Clinically significant Herpes simplex virus-1 respiratory infection in ventilated COVID-19 patients – A case series

Abstract

Background: This case series reports six critically-ill, intubated patients with severe COVID-19 infection all of whom demonstrated clinically significant HSV tracheobronchitis/pneumonitis. In each case HSV-1 positivity on bronchoalveolar lavage (BAL) was associated with clinical deterioration of the patients with no other new identifiable cause. Case series: Bronchoscopic findings associated with HSV-1 infection were: ulcers, plaque-like lesions, diffuse haemorrhage, or desquamation. There was an association with severe COVID-19 requiring endotracheal intubation for greater than seven days with steroid and IL-6 inhibitor administration. No association with immunosuppression and/or lymphopenia was present, and past medical history was unremarkable. It is impossible to estimate the numbers of patients where a significant diagnosis of HSV-1 was missed, especially as many of the most unstable patients were unable to tolerate bronchoscopy. Conclusion: A high index of suspicion should be maintained for significant Herpesviridae reactivation in patients with pneumonitis caused by influenza or COVID-19. Aciclovir prophylaxis may be appropriate for consideration in future outbreaks.

Keywords

• COVID-19
• Bronchoscopy
• Intensive Care
• Herpes Simplex Virus