AN UNUSUAL CASE OF HERPES SIMPLEX VIRUS PNEUMONIA WITH NECROTIC AND CAVITARY CHANGES

Abstract

SESSION TITLE: Global Case Report Posters SESSION TYPE: Global Case Reports PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Herpes simplex virus (HSV) pneumonia can occur in both immunocompromised and immunocompetent patients. Ground glass opacities, consolidation, and pleural effusions are observed in HSV pneumonia. Neither necrosis nor cavitation has been reported in areas of parenchymal disease. We describe a case of HSV pneumonia with unusual multiple cavitary and necrotic changes. CASE PRESENTATION: A 63-year-old woman was referred to us on January 15, 2019. She had been managed as a case of community-acquired pneumonia for 15 days at another hospital but had been progressed to respiratory failure. On January 2, chest CT scan showed peribronchial and subpleural patchy consolidation, and multiple small nodules in both lungs. She was intubated on January 4. She had a medical history of hypertension. She was newly diagnosed with diabetes at admission. Upon admission, broad spectrum antibiotics were administered but she did not improve. On January 23, chest CT showed progressive necrotic and cavitary changes in areas of consolidation and small nodules in both lungs. Bilateral pleural effusion was also increased with multiple necrotic lymph nodes. Bronchoscopy on the same day showed scattered whitish plaque-like lesions, especially on both lower lobe bronchi. Biopsy showed ulceration, necrotic inflammatory exudate, extensive squamous metaplasia and several multinucleated epithelial cells containing intranuclear inclusions, consistent with HSV or varicella-zoster virus infection. Immunohistochemical staining showed a positive reaction to HSV. Viral serology, PCR, and viral, bacterial, and fungal cultures with bronchial aspirate showed negative results. Acyclovir therapy was started on January 24. Percutaneous catheter drainage was performed for left exudative pleural effusion. The patient improved slowly; a CT scan on February 12 showed overall improvement. She was moved to the general ward after being weaned off mechanical ventilation on February 14. DISCUSSION: HSV pneumonitis cannot be diagnosed based on imaging alone; evidence of viral cytopathic effect on cytologic and/or histopathologic specimens with confirmation of HSV infection via culture, PCR, or immunohistochemical staining is required. Detection of histological hallmarks of HSV infection, such as multinucleated cells with ground glass intranuclear changes and Cowdry type A intranuclear inclusion bodies, is specific for true lower respiratory tract infections rather than a carrier state, especially in critically ill patients. In this case, we could confirm HSV pneumonia by typical endobronchial lesions, histopathologic findings, immunohistochemical staining, and overall improvement on follow-up chest CT with acyclovir therapy. CONCLUSIONS: To our knowledge, this is the first reported case of HSV pneumonia with multiple cavitary and necrotic changes in areas of consolidation and nodules. Reference #1: Chong S, Kim TS, Cho EY. Herpes simplex virus pneumonia: high-resolution CT findings. Br J Radiol 2010; 83:585–589. Reference #2: Aquino SL, Dunagan DP, Chiles C, Haponik EF. Herpes simplex virus 1 pneumonia: patterns on CT scans and conventional chest radiographs. J Comput Assist Tomogr 1998; 22(5):795-800. Reference #3: Simoons-Smit AM, Kraan EM, Beishuizen A, Strack van Schijndel AJ, Vandenbroucke-Grauls CM. Herpes simplex virus type 1 and respiratory disease in critically-ill patients: real pathogen or innocent bystander? Clin Microbiol Infect 2006; 12:1050–1059 DISCLOSURES: No relevant relationships by Cheol-Woo Kim, source=Web Response No relevant relationships by Hong Lyeol Lee, source=Web Response