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

Tracheitis Caused by Coinfection with Cytomegalovirus and Herpes Simplex Virus

Clinically significant isolated viral tracheitis is scarce in adults, and upper airway obstruction caused by viral tracheitis is even more infrequent. A 74-year-old woman, who was administered low-dose steroids for two months for chronic obstructive pulmonary disease (COPD), developed dyspnea with stridor and required mechanical ventilation for respiratory failure. Chest computed tomography showed a diffuse tracheal wall thickening with luminal narrowing and peribronchial consolidation in the right upper lobe. Bronchoscopy revealed a proximal tracheal narrowing with multiple ulcerations of the tracheal mucosa surrounded by an erythematous margin. Pathologic examinations of the tracheal mucosal tissue, including immunohistochemistry, revealed a cytomegalovirus (CMV) and herpes simplex virus (HSV) infection. Furthermore, the bronchial alveolar lavage fluid was positive on the CMV real-time polymerase chain reaction. The patient was treated with intravenous ganciclovir for 44 days. The follow-up bronchoscopy 49 days after the initiation of ganciclovir revealed improved multiple ulcerations with scars. We report a rare case of tracheitis caused by coinfection with CMV and HSV in a patient with COPD who had been taking low-dose steroids for months. The case showed that CMV and HSV are potential causes of serious tracheitis and respiratory failure.

Infections causing central airway obstruction: role of bronchoscopy in diagnosis and management

Central airway obstructive infections (CAOI) are challenging medical conditions that may represent an advanced and complicated process of ongoing infections. The epidemiology of CAOI is unknown as well as the pathophysiology and the mechanism of development. This is due to sparse data in the literature that consists mainly of case reports and retrospective case series. CAOI can be caused by fungal, bacterial, parasitic and viral infections. Most patients with CAOI can be diagnosed clinically and with chest imaging, which demonstrate obstruction of the central airways. However, bronchoscopy is commonly used to confirm and obtain a specific diagnosis to guide specific therapy. In recent years, interventional pulmonology (IP) is becoming widely available and offer a minimally invasive approach for the management of central airway diseases such as cancers, benign strictures, and other conditions. Various bronchoscopic modalities are used to treat central airway obstruction (CAO), such as mechanical debulking, endobronchial laser therapy, electrocautery, argon plasma coagulation, cryotherapy, and airway stenting. In patients with CAOI, the role of therapeutic bronchoscopy is not clearly defined, but many isolated reports in the literature described bronchoscopic intervention in combination with medical therapy as the initial management approach. In this paper, we present cases of CAOI that underwent bronchoscopic intervention as part of their management. We described the infectious etiology, locations, bronchoscopic findings and bronchoscopic modalities for airway management.

The "forgotten zone": acquired disorders of the trachea in adults

The upper airway is generally defined as the air passage segment that extends between the naso- or oropharynx and the carina. The longest segment of the upper airway—the trachea—begins at the inferior portion of the larynx and extends to the branch point of the main carina. The trachea has the potential to be a “forgotten zone” in differential diagnoses, as pathological processes involving this portion may not receive prominent clinical consideration in disorders presenting with respiratory symptoms and signs. Unlike the oropharynx, this anatomical area is beyond visualization on routine inspection; unlike the mediastinum and lung fields, it is a potential “blind spot” on initial, plain radiographic examination of the chest. Nonetheless, the adult trachea is affected by a number of primary disorders and is also a target organ of a variety of systemic diseases. This review will focus on both primary and systemic diseases involving the adult trachea with specific attention to their clinical manifestations and diagnostic hallmarks.

Clinical course and spectrum of intensive care unit patients reactivating herpes simplex-1 virus: a retrospective analysis

Background:

Herpes simplex-1 virus (HSV-1) reactivation in the respiratory tract is common in intensive care unit (ICU) patients. However, susceptible ICU populations are poorly defined. Clinical recognition of HSV infection of the respiratory tract is difficult and the impact of such reactivation is not understood.

Materials and Methods:

A retrospective analysis of HSV-1 positive patients encountered over a 5-year period at a multispecialty ICU was carried out. HSV-1 was identified in respiratory secretions using a qualitative polymerase chain reaction (PCR) technique. Patient charts were reviewed for clinical features that would typify HSV-1 respiratory involvement, and the morbidity and mortality risks found with HSV-1 respiratory involvement.

Results:

A review of 48 HSV-1 positive ICU patients showed that patients reactivating HSV in the respiratory tract fell into one of the three categories: (1) septic elderly patients with and without ARDS, (2) immunosuppressed patients, especially those receiving high-dose steroids, and (3) post-thoracotomy patients. Abnormalities suggestive of HSV-1 reactivation in the respiratory tract included, haemorrhagic or excessive respiratory secretions, concomitant orofacial herpes (42%), and bronchoscopic abnormalities (hemorrhagic ulcers and mucosal friability) (83%). Twenty eight percent of the HSV-1 infected patients experienced postextubation stridor. HSV-1 reactivation was associated with extended ventilator stays, significant mortality (42%), and ventilator-associated pneumonias (52%).

