texas–Houston, Houston, TX 77030
yu-tze.ng@uth. tmc. edu 1
Hall CB . Respiratory syncytial virus and parainfluenza virus. N Engl J Med 2001;344:1917-1928
Full Text | Web of Science | Medline2
Ng YT ,Cox C ,Atkins J ,Butler IJ . Encephalopathy associated with respiratory syncytial virus bronchiolitis. J Child Neurol 2001;16:105-108
Web of Science | Medline3
Chan P ,Goh A . Respiratory syncytial virus infection in young Malaysian children. Singapore Med J 1999;40:336-340
Medline4
Gouyon JB ,Fantino M ,Couillault G ,Durand C ,Pothier P ,Alison M . Infections à virus respiratoire syncytial du nouveau-né. Arch Fr Pediatr 1986;43:93-97
Medline
To the Editor:
Hall describes infection due to RSV mainly in elderly and immunocompromised adults. According to the 2001 guidelines of the American Thoracic Society for the management of community-acquired pneumonia,1 RSV is not considered a major pathogen in severe disease. We report several cases in which RSV was a cause of acute respiratory failure in previously healthy adults.
During the period from September 1998 through December 1999, six adults were admitted to the medical intensive care unit with hypoxemic respiratory failure due to RSV infection. Four of the patients were previously healthy women, all of whom required mechanical ventilation: a 28-year-old pregnant woman in preterm labor, a 34-year-old woman who was a nurse in the neonatal intensive care unit, a 44-year-old woman who worked as a counselor in an elementary school, and a 48-year-old woman. Chest radiographs in three patients demonstrated diffuse abnormalities; in three cases, initial lobar consolidation progressed to diffuse opacification within 24 hours. Early diagnosis was established by RSV antigen testing. Bronchoscopy was performed in the five patients who were intubated; in three of the five, a hemorrhagic bronchoalveolar-lavage specimen was obtained. In the five patients who required mechanical ventilation, the duration ranged from 1 to 3.5 months. All the patients received inhaled ribavirin. One patient died; the death was caused by massive pulmonary embolism on hospital day 34.
We believe that community-acquired pneumonia due to RSV infection must be recognized as a cause of severe, prolonged respiratory failure and critical illness in formerly healthy adults.
1 ReferencesJanet M. Shapiro, M.D.
Raymonde E. Jean, M.D.
St. Luke's–Roosevelt Hospital Center, New York, NY 100251
Niederman MS ,Mandell LA ,Anzueto A , et al. Guidelines for the management of adults with community-acquired pneumonia: diagnosis, assessment of severity, antimicrobial therapy, and prevention. Am J Respir Crit Care Med 2001;163:1730-1754
Web of Science | Medline
Author/Editor Response
Dr. Hall replies:
To the Editor: Drs. Ng and Butler suggest an association between RSV infection and encephalopathy on the basis of their retrospective review of the records of children admitted with RSV bronchiolitis over a period of four years.1 This association has not been well studied and warrants a prospective evaluation. However, as in the nine patients described by Ng et al.,1 the majority of infants hospitalized with RSV infection have underlying conditions, making it difficult to find suitable controls. This problem is compounded by the universality of RSV infection in young children. With such a prevalent infection, an infrequent disease may have an association that is temporal rather than causal. Nevertheless, RSV may have an indirect role in the pathogenesis of a nonrespiratory illness, resulting in its clinical alteration or exacerbation.
The data reported by Drs. Shapiro and Jean suggest that it may be worthwhile to include RSV infection in the group of possible diagnoses for adults with pneumonia, even those who have previously been healthy. Severe disease in previously healthy adults does occur but, fortunately, is infrequent.2-5 In the study by Dowell et al.,2 RSV infection was among the top four causes of hospitalization among adults with community-acquired pneumonia. This group included younger adults (those who were 18 to 39 years of age), most of whom had previously been healthy.
As both these letters suggest, the extent and burden of RSV infection remain unknown and are probably underestimated.
5 ReferencesCaroline Breese Hall, M.D.
University of Rochester School of Medicine and Dentistry, Rochester, NY 14642
caroline_hall@urmc.rochester. edu 1
Ng YT ,Cox C ,Atkins J ,Butler IJ . Encephalopathy associated with respiratory syncytial virus bronchiolitis. J Child Neurol 2001;16:105-108
Web of Science | Medline2
Dowell SF ,Anderson LJ ,Gary HE Jr , et al. Respiratory syncytial virus is an important cause of community-acquired lower respiratory infection among hospitalized adults. J Infect Dis 1996;174:456-462
CrossRef | Web of Science | Medline3
Levenson RM ,Kantor OS . Fatal pneumonia in an adult due to respiratory syncytial virus. Arch Intern Med 1987;147:791-792
CrossRef | Web of Science | Medline4
Spelman DW ,Stanley PA . Respiratory syncytial virus pneumonitis in adults. Med J Aust 1983;1:430-431
Web of Science | Medline5
Aylward RB ,Burdge DR . Ribavirin therapy of adult respiratory syncytial virus pneumonitis. Arch Intern Med 1991;151:2303-2304
CrossRef | Web of Science | Medline
