RSV can be a major contributor to morbidity and mortality once in the NICU [6]. Once infection of host cells occurs, epithelial cell necrosis leads to the production of mucus plugs combined with cellular debris and subsequent inflammation, creating a one-way valve mechanism for air entry and localized atelectasis, leading to hyperinflation [3]. With decreased immune function, narrow alveolar diameters, decreased lung volume and underdeveloped lung anatomy; premature infants are uniquely susceptible hosts to this pathogen [6].
Though the major clinical manifestations of RSV include increased secretions associated with obstructive-type lung disease, apnea, wheezing and respiratory distress, we report the first case of pulmonary hemorrhage associated with RSV infection in an otherwise stable low birth weight infant. Risk factors for pulmonary hemorrhage in neonates include prematurity, mechanical ventilation, bleeding diathesis, patent ductus arteriosis, exogenous surfactant administration, and barotrauma. Given the multi-factorial nature of pulmonary hemorrhage and the presence of risk factors in this infant, direct causality of RSV cannot be determined.
However, the patient's negative blood cultures, failure to improve on antibiotics, negative viral cultures for other viruses such as adenovirus, normal coagulation profile and positive RSV assay argue for this agent as a probable factor for pulmonary hemorrhage, especially in the context of a known sick contact. Further studies are required to further clarify the relationship between these two conditions.
Numerous outbreaks of RSV in the NICU have been described [7]-[9]. Given its high degree of infectivity and ability to survive on inanimate surfaces, the NICU allows for efficient spread of the virus to other neonates, especially if strict hand washing policies are not enforced. Thus once an index case is discovered, it is critical to prevent spread of the pathogen and secondary cases. Currently, American Academy of Pediatric (AAP) guidelines for control of nosocomial RSV infection is strict adherence to infection control practices, including:
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Strict handwashing policies before and after each patient contact for 15 seconds.
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Laboratory screening of patients for RSV infection.
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Cohorting infected patients and staff.
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Exclusion of visitors and staff with respiratory tract infections.
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Use of gowns, gloves goggles and masks.
These guidelines were directed at the older age high-risk pediatric hospital population, not the closed environment of the NICU. Kilani described a stricter infection control policy during eight cases of RSV in the neonatal unit. Affected patients were cohorted and examined only with gowns, gloves and masks in accordance with the guidelines established by the AAP for older children [7]. While anecdotal, such policies should also be considered in the NICU population.
Once detection of RSV had occurred in our unit, all infants cared for by the patient's nurse for the past 10 days were tested for RSV infection. RSV infection was detected in two other infants, including the patient's brother, who was symptomatic with rhinorrhea and coughing. The patients were cohorted and assigned one nurse with strict contact precautions observed. No specific medical team was assigned to these three patients and the NICU was not fumigated. Palivizumab, was administered to all infants meeting the AAP pre-discharge and outpatient criteria for preventive administration after surveillance testing documented the patients as RSV negative. Additional discussion with families and staff was enforced regarding the importance to restrict visitation by individuals with respiratory infections. No further cases were identified.