HSV PNEUMONIA IN AN IMMUNOCOMPETENT PATIENT PROGRESSING TO ORGANIZING PNEUMONIA

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: HSV pneumonia has been rarely reported in immunocompetent patients. We report a case of a 75-year-old healthy female with intractable pneumonia diagnosed as HSV that progressed to organizing pneumonia CASE PRESENTATION: A 75-year-old female with a past medical history of Barrett's esophagus presented to the ER with a 3-week history of fatigue, fevers, and shortness of breath. She had no family history of autoimmune disorders, she moved from Iran 40 years ago and had no known exposure to TB. She denied smoking and had no pets or any other exposures. Labs showed leukocytosis of 14000 with neutrophilic and monocytic predominance, mild hyponatremia (132 meq/L), and a procalcitonin of 0.25 ng/ml. Chest X-ray revealed infiltrates in the right upper and lower lobes. She was started on ceftriaxone and azithromycin but continued to worsen. Antibiotics were broadened again without clinical response. Urine streptococcus, legionella antigen, B-D-glucan, Tuberculin skin test, HIV, histoplasma were all negative. Bronchoscopy was done on day 10 that revealed copious clear, yellow clear fluid in her proximal and distal airway and with similarly appearing fluid with mucus plugs on the BAL. Cultures from BAL including modified AFB for nocardia were unrevealing. Rheumatological workup including, ANA, ANCA, anti-CCP, Sjogren's antibody, myositis panel, HSP was also negative. Subsequent CT scan revealed worsening infiltrates and a right-sided pleural effusion, patient underwent thoracentesis, and cultures on pleural fluid were positive for HSV. The patient underwent a VATS biopsy (Day 22) that revealed organizing pneumonia with thickened alveoli and fibrinous plugs. HSV 1 IgG antibodies were also positive. She was started on steroids and acyclovir with significant improvement. DISCUSSION: HSV is known to infect the upper airway and can cause gingivostomatitis and pharyngitis. It can progress to pneumonitis or pneumonia in patients who are immunocompromised or mechanically ventilated. Only in rare cases does it manifest as clinically significant lower respiratory tract infections in immunocompetent individuals. Our patient had a biphasic illness, she was diagnosed based on the HSV culture on the pleural fluid, which has a specificity of 99%. Her second episode of respiratory failure with worsening infiltrates represented the development of organizing pneumonia that responded to steroids. The use of acyclovir in such patients is not supported by clinical trials and needs to be studied. Our patient finished a course of acyclovir and was treated with steroids for several weeks. CONCLUSIONS: HSV pneumonia should be considered as an etiology of intractable pneumonia when patients do not show clinical improvement on conventional therapy. This case also suggests that acute herpes infection can have serious complications like organizing pneumonia and further studies are needed to understand this association. REFERENCE #1: Mills B, Ratra A, El-Bakush A, Kambali S, Nugent K. Herpes Simplex Pneumonia in an Immunocompetent Patient With Progression to Organizing Pneumonia. J Investig Med High Impact Case Rep. 2014 Apr 9;2(2):2324709614530560. doi: 10.1177/2324709614530560. PMID: 26425602; PMCID: PMC4528890. REFERENCE #2: Martinez E, de Diego A, Paradis A, Perpiñá M, Hernandez M. Herpes simplex pneumonia in a young immunocompetent man. Eur Respir J. 1994 Jun;7(6):1185-8. PMID: 7925891. DISCLOSURES: No relevant relationships by Chahat Puri, source=Web Response No relevant relationships by Kyunghoon Rhee, source=Web Response No relevant relationships by Donald Slack, source=Web Response No relevant relationships by Jennifer Sullivan, source=Web Response No relevant relationships by Ari Zaiman, source=Web Response