HERPES SIMPLEX VIRUS PNEUMONITIS IN A CRITICALLY ILL PATIENT WITH SARS-COV-2

ABSTRACT

SESSION TITLE COVID-19 Co-Infections SESSION TYPE Rapid Fire Case Reports PRESENTED ON 10/19/2022 1245 pm - 145 pm INTRODUCTION: Herpes simplex type 1 (HSV-1) related respiratory tract infections have been described in critically ill or immunocompromised patients. We present a case of HSV-1 pneumonia in a mechanically ventilated and immunocompromised patient in the setting of SARS CoV-2 infection. CASE PRESENTATION A 54-year-old female on Rituximab for Rheumatoid arthritis presented with shortness of breath and cough. She was afebrile, tachypneic and hypoxic. She was discharged 1 week prior after a 3 weeklong treatment for COVID-19 pneumonia. CT Angiogram showed extensive bilateral patchy consolidations with ground-glass infiltrates and subsegmental pulmonary emboli. Patient was initiated on heparin and broad-spectrum IV antibiotics with steroids for presumed ARDS with superimposed bacterial pneumonia. Her respiratory failure worsened requiring invasive mechanical ventilation. Failing oxygenation despite aggressive therapy prompted further workup that showed a normal echo and negative blood cultures. Sputum was negative for Pneumocystis pneumonia and Tuberculosis. Cytology from tracheal aspirate showed bronchial cells with inclusions and multinucleations consistent with HSV-associated cytopathic changes. A positive serum HSV-1 IgG and serum quantitative PCR of HSV-1 DNA solidified the diagnosis. Ganciclovir therapy was initiated to cover for HSV and Cytomegalovirus (CMV), however, a serum CMV PCR was negative. Within a day, her clinical course took a downward spiral. CT chest was repeated which showed worsening airspace disease. Despite ganciclovir therapy, the severity of lung disease led to eventual failure of oxygenation and patient demise. DISCUSSION: Prolonged mechanical ventilation due to ARDS is a risk factor for HSV bronchopneumonia in patients with COVID-19 and has shown an increased mortality 1,2. Diagnosis can be achieved by viral culture or observing cytopathic effects of HSV on cells in tracheobronchial aspirates, bronchoalveolar lavage, or biopsy3. In critically ill patients early treatment has been shown to prolong the ICU time to death and improved oxygenation4. It is important to test for co-infections as about 65% of HSV pneumonia cases are associated with pathogens like CMV and Pneumocystis5. CONCLUSIONS: Worsening respiratory disease in mechanically ventilated COVID-19 patients despite antibiotic therapy for suspected superimposed bacterial infection warrants a workup for secondary viral infections like HSV. Increased mortality is seen if not promptly treated. Reference #1 1. Meyer A, Buetti N, Houhou-Fidouh N, et al. HSV-1 reactivation is associated with an increased risk of mortality and pneumonia in critically ill COVID-19 patients. Critical Care. 2021/12/06 2021;25(1)417. doi10.1186/s13054-021-03843-8 Reference #2 Le Balc'h P, Pinceaux K, Pronier C, Seguin P, Tadié J-M, Reizine F. Herpes simplex virus and cytomegalovirus reactivations among severe COVID-19 patients. Critical Care. 2020/08/28 2020;24(1)530. doi10.1186/s13054-020-03252-3 Reference #3 Shah JN, Chemaly RF. Herpes Simplex Virus Pneumonia in Patients with Hematologic Malignancies. Pulmonary Involvement in Patients with Hematological Malignancies. 2010301-311. doi10.1007/978-3-642-15742-4_24 DISCLOSURES No relevant relationships by Andrew Cox No relevant relationships by Syeda Hassan No relevant relationships by Maria Khan No relevant relationships by Malik Muhammad Uzair Khan No relevant relationships by Rameesha Mehreen No relevant relationships by Rahat Ahmed Memon No relevant relationships by Ifrah Naeem No relevant relationships by Laura Walters