Herpes Simplex Virus (HSV)

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
  • Clinical: bronchospasm unresponsive to conventional therapy (see Obstructive Lung Disease, [[Obstructive Lung Disease]])

Chronic HSV Ulcerative Pharyngitis-Laryngotracheitis

  • Risk Factors
  • 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
  • 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)
  • Clinical

Genital Manifestations

  • Genital Herpes Simplex Virus (HSV)
    • Painful, Genital Ulcers
    • Headache
    • Fever
    • Tender Inguinal Lymphadenopathy

General Dermatologic Manifestations


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]