Herpes Simplex Pneumonia in an Immunocompetent Patient With Progression to Organizing Pneumonia

Abstract

Background. Organizing pneumonia is an uncommon diffuse interstitial lung disease that affects the terminal and respiratory bronchioles, alveolar ducts, and alveoli. Most cases are idiopathic, but some are associated with infections. We present an uncommon case of organizing pneumonia associated with herpes simplex virus-1 (HSV-1). Case. A 39-year-old man with hypertension presented with dyspnea, fever, and productive cough for 2 weeks. He was treated for 5 days for acute bronchitis as an outpatient with no improvement. His examination revealed mild respiratory distress, O2 saturation 92% on room air, and right sided crackles. Labs included a white blood cell count of 19 300/µL. His chest x-ray showed bilateral infiltrates greater on the right. Bronchoalveolar lavage was positive for HSV-1; transbronchial biopsies showed focal pneumonitis with plentiful intra-alveolar macrophages. His respiratory status progressively deteriorated, and he was intubated for mechanical ventilation. He received 10 days of intravenous (IV) antibiotics and 14 days of IV acyclovir. He was readmitted 10 days later with worsening symptoms and was intubated for respiratory failure. His CT chest showed diffuse, patchy consolidation of both lungs, right more than left. Open lung biopsy showed extensive organizing pneumonia, diffuse alveolar damage, intra-alveolar macrophages, and pleural fibrosis; he was treated with IV corticosteroids. He was extubated after 10 days; within 2 weeks his chest x-ray was markedly improved. Discussion. Organizing pneumonia is usually idiopathic; infection is one of the secondary causes. To our knowledge this is only the second reported case associated with HSV. This association may have important pathogenic and therapeutic implications.

Herpes Simplex Virus Type 1 Pneumonia—A Review

“…It may cause infection of the lower respiratory tract, pneumonia or necrotizing pneumonitis. 1,3 –9 Pneumonia due to HSV can be seen in immunocompromised patients and may be due to direct extension from the upper airways secondary to tracheobronchitis. 1,3,6,7 Reports of healthy children with HSV pneumonia are infrequent.…”

“…1 In regards to the respiratory system, HSV-1 usually infects the upper airway and causes gingivostomatitis and pharyngitis. 1,7 The virus has been reported to be associated with pulmonary disease since 1949 but until 2 decades ago, HSV pneumonia was considered rare. The diagnosis was usually based on autopsy findings.…”

Herpes Simplex Virus Pneumonia: Importance of Aspiration Etiology

“…HSV pneumonia usually occurs in immunocompromised patients [5, 6] or in patients with preexisting lung disorders [6, 7]. HSV pneumonia in immunocompetent patients is rare [8, 9]. Our patient was old-aged, and his performance status was poor.…”

A 72-Year-Old Woman With Respiratory Failure and Bilateral Ground-Glass Opacities

“…HSV1P is rare and mostly observed in transplant recipients and those receiving immunosuppressants or steroids. As far as we know, the number of reports of HSV1P is limited to 10 cases of patients unaffected by transplantation, HIV, immunosuppressants, corticosteroids, burns, or malignancy [6][7][8][9][10][11][12][13][14] (Table 1). Unfortunately, although we did not initially suspect HSV1P in the current patient, cytologic findings of sputum provided a diagnostic clue, and we subsequently investigated HSV infection.…”

“…Acyclovir was generally selected for the treatment of HSV1P, [6][7][8][9][10][11][12][13][14]19 except in two cases (Table 1). The study patient improved spontaneously with no medications, 6 and a postmortem diagnosis of HSV1P was made in the other patient.…”