(1233) The Silent Storm: From RSV to ARDS

Introduction: Respiratory syncytial virus (RSV) is a common respiratory virus that typically causes mild, cold-like symptoms. Severe manifestations are prevalent in young children, immunocompromised, and those with underlying cardiopulmonary conditions. RSV rarely causes respiratory failure and acute respiratory distress syndrome (ARDS) in adults without significant comorbidities.

Description: Our case entails a 48-year-old Hispanic female who presented with persistent shortness of breath, dry cough, and wheezing for 4 days. She denied any exposure to sick individuals, recent travels, or hospitalizations. On examination, she was tachycardic, tachypneic, with increased work of breathing, saturating 68% on nebulizer treatment and then 89-90% after transitioning to Bilevel positive airway pressure (BPAP) therapy. BP 102/83 mmHg, HR 128 beats/min, RR 16 breath/min, T 36.2 C. Chest imaging showed bilateral ground-glass opacities. She was treated with Dexamethasone, Magnesium, and Duonebs, but left against medical advice.
The next day, she returned with worsening symptoms and severe hypoxia (SpO2 68%). Started on BPAP but was intubated due to persistent respiratory distress. RSV was confirmed, and chest X-ray revealed bilateral pulmonary infiltrates. Arterial blood gas analysis indicated hypoxia with a P:F ratio 85.6 revealing severe ARDS.
Ventilator settings were adjusted routinely, to keep a plateau pressure ≤30 cm H2O and tidal volume of 6cc/kg. She required increased PEEP as high as 14cmH2O. She underwent a 4-day proning protocol, was paralyzed/sedated, and treated with diuretics, antibiotics and systemic corticosteroids. Her condition improved and was extubated to high-flow nasal cannula. An echocardiogram showed an LVEF of 55-60% with trace pericardial effusion. She was discharged without the need for supplemental oxygen.

Discussion: RSV can present similarly to COVID-19, causing severe ARDS even in adults without significant comorbidities or immunocompromised conditions. Although steroid use in viral infections can be controversial, it appeared beneficial in this case. With the RSV vaccine recent approval for adults aged ≥60, it is reasonable to add RSV to the differential diagnosis. Just as we have learned to recognize COVID-19 rapidly, we should apply similar strategies for identifying RSV cases.