Variable extrathoracic airflow obstruction and chronic laryngotracheitis in Gulf War veterans

STUDY OBJECTIVES

To study the flow-volume loop for evidence of variable extrathoracic airflow obstruction in Persian Gulf War veterans.

DESIGN

Retrospective case-control, single-center study.

SETTING

The pulmonary division of an academic health-care center.

SUBJECTS

A convenience sample of the Persian Gulf Registry.

MEASUREMENTS AND INTERVENTIONS

(1) Midvital capacity ratio (ratio of maximum forced midexpiratory to maximum forced midinspiratory flow). This ratio is the criterion standard for the diagnosis of variable extrathoracic airflow obstruction. (2) Evaluation of the anatomy and function of the extrathoracic airway by fiberoptic bronchoscopy. (3) Further investigation into the airway abnormality by histologic evaluation of tracheal biopsy samples in Gulf War veterans only.

RESULTS

Midvital capacity was > 1.0 in 32 of 37 Gulf War veterans compared with only 11 of 38 control subjects. The mean (+/-SD) value was 1.37+/-0.4 among Gulf War veterans and 0.88+/-0.3 among control subjects (p=0.0000005). FVC and its ratio to FEV1 were normal in all these subjects. Bronchoscopy showed inflamed larynx and trachea in all (n=17) Gulf War veterans. Histologic study showed chronic inflammation of the trachea in everyone (n=12) who had an adequate biopsy sample.

CONCLUSION

Physicians should be made aware of the presence of chronic inflammation of the upper airways and inspiratory airflow limitation in a number of Gulf War veterans.

Necrotizing tracheobronchitis with progressive airflow obstruction associated with paraneoplastic pemphigus

Paraneoplastic pemphigus (PNP) is an autoimmune disease associated with leukemia and non-Hodgkin's lymphoma. A patient with stage IVB poorly differentiated lymphocytic lymphoma developed characteristic upper and lower airway involvement with profound mucocutaneous erosion and tracheobronchial epithelial desquamation. Immunofluorescence testing confirmed autoantibody deposition along the basement membrane of bronchial epithelium. Disruption of the cellular adhesion mechanisms, including desmosomes, hemidesmosomes, and possibly the integrin subunits, is presumed to have led to disruption and desquamation of the tracheobronchial epithelial barrier, severe obstruction of the airways and hypoxia, and possibly bacterial superinfection. As far as can be determined, the feature of airflow obstruction occurring in association with PNP has not been described. Physicians should be aware that these complications of PNP may rapidly lead to hypoxic respiratory failure and death.

Chlamydia pneumoniae respiratory infections among patients infected with the human immunodeficiency virus

Thirteen cases of Chlamydia pneumoniae infection in patients seropositive for the human immunodeficiency virus (HIV) are described. The occurrence, the clinical spectrum, and the significance of the infection during HIV disease are compared with data reported in the literature. Chlamydia pneumoniae infection was established by a serologic micro-immunofluorescence test using standard diagnostic criteria. In four cases the results of serological tests were confirmed by direct immunofluorescence on respiratory specimens. Five patients developed focal pneumonia but recovered completely after specific antibiotic treatment. Three patients developed severe and diffuse interstitial pulmonary involvement, two of whom died of acute respiratory failure. Five patients developed upper respiratory tract infection. Using 39 pair-matched HIV-seropositive subjects as controls, the cases of infection were found to be significantly associated with a previously diagnosed pulmonary disease. Upon retrospective analysis of 319 consecutive cases of pneumonia among HIV-infected patients, Chlamydia pneumoniae was the sole agent detected in eight (2.5%) cases, and Chlamydia pneumoniae together with other infectious agents was detected in seven (2.2%) cases. Chlamydia pneumoniae is a possible cause of severe respiratory infection in Italian HIV-infected immunocompromised patients, and its presence must be suspected when patients do not respond to therapy with beta-lactam agents or to anti-Pneumocystis carinii treatment.

Bacterial tracheitis caused by Corynebacterium diphtheriae

Diphtheria has become a rare disease in Germany. We report on an unimmunized 3.5-year-old German girl with a 7-day history of respiratory distress and fever, presenting a clinical picture mimicking typical bacterial tracheitis without pharyngeal and laryngeal manifestation. Diagnosis of diphtheria was not made until culture of tracheal secretions yielded growth of a toxigenic strain of Corynebacterium diphtheriae. The patient died from toxic cardiac failure despite treatment with diphtheria antitoxin. This is the second reported case of isolated bacterial tracheitis caused by Corynebacterium diphtheriae.

