36-YEAR-OLD MAN WITH ACUTE INFLUENZA AND SECONDARY BACTERIAL PNEUMONIA COMPLICATED BY HERPES VIRUS INFECTION

Abstract

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Herpes Simplex Virus (HSV) pneumonia is rare in immunocompetent individuals. It has been described in young to middle aged patients with flu-like symptoms [1]. It should be suspected in patients with clinical deterioration despite antimicrobial therapy [2]. Diagnosis is made by PCR, culture, cytopathology and response to acyclovir therapy. Active infection is controversial since HSV-1 is commonly identified in the respiratory tract mucosa of critically ill patients [1-3]. CASE PRESENTATION: Patient is a 36 year-old male with history of bronchial asthma presented to an outside hospital with acute onset dyspnea, productive cough and worsening of hemoptysis for one week prior to admission. Exposures include sand blasting and cotton processing. He presented with fever, bilateral pulmonary infiltrates, and respiratory failure that required intubation with mechanical ventilation. Multifocal consolidative changes with air bronchograms and ground glass opacities were seen on CT Chest. Influenza A/H1 was diagnosed by PCR and treated with oseltamivir as well as antibacterial antibiotics for superimposed bacterial infection. Initial bronchoscopy with BAL did not show fungal or bacterial growth. Autoimmune panel and HIV were negative. Despite appropriate antibiotic coverage, he failed he failed to improve. On hospital day 7, he developed fever and a rash. His antibiotics were changed to vancomycin and meropenem. Repeat bronchoscopy was performed. Erythematous bronchial mucosa with mucopurulent exudate were seen. BAL cultures were negative for bacteria, fungi or PJP. DFA was positive for HSV1 with a positive viral culture. Antibiotics were discontinued, and he was started on acyclovir. Patient’s ventilator requirements decreased and chest imaging improved. He was successfully extubated on day 16th DISCUSSION: Pathogenic mechanisms for HSV pneumonia include stress induced by mechanical ventilation, systemic inflammation and respiratory distress which contribute to viral reactivation in the lower respiratory tract [1-3]. Chronic lung disease can also be an important factor as illustrated in our case. There are no established diagnostic criteria for HSV pneumonia and guidelines on its treatment with acyclovir are sparse. HSV diagnosis is a challenge, and it should be considered after excluding other infection sources, inflammatory and autoimmune causes. CONCLUSIONS: HSV pneumonia can be suspected in patients with prolonged mechanical ventilation. It requires a high index of suspicion. HSV pneumonia is associated with worse outcomes and longer hospital stays. Reference #1: Ishihara T, Yanagi H, Ozawa H, et al. Case report: Severe herpes simplex virus pneumonia in an elderly, immunocompetent patient. BMJ Case Rep (2018) 18 July 2018: 1- 4. Reference #2: Linssen CF, Jacobs JA, Stelma FF, et al. Herpes simplex virus load in bronchoalveolar lavage fluid is related to poor outcome in critically ill patients. Intensive Care Med 2008;34:2202–9. Reference #3: Simoons-Smit AM, Kraan EM, Beishuizen A, et al. Herpes simplex virus type 1 and respiratory disease in critically-ill patients: Real pathogen or innocent bystander? Clin Microbiol Infect 2006;12:1050–9. DISCLOSURES: No relevant relationships by Mohamed Elmassry, source=Web Response No relevant relationships by John Makram, source=Web Response No relevant relationships by Barbara Mantilla, source=Web Response No relevant relationships by Arunee Motes, source=Web Response No relevant relationships by Victor Test, source=Web Response No relevant relationships by Myrian Vinan Vega, source=Web Response No relevant relationships by Wasawat Vutthikraivit, source=Web Response