Microbiology
- Herpes Simplex Virus (HSV): xxx
Clinical Manifestations
Pulmonary Manifestations
HSV Tracheobronchitis
- Epidemiology
- HSV has been prospectively cultured from 78% of ARDS patients -> however, isolation does not imply infection
- May present without any antecedent HSV mucocutaneous lesions
- Diagnosis
- FOB:
- Diffuse Erythema:
- Pearl-White Fibrinous Plaques:
- Diffuse Bronchial Wall Edema:
- BAL Cytology: intranuclear inclusions (dark material in nuclei) and diagnostic triple-M nuclear features of HSV infection:
- Molding (nuclei abut and line up with each other)
- Margination (condensation of nuclear chromatin along the margin of nuclei)
- Multinucleation
- FOB:
- Clinical: bronchospasm unresponsive to conventional therapy (see Obstructive Lung Disease, [[Obstructive Lung Disease]])
Chronic HSV Ulcerative Pharyngitis-Laryngotracheitis
- Risk Factors
- Advanced Age
- Human Immunodeficiency Virus (HIV) (see Human Immunodeficiency Virus, [[Human Immunodeficiency Virus]])
- Immunosuppression
- Physiology: spread may occur form oral/labial lesion to airway or esophagus
- Diagnosis
- FOB: predominantly central bronchial 5-15 mm heaped-up mucosal ulcerations (slowly progressive and may coalesce) on white or gray base with surrounding erythema
- Brush of lesion: HSV-DFA may be positive/HSV culture may be positive
- CXR/Chest CT Patterns
- Normal CXR: usual pattern in elderly cases
- FOB: predominantly central bronchial 5-15 mm heaped-up mucosal ulcerations (slowly progressive and may coalesce) on white or gray base with surrounding erythema
- Clinical
- Painful Oral/Labial/Pharyngeal Mucosal Ulcerations (see Pharyngitis, [[Pharyngitis]]): usually absent in elderly cases
- Dyspnea
- Wheezing: some elderly cases may present mainly with wheezing (typically refractory bronchospasm) and respiratory failure (notably without previous history of lung disease)
- Chest Pain
- Cough
- Dysphagia (if esophagus involved)
- Diaphoresis
- Fever/Chills
- Hypotension: may occur
HSV Pneumonia
- Risk Factors
- Burns
- Human Immunodeficiency Virus (HIV) (see Human Immunodeficiency Virus, [[Human Immunodeficiency Virus]])
- Immunosuppression
- Malignancy
- Neonates
- Post-Transplant
- Diagnosis
- CXR/Chest CT Patterns
- Focal or multifocal infiltrates (in cases of direct extension)
- Diffuse bilateral infiltrates (in cases of hematogenous spread)
- CXR/Chest CT Patterns
- Clinical
- Pneumonia-Like Presentation (see Pneumonia, [[Pneumonia]])
- Acute Lung Injury-ARDS (see Acute Lung Injury-ARDS, [[Acute Lung Injury-ARDS]])
- Pleural Effusion (see Pleural Effusion-Exudate, [[Pleural Effusion-Exudate]])
Genital Manifestations
- Genital Herpes Simplex Virus (HSV)
- Painful, Genital Ulcers
- Headache
- Fever
- Tender Inguinal Lymphadenopathy
General Dermatologic Manifestations
- Vesicular Skin Lesions (see Vesicular-Bullous Skin Lesions, [[Vesicular-Bullous Skin Lesions]])
- Erythema Multiforme (see Erythema Multiforme, [[Erythema Multiforme]])
- Stevens-Johnson Syndrome (SJS)/Toxic Epidermal Necrolysis (TEN) (see Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis, [[Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis]])
Treatment
- Acyclovir (see Acyclovir, [[Acyclovir]])
- Dose/Administration: 5 mg/kg IV q8 hrs (with optimal duration unknown)
- Decrease dose for /CrCl <50 mL/min (high drug levels in these patients may cause encephalopathy, seizures)
- Adverse Effects: N/V/D, headache, rash
- Pregnancy: safe during first trimester
- Foscarnet (see Foscarnet, [[Foscarnet]])
- Dose/Administration: 40 mg/kg IV q8 hrs x 14-21 days
- For acyclovir-resistant HSV
- Prophylactic Acyclovir (see Acyclovir, [[Acyclovir]])
- Decreases HSV isolation rates in the ICU, but does not impact outcome
References
- Prevention of lower respiratory Herpes simplex virus infection with acyclovir in patients with the adult respiratory distress syndrome. Am Rev Respir Dis 1987; 136:402-405
- Herpetic tracheobronchitis. Ann Intern Med 1988; 109:229-233
- Herpes simplex virus involvement of the lower respiratory tract following surgery. Chest 1994; 106(suppl):8S-14S [MEDLINE]