CONCLUSION

The observation of a lethal course of diphtheric tracheitis emphasizes the paramount importance of immunization against diseases like diphtheria.

[Infections of the lower airways]

Lower airway infections are very common. A distinction should be made between acute tracheobronchitis, exacerbation of chronic bronchitis and pneumonia, since prognosis and therapy of these diseases are different. Community-acquired pneumonia has to be treated without delay by an antibiotic which is efficient against pneumococci.

Bacterial tracheitis: a case report

An 18-month-old girl was brought to the emergency room of Chang Gung Children's Hospital with inspiratory stridor, suprasternal retractions and imminent respiratory failure. Despite orotracheal intubation, persistent poor air-entry was noted. Flexible bronchoscopy via the endotracheal tube showed a copious amount of mucopurulent secretions in the tracheobronchial tree without any foreign bodies. With vigorous suctioning and antibiotic treatment, she had a rapid recovery. Tracheal aspirates showed a growth of Haemophilus influenzae. Cefamandole was used with good response. In conclusion, although bacterial tracheitis is an uncommon obstructive upper airway disease in children, using a bronchoscope to diagnose and to guide specific therapy can decrease the morbidity and mortality.

[Interdisciplinary therapeutic concept in severe bacterial infections of the central respiratory tract in childhood]

BACKGROUND

Apart from all advances made in the management of central airway infections, Acute Epiglottitis (AE) and Bacterial Tracheitis (BT) continue to be causes of life-threatening airway obstruction in children. The aim of this retrospective study was to evaluate deficiencies in the diagnostical protocol, to clarify the role of airway endoscopy in acute childhood stridor, and to identify current reasons for fatalities in these diseases.

MATERIAL

In the observation period between 1980-92, we found 12 patients suffering from BT and 21 from AE managed in close cooperation of the involved disciplines at the pediatric intensive care unit of the University of Cologne.

RESULTS

Laryngoscopy with fiberoptic or small rigid endoscopes allowed in awake cooperative children accurate diagnose of AE, and the exclusion of supraglottic inflammation in BT without complications. Furthermore, additional endoscopic information of the degree of inflammation was helpful in the next critical decision, whether artificial airway or rigid tracheobronchoscopy was required. Nasotracheal intubation was necessary in 76% of our patients, in one child tracheostomy was performed (5%). Premature extubation necessitating reintubation occurred in 33% of the children suffering from BT. In these patients, our method of advancing a flexible endoscope for tracheoscopy through the respiration tube failed because of a low tube diameter. Another remarkable finding was the high mortality in AE (14%). Affected children were admitted in poor post-hypoxia conditions following outdoor cardiorespiratory arrest.

CONCLUSION

In the analysis of the clinical course we found three decisive turning points in managing the disorder; First, the confirmation of the correct admission diagnosis; second, the decision, as to whether an artificial airway should be established; and third, the proper time of extubation. The most decisive factor in decreasing mortality seems to be timely, appropriate presentation at referral centers if AE or BT is suspected. Clinically, progressive management of childhood stridor requires close cooperation between the Pediatric, Anesthesiologic, and ENT Departments. Fiberoptic endoscopy as a guide to current airway management is a major step forward and should be a part of every established protocol.

New approaches to upper airway disease

Although laryngotracheobronchitis is the most common upper respiratory tract disorder in pediatrics, several other diseases are potentially life-threatening. The emergency physician must recognize both the obvious and subtle distinctions among upper airway diseases. The status of the patient's airway remains the primary concern regardless of the suspected disorder, but further definitive care depends on the specific disease entity. The prompt recognition and action of both the prehospital care provider and the ED physician in maintaining a critical airway and supporting ventilation until definitive pediatric critical or surgical care can be delivered is essential in ensuring optimal outcome for children suffering from a life-threatening upper airway illness.

The pediatric airway

Accurate diagnosis is important in the evaluation of airway disorders of infants and children. Today, multiple imaging techniques are available to evaluate the pediatric airway. In general, it is best to start with simple and readily available examinations, which may provide a diagnosis in most cases, and progress to more sophisticated studies only in cases where needed.

Racemic epinephrine in the treatment of laryngotracheitis: can we identify children for outpatient therapy?

