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The impact of novel influenza A (H1N1) after hematopoietic SCT

Bone Marrow Transplantation volume 45, pages 1756–1757 (2010)Cite this article

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Patients with hematological malignancy who undergo hematopoietic SCT (HSCT) remain profoundly immunosuppressed for approximately 1 year, or even longer if on prolonged anti-GVHD therapy. Based on evidence from previous influenza outbreaks,1 these patients are likely to be at a high risk of contracting novel influenza A (H1N1) during the current pandemic and of developing severe respiratory complications. However, data relating to the course of H1N1 infection in patients after HSCT are sparse, with only four anecdotal cases reported so far.2, 3, 4 Moreover, the role of steroids in the course of influenza in these patients is still unclear.5 Here we describe five cases of H1N1 infection identified at our institution in the past 6 months in adult patients transplanted with peripheral blood HSC. None of them had been vaccinated against H1N1 virus. Diagnosis of H1N1 was made by real-time reverse transcriptase PCR (rRT-PCR) assay in four cases and by rapid-Ag detection in one case. Patient characteristics and outcome are shown in Table 1. Of the five patients, one patient received an autologous and four patients an allogeneic HSCT from related (n=3) or unrelated (n=1) donors. The time from transplant to H1N1 was on average 14 months for allo-transplant patients and 3 months for the autologous transplant case. Late infection in allotransplant cases is likely associated with the development of chronic GVHD. In fact, all the four allotransplant patients had a history of GVHD, and three were still on immunosuppression with either tacrolimus and/or prednisone or mycophenolate mofetil at the time of the H1N1 infection. Of five cases only one died. This was a patient on high-dose corticosteroids for chronic GVHD. She developed progressive pneumonia despite prolonged treatment initially with oseltamivir and then with i.v. peramivir. rRT-PCR on nasal swab and bronchoscopy specimens 9 days apart was positive for H1N1 infection; the bronchoscopy also demonstrated parainfluenza type 1 and invasive pulmonary aspergillosis. The patient required admission to the intensive care unit, intubation and mechanical ventilation. She had Rhizopus growing from sputum cultures shortly before her death.

Table 1 Characteristics, treatment and outcome of the five transplanted patients with H1N1 infection in the study
Full size table

All our patients were started on early empirical treatment with oseltamivir, and this may have helped the course of symptoms in four of them. However, in the case of patients on high-dose steroids, or on multiple lines of immunosuppressive therapy due to GVHD, the risk of lethal complications remains very high. Based on these findings, our current strategies to limit infection in the transplant population include not only recommending isolation from contacts with influenza-like illness but also offering H1N1 vaccination. Although sub-optimal immune responses may be observed in these immuno-compromised patients,6 we believe it may still represent a useful preventive tool against lethal complications.

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Authors and Affiliations

  1. Section of Hematology/Oncology, Chicago, IL, USA

    P Patel, K Sweiss, S Shatavi, D Peace & D Rondelli

  2. Section of Infectious Diseases, University of Illinois at Chicago, Chicago, IL, USA

    N Clark

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  1. P Patel
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  2. K Sweiss
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Correspondence to D Rondelli.

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Patel, P., Sweiss, K., Shatavi, S. et al. The impact of novel influenza A (H1N1) after hematopoietic SCT. Bone Marrow Transplant 45, 1756–1757 (2010). https://doi.org/10.1038/bmt.2010.57

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