Herpes Simplex Pneumonitis Presenting As Acute Respiratory Distress Syndrome and Septic Shock

Abstract

We present a case report of a 72-year-old female with a history of stage III rectal adenocarcinoma undergoing chemotherapy who developed neutropenic sepsis and acute respiratory failure. The patient was admitted to the intensive care unit (ICU) due to worsening respiratory status and was subsequently diagnosed with disseminated herpes simplex virus (HSV) infection including acute respiratory distress syndrome (ARDS). This case highlights the challenges in diagnosing and managing HSV infection in critically ill patients and emphasizes the importance of early recognition and appropriate treatment in improving patient outcomes. This case underscores the significance of considering viral etiologies, such as HSV, in patients with unexplained respiratory symptoms presenting as ARDS.

Keywords: acute respiratory distress syndrome (ards); acute respiratory failure; disseminated herpes simplex virus infection; herpes simplex virus; herpetic tracheobronchitis; hsv pneumonia; immunocompromised patients; neutropenic sepsis; septic shock; septic shock (ss).

Figure 1. Bedside bronchoscopy revealed multiple erosions (arrow) with erythematous bases suspicious of herpetic tracheobronchitis.

Figure 2. A chest CT scan (axial view, lung window) at the level of the trachea revealed patchy ground-glass opacities with interlobular septal thickening (arrow), primarily in the upper lobes. Centrilobular emphysema was also observed, predominantly in the upper lobes.

Figure 3. A chest CT scan (axial view, lung window) at the level of the pulmonary artery bifurcation revealed diffuse bilateral patchy ground-glass opacities with interlobular septal thickening, raising suspicion for pneumonitis. The ground-glass opacities (arrow) may indicate inflammation or alveolar hemorrhage. Bilateral pleural effusions with dependent consolidation were also noted, likely due to fluid overload secondary to acute kidney injury.

Figure 4. A chest CT scan (axial view, lung window) at the level of the left atrium demonstrated diffuse bilateral patchy ground-glass opacities with interlobular septal thickening, predominantly in the peribronchiovascular areas, raising suspicion for viral pneumonia. These findings suggest that the origin is primarily the airways with secondary viremia rather than the reverse. The ground-glass opacities (black arrow) are patchy and predominantly located in non-dependent areas, ruling out pulmonary edema as the cause. Evidence of traction bronchiectasis (red arrow) is also present, suggesting pulmonary fibrosis. Bilateral pleural effusions with dependent consolidation (green arrow) are noted, likely due to fluid overload secondary to acute kidney injury.