Impact of Cidofovir and Immunomodulation in Adenoviral ARDS: Our Experience

INTRODUCTION: Almost all of ARDS care continues to be supportive, and mortality remains high at 34% to 45% Time tested intervention has been lung protective mechanical ventilation and ECMO support. Recent review of 163 immunocompetent children with adenoviral pneumonia requiring ECMO has reported a survival rate of 38%. METHODS: INCLUSION: All children with adenoviral ARDS admitted in PICU EXCLUSION: Death within 24 hrs Ciofovir was administered with IVIG, once blood adenoviral copies were significant (10,000) with ARDS, adenoviral copies were repeated on Day 5 and repeat dose was given if they continued to be on respiratory support. RESPONDER: Increase in ALC count by 500. IMMUNOMODULATION: All patients received IVIG, if systemic hyperinflammation was present Anakinra was added as per unit protocol. RESULTS: Number of patients who recieved cidofovir was 14, Mean age was 73.6+/-22.8 months. Mean adenoviral copies in immunocompetent was 1,22,44,887 copies/mL whereas in immunocompromised patients it was 22, 28, 83,605 copies/mL. Only one dose of cidofovir was given in 59% of the patients, 2nd dose was given in 33% and 3rd dose in 8% of the patients. Mean ferritin was 8700(2000-25456). Acute Kidney injury was seen in 1 patient requiring dose modification. IVIG was given in all patients and anakinra was given in 28.5%. 42.8% children required HFOV. Among non-responders, ALC @ day 1 was 1680 and day 3 was 1930, with ICU stay of 16.8 %, compared to responders where ALC @ day 1 was 1511 and day 3 was 2074 with ICU stay of 11.25 days. Mortality was 37% in non-responders. Improvement in ALC had a direct relationship with improvement in Oxygenation index and outcome. CONCLUSION: Early identification of etiology is important, to deliver targeted therapy. Cidofovir helps in reducing the viral load and immunomodulation reduces ongoing lung injury secondary to cytokine storm. Early initiation of cidofovir helps in improvement in mortality and shorter duration of ventilation. ARDS: acute respiratory distress syndrome, ALC Absolute count, ICU- Intensive care.