The purpose of this study was to identify a cohort of children with laryngotracheitis (croup) who may be safely discharged from the emergency department (ED) after treatment with nebulized racemic epinephrine (RE), corticosteroids, and prolonged observation. Consecutive children (younger than 13 years of age) presenting to the ED with the diagnosis of laryngotracheitis were evaluated prospectively according to a croup scoring system. Sixty-one patients (4 to 108 months of age) with persistent inspiratory stridor at rest after 20 minutes of mist therapy who received nebulized RE (0.05) mL/kg of a 2.25% solution) and intramuscular dexamethasone (0.6 mg/kg) were enrolled in the study. Patients were observed in the ED while croup scores were assessed at 15, 60, 120, and 180 minutes. Croup scores were significantly improved (analysis of variance, P < .01) throughout the observation period in 31 patients (51%) who were discharged from the ED. Only one patient returned within 48 hours for further cool mist therapy. The maximum benefit from RE therapy was seen at 60 minutes. If a child had persistent resting stridor or a croup score greater than 2 at that time, hospitalization was inevitable. The 30 patients admitted to the hospital were younger (19.1 v 27.8 months) and had higher pretreatment croup scores (5.7 v 4.1). This was the first prospective study to identify a subset of children who have received RE to be safely discharged home after observation in the ED.

Respiratory failure complicating rubeola

We reviewed the charts of 19 patients with the diagnosis of measles who were admitted to the pediatric intensive care unit for respiratory failure requiring intubation and mechanical ventilation. Patients studied were admitted during the period June 1989 to June 1990. The mean age was 19 months (range, 3 to 51 months). The cause for respiratory failure fell into two groups: 47 percent developed pneumonitis and refractory hypoxemia. Patients with pneumonitis and hypoxemic respiratory failure had a 56 percent mortality. An oxygenation index of greater than 40 for 4 h separated survivors from nonsurvivors (oxygenation index = [mean airway pressure x FIo2/PaO2 x 100]). Patients with tracheitis alone all survived. In these patients the organism primarily responsible was Staphylococcus aureus (70 percent). Two of the seven patients with S aureus tracheitis had signs and symptoms of toxic shock syndrome and we subsequently demonstrated toxic shock syndrome toxin 1 in both patients.

Airway endoscopy in the diagnosis and treatment of bacterial tracheitis in children

Children with bacterial tracheitis present with the symptoms of viral laryngotracheobronchitis or epiglottitis, but do not respond to appropriate therapy for these diseases and frequently develop acute respiratory decompensation. Since the treatment and outcome of bacterial tracheitis differ so much from those of viral laryngotracheobronchitis and epiglottitis, prompt and accurate diagnosis is essential. The aim of this study was to evaluate the significance of different diagnostic characteristics in a group of eleven patients and to compare the results to those recently reported in the pediatric and otorhinolaryngologic literature. The present study suggests that reliable predictive factors do not exist for bacterial tracheitis. No single clinical, radiological or laboratory feature was a reliable diagnostic predictor for bacterial tracheitis, nor was it any combination of these features. The only diagnostic procedure to distinguish bacterial tracheitis accurately and promptly from other forms of acute obstructive upper airway diseases was direct laryngo-tracheo-bronchoscopy. Following endoscopic removal of all tracheal secretions and pulmonary toilet, nasotracheal intubation provides sufficient airway maintenance and obviates the need for tracheostomy. Endoscopy is thus diagnostic and therapeutic at the same time. If bacterial tracheitis is suspected a direct laryngoscopy and rigid tracheobronchoscopy should be performed under general anesthesia, as prompt diagnosis and adequate treatment are essential to survival. The cultures of the purulent tracheal secretions frequently revealed Staphylococcus aureus in combination with various pathogens, particularly the involvement of Pseudomonas aeruginosa was noted in two patients. Our data imply a susceptibility of children with Down's syndrome or immunodeficiency to bacterial tracheitis.

Herpes laryngitis and tracheitis causing respiratory distress in a neonate

A newborn presented 1 week after birth with the sudden onset of stridor and respiratory distress. At endoscopy, the supraglottic and subglottic tissues were edematous and erythematous, and numerous plaquelike ulcers were seen on the mucosal surface. Cultures of the lesions yielded herpes simplex virus type 2. The infant required a prolonged course of acyclovir and remained intubated for 31 days, but ultimately had both virological and clinical cure. Evaluation and further treatment of this unusual presentation of herpes simplex virus are discussed, as are the implications of herpes infections in neonates.

