Introduction: Respiratory Syncytial virus causes severe illness in children and immunocompromised elderly persons on chemotherapy  but has been reported rarely in liver transplant recipients. we report a case of a living donor transplant recipient who presented with severe RSV pneumonitis following urgent LDLT for ACLF.

Method: 63 yr NASH cirrhosis with DM type I, prior CABG 10 yrs ago was initially listed at MELD 15 for DDLT. He was infected with COVID 19 during the second wave of infections in India reuiring hospitalisation. developed ACLF grade 1 with SBP, AKI and HE; advised early LDLT. A suitable related ABO compatible donor was found and evaluated. pre op Covid PCR was negative both donor and recipient. Pre Transplant MELD Na was 31.

Result: Right lobe LDLT ( with Splenic artery ligation was performed. The graft weighed  630 gm( GRWR 0.84.Due to high intraop portal flow (310 ml/100gm/min)  SAL was done with final flow 210 ml/100gm /min. Received Bsasiliximab 20 mg intraop and D4 and Steroid 10 mg per kg intraop that was tapered to 20 mg by D5. tacrolimus started d4 with target levels 5-8 by D7. Post op course complicated by hypoactive delirium that gradually improved. Shifted to room on D14. During dicharge planning and education developed CMV viremia with thrombocytopenia and anemia. Managed with oral therapeutic Valganciclovir for 2 weeks then prophylactic dose continued. D22 wosening cough and  febrile illness. ANtibiotics and antifungals restarted. CMV DNA PCR and all cutltures were negative. Devloped worsening chest infiltrates and hypoxemia requiring intubated and ventilation. Serum and BAL for galactomannan, Beta glucan and Pneumocystis staining were negative. PCR based respiratory virus panel positive for RSV. Started on IVIg (0.4 gm/kg X 4 days) &Ribavirin (15 mg/kg, 4 weeks). Tracheostomy done on D5 of intubation. Became afebrile after 3 days of therapy with gradual improvement in respiratory parameters and chest imaging. RSV DNA negative after 3 weeks. Finally trachesotomy removed and discharged on D 65.

Conclusion: This patient had  multiple predisposing factors  for RSV (age, DM, immunosuppression and CMV). Prior COVID 19 pneumonia is likely  another  factor repsonsible for devloping RSV. Respiratory viral panel including RSV PCR is recommended in elderly Liver Transplant recipients to diagnose atypical pneumonitis not responding to antibiotics and antifungals. Ribavirin and IVIg may help in salvaging these sick patients. RSV vaccine once available should be added to pretransplant protocol in elderly and other high risk recipients.