Bone Marrow Transplantation (2001) 27, 1071–1073  2001 Nature Publishing Group All rights reserved 0268–3369/01 $15.00 www.nature.com/bmt Viral complications Respiratory syncytial virus infection in the late bone marrow transplant period: report of three cases and review NI Khushalani 1 , FG Bakri 2 , D Wentling 1 , K Brown 1 , A Mohr 1 , B Anderson 1 , C Keesler 1 , D Ball 1 , ZP Bernstein 1 , SH Bernstein 1 , MS Czuczman 1 , BH Segal 1,2 and PL McCarthy Jr 1 1 Division of Medicine, Roswell Park Cancer Institute, Buffalo; and 2 Division of Infectious Diseases, State University of New York, Buffalo, NY, USA Summary: Respiratory syncytial virus (RSV) infection is an important cause of respiratory mortality in immunosup- pressed patients, including bone marrow transplant (BMT) recipients. The presence of lower respiratory tract infection and infection in the pre-engraftment phase of BMT is believed to confer a poor prognosis. Three patients who underwent allogeneic BMT at our institution developed RSV pneumonia over 1 year post BMT, with the underlying disease in remission. All three were hypoxic with extensive pulmonary disease at presentation. Treatment consisted of aerosolized ribavi- rin and intravenous immune globulin with successful clearing of viral shedding and excellent clinical out- comes. RSV infection is probably less severe in the late post-BMT period, but needs to be considered early in the differential diagnosis of pulmonary infiltrates in this patient population. Bone Marrow Transplantation (2001) 27, 1071–1073. Keywords: RSV infection; late; BMT; ribavirin Respiratory syncytial virus (RSV) is a common pediatric pathogen with a predilection for winter outbreaks. In the adult population, RSV infections are increasingly recog- nized as important causes of respiratory mortality, primarily in immunosuppressed patients, including allogeneic bone marrow transplant (BMT) recipients. The clinical presen- tation in these sub-groups is frequently as an upper respir- atory tract infection (URTI) that can rapidly progress to viral pneumonia if untreated. This progression from URTI to pneumonia is much higher in the immediate post- transplant period. 1,2 RSV pneumonia in allogeneic BMT patients has been associated with mortality rates between 60% and 80%, despite aggressive treatment. Negative pre- dictors of outcome following RSV infection in BMT recipi- ents remain ill-defined, but include infection in the pre- Correspondence: Dr NI Khushalani, Division of Medical Oncology, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, USA Received 18 December 2000; accepted 12 March 2001 engraftment period, lower respiratory tract infection, delay in initiation of ribavirin therapy, and possibly unrelated donor transplants and acute myeloid leukemia (AML) as the underlying disease. 1–5 There are few data regarding RSV infections in adult BMT recipients 1 year or more after transplant. We report three such cases of RSV infection at the Roswell Park Can- cer Institute (Buffalo, NY) treated successfully with aero- solized ribavirin and intravenous immune globulin (IVIG) during the winter of 1999–2000. The absolute neutrophil count was normal and the underlying disease was in complete remission in all three patients. Case reports Patient 1 is a 24-year-old female, who was 384 days follow- ing an allogeneic BMT for chronic myelogenous leukemia from an HLA-matched sibling donor. The conditioning regimen used for BMT was busulfan and cyclophospham- ide. The post-BMT course was complicated by acute and chronic graft-versus-host disease (GVHD) requiring methy- prednisolone, cyclosporine and tacrolimus therapy. She had completed a course of immunosuppressive therapy 2 weeks prior to detection of RSV infection. The patient was receiv- ing trimethoprim/sulfamethoxazole, penicillin and acyclo- vir prophylaxis. Presenting symptoms included sinus con- gestion, cough with mucopurulent expectoration and dyspnea on exertion. Her 15-month-old infant had had symptoms of URTI within the preceding weeks. She was afebrile and hemodynamically stable. Pulmonary examin- ation revealed clear lung fields. Pulse oximetry upon ambu- lation dropped to 80% on room air and she was admitted to hospital. Chest radiograph was normal. Computerized tomogram (CT) of the sinuses revealed pan-sinusitis. Chest CT scan showed bilateral interstitial infiltrates predomi- nantly reticular with a nodular component. Ampicillin/ sulbactam and levofloxacin (to cover atypical bacteria) were begun. A bronchoscopic alveolar lavage (BAL) done the next day revealed mild neutrophilic pleocytosis. Bac- terial culture grew viridans streptococci, felt to be an oral contaminant. Fungal and mycobacterial cultures were nega- tive. RSV was detected by immunofluorescence assay (IFA) in the bronchial washings, while other viral studies