An approach to the diagnosis and treatment of membranous laryngotracheobronchitis in infants and children

The purpose of this study is to report 18 cases of membranous laryngotracheobronchitis (MLTB) and to review 143 published cases in order to accurately characterize the epidemiology, presentation, clinical course, treatment, and outcome of patients with this disorder. The male:female ratio was 2:1; mean age was four years. Most patients presented with acute onset of respiratory distress with fever, toxicity, and stridor after a prodrome of upper respiratory tract infection lasting a few days. White blood cell counts varied over a wide range, and blood culture results were rarely positive. Respiratory cultures commonly yielded Staphylococcus aureus or Haemophilus influenzae. Diagnosis was usually confirmed by airway radiographs or endoscopy. An artificial airway was required in 83% of patients. Complications included respiratory failure, toxic shock syndrome, anoxic encephalopathy, and death. MLTB is a serious, potentially fatal cause of acute infectious airway obstruction in infants and children that requires an organized approach to diagnosis and management.

Croup. A common cause of airway obstruction in children

Although viral croup is usually a self-limiting disease, its signs and symptoms are distressing enough to make parents seek immediate medical advice. This is fortunate because a much more serious disorder may be present. Indeed, morbidity requiring hospitalization may occur, as may a true emergency. Drs Thomsen and Edmonds discuss the epidemiology and current management of croup and related conditions.

[Bacterial tracheitis in children]

Bacterial tracheitis (BT) was found in 10 of 748 children (1.3%) admitted with croup during 1983-1990. 9.9% of all the 748 croup cases seen (74) were admitted to the pediatric intensive care unit (PICU) and 16 of the 74 required intubation. 10 of those intubated (62.5%) were found to have BT and had typical features of croup, including inspiratory stridor, hoarseness and cough. Airway obstruction resulted mainly from accumulated tracheal pus. After endotracheal intubation all required frequent suctioning of thick purulent secretions. In 2 children causative microorganisms were cultured from the blood, and in all 10 from the tracheal pus. All children were given antibiotic therapy but a 7 month-old girl died of secondary complications (respiratory syncytial virus infection, pneumonia and adult respiratory distress syndrome). The others recovered and were discharged from the PICU within 3-14 days. BT should be suspected when tracheal intubation is required in croup. In such cases close monitoring in a PICU and frequent tracheal suctioning after intubation is necessary; antibiotic therapy should be considered.

Tracheal stenosis and failure to wean from mechanical ventilation due to herpetic tracheitis

A 64-year-old man with chronic obstructive pulmonary disease presented with pneumococcal pneumonia that progressed to respiratory failure within one week, requiring mechanical ventilation. Despite a low minute ventilation and clear chest roentgenogram, multiple weaning attempts failed. Bronchoscopy revealed significant narrowing of the distal trachea with erythema, edema, and ulceration of the mucosa. Cytology of tracheal washings was consistent with herpes simplex virus, and the patient was successfully extubated following treatment with intravenous acyclovir. Bronchoscopy following acyclovir therapy demonstrated resolution of the inflammation and narrowing. Herpetic tracheitis is a rarely recognized reversible cause of tracheal stenosis, especially in a nonimmunocompromised patient. It should be suspected in patients without an obvious cause of failure to wean from mechanical ventilation, and can be successfully treated with acyclovir.

[A clinical study on 65 cases with tracheobronchial tuberculosis]

We recently diagnosed 65 cases with tracheobronchial tuberculosis using fiberbronchoscope. All the patients presented TB symptoms and were smear positive, some of them had been misdiagnosed for chronic bronchitis or lung cancer. Among them, 16 cases were simple tracheobronchial tuberculosis (24.6%) without TB lesions in the lungs. The results show that fiberbronchoscopic examination is a good method to diagnose tracheobronchial tuberculosis and distinguish lung cancer by direct observation of tracheobronchial lostons or brush biopsy for TB.

[Laryngitis epidemic (893 cases of acute laryngotracheitis and spastic croup). II. Clinical, diagnostic and therapeutic aspects]

We retrospectively review 893 cases of children, occurred in epidemic bout in September-October 1987, in order to study the usual management of his pathology in our hospital. In most cases (82.3%) diagnose was laryngitis or acute laryngitis without specification acute laryngotracheitis or spasmodic group. Epiglottitis was no detected in any case. Complementary tests were performed only in 5% of the patients, but they were of little help for the diagnose. Treatment applied was ambiental hummidiffication (95.5%), followed by water and alcohol impregned neck collar (87.2%), rectal magnesium-sulfate + papaverine (67.5%), epinephrine nebulization (63%), antibiotics (44.3%), steroids (9%), bronchodilatadors (4.8%). This therapeutic approach is discussed.

