Human rhinovirus infection and cirrhosis: A potential fatal complication

Dear Editor,

A 39-year-old male patient was admitted to our hospital for fever, chest pain, altered mental status, and vomiting. Medical history included active alcoholic liver cirrhosis (Child Pugh B9, MELD 15). On initial examination Glasgow Coma Scale score was 11, body temperature was 38.2 °C, poor nutritional status was poor (body mass index 15.8) and ascites was present. Laboratory results showed: C-reactive protein (CRP) 106 mg/L, white blood cell count (WBC) 9.8 Giga/L (84% neutrophils), international normalised ratio (INR) 1.83, and total bilirubin 64 μmol/L. Blood gas analysis showed respiratory alkalosis (pH 7.55, paCO₂ 17 mmHg, HCO₃ ⁻ 15 mmol/L), without hypoxaemia (paO₂ 109 mmHg). Brain computed tomography (CT) was normal, and chest X-rays showed diffuse alveolar pneumonia, mainly affecting the right lung.

Aspiration pneumonia with acute-on-chronic liver failure was suspected due to the vomiting and altered mental status, and antibiotic therapy with ceftriaxone and metronidazole was started in the Emergency Room, along with disaccharides. After an initial improvement, his respiratory status worsened 5 days later. Blood gas analysis showed compensated metabolic acidosis (pH 7.39, paCO₂ 19 mmHg, HCO₃ ⁻ 11 mmol/L) with hypoxaemia (paO₂ 81 mmHg on 6 L/min oxygen). The WBC increased to 16.7 Giga/L (83% neutrophils). CRP value had initially improved and remained unchanged (31 mg/L). Chest CT (Fig. 1 ) showed an alveolar and interstitial infiltrate different from the initial images and led to a suspicion of opportunistic Pneumocystis jirovecii pulmonary infection. Human immunodeficiency virus testing was negative. Bronchoscopy with bronchoalveolar lavage (BAL) was performed: immunofluorescence assay and polymerase chain reaction (PCR) for P. jirovecii was negative, and other classical opportunistic microorganisms. Other unusual microorganisms were considered and human rhinovirus (HRV) was identified by culture and PCR, with rhinovirus A/B/C detection. No other viruses (Influenza, Parainfluenza, Syncytial, Coronavirus, Metapneumovirus, Cytomegalovirus, Human bocavirus) were detected.

Fig. 1.

Lung computed tomography scan at Day 5, showing alveolar and interstitial pneumonia.

Despite the worsening of respiratory status, after consulting a pulmonologist and an infectious disease specialist, corticosteroids were not administered in this immunocompromised patient with a viral lung infection. The patient developed acute respiratory syndrome distress and died following multi-organ failure.

To our knowledge, this is the first reported case of fatal HRV infection in a cirrhotic patient. Cirrhotic patients are immunocompromised [1], and can develop more obvious and more severe infections compared to non-cirrhotics; bacterial infections result in higher mortality in cirrhotic patients and spontaneous opportunistic infections have been described [2]. In this patient, alcohol abuse and malnutrition might have contributed to a dysfunction of cellular immunity with a reduction in T-lymphocyte-mediated response [3] that worsened the immunosuppression due to cirrhosis. Furthermore, malnutrition and alcohol abuse increased the risk of pneumonia with a poor prognosis once established.

HRV is an RNA virus belonging to the Picornavirus family. Typically, it is found in the lungs and oropharynx and causes the “common cold” [4]. Generally, the course of infection is favourable and it mainly affects children. In adults, HRV can cause chronic bronchitis exacerbation and lobar lung infection. Patients with HRV are rarely admitted to the Intensive Care Unit unless they have comorbidities [4]. Severe HRV infections are described in severely immunocompromised patients, such as haematopoietic cells transplant recipients [5]. No specific treatment is available, although recent studies have examined potential therapies, such as pleconaril and BTA-798 [5].

In conclusion, Liver cirrhosis results in an immunosuppression condition that can expose the patient to various opportunistic infections. Here, we report the first case of fatal pneumonia due to HRV in a cirrhotic patient.

Opportunistic lung infections should be suspected in patients with alcoholic cirrhosis developing interstitial pneumonia. Extended research of opportunistic microorganisms included HRV must be performed because of their potential life-threatening nature.

Conflict of interest

None declared.