Conclusions:

Identification of susceptible populations and definition of clinical features of HSV-1 related respiratory disease can enable diagnosis of HSV-1 infection in ICU patients. Although detection by a PCR technique can rapidly diagnose HSV-1 reactivation, prospective studies are required to clarify HSV disease versus mere shedding, and understand the impact of HSV-1 reactivation in hospitalized patients.

An unusual exacerbation of chronic obstructive pulmonary disease (COPD) with herpes simplex tracheitis: case report

Chronic obstructive pulmonary disease (COPD) is a common cause of morbidity in the UK and is increasingly seen in elderly patients, often requiring multiple courses of steroids. We present a case of a 72 year old lady with repeated exacerbations of COPD which did not respond to conventional treatment. Herpes simplex virus (HSV1) tracheobronchitis was diagnosed following a rigid bronchoscopy and her symptoms improved with intravenous acyclovir. This is the first published case of HSV tracheitis in a non immunosuppressed individual with chronic lung disease.

Tracheobronchitis in the Intensive Care Unit

Tracheobronchitis can be broadly defined as inflammation of the airways between the larynx and the bronchioles. Clinically, this syndrome is recognized by an increase in the volume and purulence of the lower respiratory tract secretions and is frequently associated with signs of variable airflow obstruction. In the intensive care unit (ICU), tracheobronchitis is a relatively common problem with an incidence as high as 10.6% [1]. Although tracheobronchitis is associated with a significantly longer length of ICU stay and a prolonged need for mechanical ventilation, it has not been shown to increase mortality. These outcomes can be improved through the use of antimicrobial agents [1].

Herpes Simplex Infections in the Critical Care Setting

Infections caused by herpes simplex virus (HSV) types 1 and 2 are widely prevalent and usually asymptomatic. In the immunocompromised or severely ill patient, however, HSV can cause a variety of mucosal and systemic syndromes. Organ systems most susceptible include the gastrointestinal tract, lungs, and the central nervous system. Systemic disseminated disease may also occur. With the exception of herpes encephalitis, clinical diagnosis of serious HSV infections is difficult, because it occurs in hosts who are susceptible to a wide range of infectious and metabolic problems. We review the presenting syndromes of HSV infection in the critically ill patient, and outline current concepts for diagnosis and treatment.

Chronic obstructive pulmonary disease: less common causes--an algorithm for the primary care physician

The clinical features and distinguishing characteristics of the less common causes of chronic airflow obstruction have been reviewed. Clearly, the majority of patients have cigarette-induced chronic bronchitis and/or emphysema. However, for those patients with chronic airflow obstruction who are younger than 40 years old and/or have no or modest (less than 20 pack-years) smoking histories, a detailed assessment is warranted. A logical approach to the evaluation of the patient with dyspnea and chronic airflow obstruction has been outlined, with the goal of identifying those patients with potentially reversible disease, and to underscore the fact that not all "COPD" is due to cigarette smoking.

Herpes simplex virus from respiratory tract secretions: epidemiology, clinical characteristics, and outcome in immunocompromised and nonimmunocompromised hosts

PURPOSE

The purpose of this study was to review the course of patients with herpes simplex virus (HSV) recovered from respiratory tract secretions, and to compare the demographics, clinical characteristics, and outcomes of immunocompromised versus nonimmunocompromised patients.

PATIENTS AND METHODS

Retrospective review of medical records of 42 consecutive patients who had respiratory tract cultures positive for HSV-1 between May 1988 and August 1990 at a major university-affiliated hospital.

RESULTS

Twenty-seven patients (64%) were not immunocompromised. On the average, the nonimmunocompromised patients were 20 years older (mean age: 67 +/- 15, p = 0.001), had a higher incidence of tobacco smoking (p = 0.04), and were more frequently endotracheally intubated prior to HSV isolation (p = 0.002). Nonimmunocompromised patients more frequently had bronchospasm (44% versus 7%, p = 0.01), leukocytosis (16,400 versus 6,900/mm3, p = 0.001), and difficulty weaning from mechanical ventilation (63% versus 13%, p = 0.002). Mortality was also greater in the nonimmunocompromised group (70% versus 33%, p = 0.02). In addition, for survivors, days of mechanical ventilation (8 +/- 7 versus 2 +/- 4, p = 0.03), length of stay in the intensive care unit (10 +/- 8 versus 2 +/- 4 days, p = 0.004), and length of stay in the hospital (37 +/- 23 versus 16 +/- 14 days, p = 0.04) were all significantly longer for the nonimmunocompromised patients.

CONCLUSION

These data suggest that HSV isolation from lower respiratory secretions is associated with a more severe presentation and a worse outcome in immunocompetent patients than in immunosuppressed patients.