Treatment of croup. A critical review

Although viral croup is the most common form of airway obstruction in children 6 months to 6 years of age, there is debate regarding medical care for the hospitalized patient. A complete review of the English-language literature from 1960 to 1988 was performed, using both manual and Medline searches. Critical review shows that laryngotracheitis and spasmodic croup, previously emphasized in the literature as having distinct etiologies, most likely are two ends of a broad spectrum in the clinical presentation of a single disease. Critical assessment of all prospective randomized double-blind placebo-controlled trials reported during the study period shows that there is little information on the use of humidified air or supplemental oxygen, that racemic epinephrine hydrochloride is of well-demonstrated efficacy, and that dexamethasone phosphate at a dose greater than 0.3 mg/kg is effective in decreasing the length and severity of respiratory symptoms associated with viral croup.

Bacterial tracheitis in children

Bacterial tracheitis is a relatively rare cause of respiratory distress in children and is associated with a high morbidity and mortality rate. Three children who have survived this affliction are presented: one developed toxic shock syndrome in the acute phase and two developed late complications. The authors review the pediatric literature and postulate possible etiological factors. Prompt diagnosis and aggressive airway management are essential to survival. Early tracheotomy is recommended as the primary form of airway management.

Bacterial tracheitis in children

We examined the records of 14 patients aged 7 months to 10 1/4 years who were treated for bacterial tracheitis from May 1982 to December 1987; the management protocol for 13 of the patients included the use of nasotracheal intubation. The infection was caused by Staphylococcus aureus in seven, Haemophilus influenzae in three, Branhamella catarrhalis in one and Streptococcus pneumoniae in one. Both H. influenzae and B. catarrhalis were isolated in another patient, and no organism was found in the remaining patient. In addition to the bacteria, viruses were cultured from the tracheal secretions of two patients. The mean duration of intubation was 7.6 days and of hospital stay 9.2 days. Twelve of the cases occurred during the cold months of the year (October to March). Of the three deaths only one occurred in the pediatric intensive care unit and was due to severe bronchospasm and an air leak that caused bilateral pneumothorax and pneumomediastinum. In one patient subglottic stenosis developed that necessitated tracheostomy. Healing began 5 to 9 days after the onset of symptoms, as demonstrated with the use of repeated fibreoptic bronchoscopy. We found that the airway could be safely managed with the use of a nasotracheal tube. Bronchoscopy helped to confirm the diagnosis, to remove adherent secretions and to monitor the course of the disease. The ventilation tube can be removed after the patient's temperature returns to normal, if there is an air leak around the tube, if the quantity and viscosity of the secretions decrease and if healing is observed at bronchoscopy.

Issues in airway management--1988

Knowledge of the airway is expanding. New conditions, modern management strategies, and a more complete understanding of the interaction between the airway and fluid flux in the lung are presented.

Bacterial tracheitis in a young adult

A previously healthy young adult presented with inspiratory stridor and hoarseness but minimal dysphagia. Indirect laryngoscopy and lateral neck X-rays confirmed a diagnosis of membranous tracheitis. This responded to humidification, antibiotics and steroids. Secretions removed at direct laryngoscopy sent for culture grew Staphylococcus aureus. The literature is reviewed.

Differentiation of epiglottitis from laryngotracheitis in the child with stridor

To identify which clinical findings serve to differentiate acute epiglottitis from laryngotracheitis and also to evaluate the role of direct inspection of the epiglottis in the evaluation of children initially thought to have laryngotracheitis, we prospectively evaluated 155 children presenting to the emergency room with acute stridor. Three of the findings on physical examination were associated with epiglottitis: absence of spontaneous cough, drooling, and agitation. The diagnosis assigned prior to inspection of the epiglottis was incorrect in two of six patients with epiglottitis and in three of 149 patients with laryngotracheitis. The diagnosis made after inspection was correct in all 155 patients. Minor complications of inspection were seen in seven patients with laryngotracheitis. No complications were seen in the children with epiglottitis. We conclude that drooling, agitation, and absence of cough are predictors of epiglottitis, but clinical findings alone cannot exclude epiglottitis in every child who appears to have laryngotracheitis. When laryngotracheitis is the suspected diagnosis, inspection of the epiglottis by a pediatrician in a hospital emergency room is an effective aid to the evaluation of the child with acute stridor.

