Teaching Case

We present the case of a 62 year old female Caucasian patient, who was transferred to our intensive care unit (ICU) because of respiratory distress.

The patient received a renal transplantation 10 years ago due to hypertensive glomerulonephritis. The immunosuppressive regimen of the patient consisted of 125mg cyclosporine per day. The chest x-ray showed bilateral interstitial opacities as well as moderate pleural effusions (Fig 1). The patient developed severe respiratory distress and was transferred to the ICU. The follow up chest x-ray showed central airway consolidations in both lungs (Fig 2). Antibiotic therapy with Piperacillin / Tacobactam (urin 106 CFU/ml E.coli) was started but nevertheless the patient’s condition deteriorated.
Because of the high suspicion of nosocomial infection and the lack of improvement under wide spectrum antibiotic therapy, a bronchoalveolar lavage (BAL) was carried out. Cytologic examination of the BAL fluid showed cells according to high grade neutrophil alveolitis.
The workup of the BAL was positive for HSV type 1 (HSV1 HSV2 VZV R-gene TM Quantification kit, Argene SA, Varilhes, France) as well as a weak positivity for HSV type 6. This result was received on day 9 of ICU treatment. Antiviral therapy with Aciclovir 10 mg/kg body weight b.i.d. due to restricted renal function was started immediately. However the patient’s condition further deteriorated, making invasive respiration therapy and tracheotomy necessary. Further chest x-rays showed central, bilateral mixed interstitial and airway consolidations with moderate pleural effusions and intermitted lung oedemas, which were frequently observed in patients with a manifest ARDS (Fig 3).

Because of clinical deterioration a BAL of the distal airways in this patient was performed to screen for pulmonary pathogens.
Screening for viral infection was performed by real time PCR and was positive for HSV1. In our case the most likely cause for HSV1 infection was reactivation of a latent infection by immunosuppression [2]. The patient developed ARDS with serve hypoxemia. An association between ARDS and HSV 1 has already been described by A. Francois- Dufresne et al.
The identification of risk factors for HSV reactivation and the typical morphologic pattern in conventional chest radiographic led to the suspicion of HSV pneumonia and the results of the BAL confirmed the diagnosis of HSV pneumonia.
However, there are no pathognomonic signs for HSV pneumonia on conventional chest radiographs. A study by Umans et al. found out that most patients with HSV pneumonia had diffuse bilateral opacities with predominantly an airspace or mixed airspace and interstitial pattern, as we found in our patient (Fig. 1). Unilateral consolidations, large atelectasis and significant amounts of pleural effusions were less frequently observed [1].
Linssen et al. showed that HSV type 1 was present in approximately one third of all BAL fluid samples acquired from ICU patients. Furthermore a high HSV1-viral load lead (105 / ml) to a poor outcome in critically ill patients with an increase mortality rate of 21%.