Age: 27.0
Sex: F
Vaccine: FLUX, FLUX
Symptoms: Exposure during pregnancy, Foetal disorder, Hypotension, Increased upper airway secretion, Influenza A virus test positive
Clinical narrative: Mother case: Case number PHHY2015US143897 is an initial literature report received on 02 Nov 2015. The author described 3 cases of Respiratory Syncytial Virus (RSV) infection diagnosed at a center during winter 2014. This report refers to a 27 year old female patient who was pregnant (gravida 2, para 0). Her medical history included obstetric history of spontaneous abortion at 8 weeks and smoking half to one pack of cigarettes per day before pregnancy. Her current condition included asthma from childhood. Her concomitant medications were not reported. She was vaccinated with influenza vaccine (manufacturer and batch number: not reported) on an unknown date during pregnancy. Her pregnancy was complicated by fetal hydrocephalus consistent with aqueductal stenosis, which was diagnosed during the second trimester and was therefore unrelated to her pulmonary complications. Her fetus was noted to be in the breech presentation. Five days before seeking treatment at the institution, she was seen in a local emergency room for worsening cough and dyspnea. A rapid influenza test was negative, and she was treated with a 5-day course of prednisone (unknown manufacturer) and salbutamol (unknown manufacturer) for exacerbation of asthma. Three days later, fever developed, and her cough was productive for green sputum. She was given azithromycin (unknown manufacturer). She sought treatment with worsening cough, congestion, fever and chills at week 34 and day 4 of gestation. She was admitted to the hospital after no improvement of her illness. At the time of admission, her leukocyte count was 21 x 10^9 cells/L and chest radiograph showed a nonspecific opacity in the right middle lobe, which evoked concern for pneumonia. Nasopharyngeal aspirate was sent to be tested by viral respiratory Polymerase Chain Reaction (PCR) panel. The panel was positive for influenza A (H1N1) virus and RSV. The patient was given ceftriaxone (unknown manufacturer, vancomycin (unknown manufacturer), azithromycin and oseltamivir (unknown manufacturer) because of concern for secondary bacterial infection. Her oxygen saturation was stable (91%-94% on room air). On the afternoon of hospital day (HD) 2, her membranes ruptured. Because of her pulmonary status, the decision was made to defer delivery because there were no signs of active labor. On HD3 at week 34 and day 5 of gestation, she reported contractions, and cervical dilation was noted. Given the fetal hydrocephalus (biparietal diameter 11.6 cm) and breech presentation, she underwent a classical cesarean delivery of a female infant weighing 3,640 grams and with 1- and 5-minute Apgar scores of 3 and 7, respectively (see child case: PHHY2015US146254). During the cesarean closure, the patient required intubation and conversion to general anesthesia owing to increased secretions, hypotension and tachycardia. She remained intubated and was transported to the surgical intensive care unit (ICU) after delivery. She was extubated without difficulty within an hour of ICU admission and transferred to the postpartum unit 12 hours after delivery. While recovering in the postpartum unit, she had an episode of pulmonary edema that was successfully treated with furosemide. The remainder of her postpartum course was uncomplicated and she completed a regimen of 10 days of azithromycin and 5 days of oseltamivir. She was discharged to her home on HD10 with percentages of oxygen saturation in the mid-90s on room air. Action taken with prednisone, azithromycin, ceftriaxone, vancomycin, albuterol and oseltamivir were not known. The infant did well from a respiratory standpoint and was discharged on day of life 20 after an uncomplicated shunt placement due to hydrocephalus. The infant was doing well at the date of reporting. The outcome of the events was not reported. The author concluded the article stating that RSV infection might pose a substantial risk for hospitalization and further complications in pregnant women and the infection was likely worsened in the setting of baseline pulmonary disease such as asthma and tobacco use. The author also stated that the cases presented demonstrated the wide spectrum of maternal disease and emphasized the potential for maternal benefit for an RSV vaccine administered during pregnancy.