Croup syndrome

Spasmodic croup has a sudden onset, almost always at night, and usually responds well to humidification. Laryngotracheobronchitis is the most common form of the croup syndrome; children with this disease generally do well, although some require hospitalization and intubation. Bacterial tracheitis may mimic severe laryngotracheobronchitis; diagnosis is usually established during visualization of the airway. Epiglottitis is rare but is often life-threatening.

Development of a biotinylated probe for the rapid detection of Mycoplasma gallisepticum

Mycoplasma gallisepticum causes respiratory diseases in the form of tracheitis and air sacculitis in chickens and turkeys. It is a major cause of reduced egg production, reduced hatchability, and downgrading of carcasses. Current means of diagnosis depend on the isolation and identification of the organisms, or on serological assays to detect serum antibodies. The evaluation of avian sera for M. gallisepticum antibodies is becoming more difficult to interpret, and thus less useful, due to the increasing use of killed M. gallisepticum vaccines. Maximum efficiency of M. gallisepticum disease control requires a rapid and sensitive identification system. A biotinylated total genome M. gallisepticum DNA probe was constructed by labeling the DNA with biotin-11-dUTP in a standard nick-translation reaction. Hybridization reactions with 100 ng/ml of biotinylated probe were capable of detecting 75 ng of M. gallisepticum target-DNA and 1.5 x 10(4) M. gallisepticum/ml within 24 h. The probe did hybridize to other mycoplasma DNAs, but to a greatly reduced degree.

Bacterial tracheitis: a resurfacing airway emergency

Children presenting to the emergency department with symptoms of upper respiratory distress represent a diagnostic and therapeutic challenge. An acute onset associated with fever most often indicates epiglottitis or laryngotracheobronchitis. Presented here is a case of acute bacterial tracheitis, a life-threatening entity that apparently has reemerged recently. Prompt recognition is essential but can be difficult. Historical perspectives, clinical features, and pitfalls in diagnosis and management are discussed.

Bacterial tracheitis in adults

Bacterial tracheitis is characterized by acute upper airway obstruction in which indirect laryngoscopy is normal. Roentgenograms reveal an irregular tracheal air column. Endoscopic evaluation demonstrates a normal supraglottic and glottic larynx with purulent debris, mucosal ulcerations, and edema of the subglottic larynx and trachea. To our knowledge, this entity has not been previously described in an adult. We report herein three cases of bacterial tracheitis in adults.

Infectious croup: a critical review

Infectious croup is a viral or bacterial syndrome characterized by a barking cough, hoarseness, and stridor. Three separate conditions will be discussed: laryngotracheobronchitis, spasmotic croup, and bacterial tracheitis. Each clinical entity will be defined and its treatment reviewed. Current treatment regimens for infectious croup involve various combinations of mist therapy, racemic epinephrine, corticosteroids, and syrup of ipecac. Tradition, rather than science, appears to be the basis of many of these treatments. Despite the frequent occurrence of infectious croup, no treatment has proved consistently successful. Prevention and better treatment methods are the keys for reducing the high cost of infectious croup to the medical care system.

A case report of tracheobronchitis by herpes simplex virus, type I

Herpes simplex virus (HSV) infection of the lung and lower respiratory tract has been thought to be a rare and fatal disease, usually in patients with immunosuppression, severe burns, or prolonged intubation. However, recently, increasing numbers of patients have been reported to have a localized infection and some of them have recovered without specific therapy.

In Korea, there has been yet no proven case of HSV infection of the lower respiratory tract. Recently, we saw a case of localized HSV infection of the tracheobronchus. A 78-year-old male patient was admitted in acute respiratory failure, with COPD and old pulmonary trberculosis. After the clinical condition improved, a bronchoscopy was done which revealed a localized area of swelling, hyperemia, and mucosal irregularity at the lower trachea and right upper lobar bronchus. Bronchial brushing and biopsy showed typical cytologic changes including intranuclear inclusion body. Viral culture of a bronchial washing revealed a growth of HSV, type I. The patient died of unrelated, acute myocardial linfarction.