Herpes Simplex Virus-1 Tracheitis and Failure to Wean From Mechanical Ventilation in an Immunocompetent Host

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SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Herpes simplex virus-1 (HSV -1) is an ever-ubiquitous pathogen with the ability to infect multiple organ systems. In immunocompetent adult hosts, clinical infection with HSV-1 in the respiratory system is rare, though HSV-1 has been detected in respiratory secretions of mechanically ventilated, immunocompetent patients. It has also been implicated as a rare and reversible cause of tracheal stenosis in patients with failure to wean from mechanical ventilation. CASE PRESENTATION: We present a 42 year old woman with a past medical history of asthma, history of pulmonary embolism and prior history of tracheostomy, who presented to our intensive care unit (ICU) as a transfer from an outside hospital where she had been treated for non-productive cough, fever, chills and acute hypoxic respiratory failure. On admission to our facility, she had increased oxygen requirements which escalated from high flow nasal cannula to mechanical ventilation. A CT scan revealed diffuse bilateral airspace and interstitial disease as well as tracheal stenosis at the site of her prior tracheostomy. Though the patient had been treated appropriately with broad-spectrum antibiotics for an extensive period of time, she had worsening respiratory failure with persistent leukocytosis and fevers. A bronchoscopy with bronchoalveolar lavage was performed, revealing a negative microbial work up with exception of polymerase chain reaction (PCR) detection of HSV-1. She was started on acyclovir, and in under 48 hours, was subsequently weaned from the ventilator. DISCUSSION: Respiratory failure with tracheobronchial involvement secondary to HSV infection in immunocompetent hosts is likely under recognized and under-reported. Based on our case and limited literature, HSV-1 has the potential to cause tracheal stenosis with tracheitis and respiratory failure with failure to wean from ventilation. Current treatment with acyclovir is effective in resolving the infection, and may have the additional benefit of reversing tracheal stenosis. Post treatment bronchoscopy has even demonstrated resolution of the inflammation and narrowing in some reports. CONCLUSIONS: In immunocompetent hosts with respiratory failure with tracheal stenosis and failure to wean from ventilation, HSV infection of the trachea or bronchial tree should be considered. Testing of HSV via PCR is available, and further case series and reports can add to this growing body of literature.





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