Herpes Simplex Virus Pneumonia in Immunocompetent Patients Undergoing Cardiac Surgery: Case Series

Abstract

Objective: To describe the frequency, diagnosis, and management, of herpes simplex virus-1 (HSV-1) pneumonia in patients without known immunodeficiency undergoing cardiac surgery with cardiopulmonary bypass.

Design: Retrospective observational case series.

Setting: Intensive care unit.

Participants: Adult patients without known immunodeficiency who developed HSV-1 pneumonia after cardiac surgery.

Interventions: Baseline, perioperative, and postoperative data were collected. HSV-1 pneumonia was diagnosed by a multidisciplinary team when progressive respiratory deterioration was unresponsive to standard antibiotic therapy and quantitative HSV-1 polymerase chain reaction in a bronchoalveolar lavage (BAL) or bronchial aspirate (BAS) sample documented a viral load >10,000 copies/mL.

Measurements and main results: Among 818 patients undergoing cardiac surgery during the study period, 43 were tested for HSV. Among them, 15 (34.9%) had a positive BAL/BAS for HSV-1. In these patients (8 males [53%]; median age, 69 years [interquartile range (IQR), 63-73 years]), quantitative HSV-1 polymerase chain reaction on BAL/BAS documented a median of 3.21 × 10⁶ (IQR, 5.62 × 10⁵-5.73 × 10⁶) copies/mL. Diagnosis was made at a median of 12 days (range, 7.5-19 days) after surgery. Thirteen of the 15 patients (86.7%) were mechanically ventilated, and 11 (73.3%) met criteria for acute respiratory distress syndrome. Median C-reactive protein and procalcitonin values were 108.6 (IQR, 85.7-141.4) mg/L and 1.1 (IQR, 0.4-1.4) ng/mL, respectively. All patients received antiviral therapy. The median length of stay in the intensive care unit was 54 days, and in-hospital mortality of 66.7%, higher after urgent surgery (85.7%) compared to elective surgery (50.0%).

Conclusions: HSV-1 infection emerged as a relevant finding among these cardiac surgery patients with respiratory deterioration. Further studies are warranted to clarify the impact of HSV-1 on patient outcomes and to optimize treatment strategies.

Keywords: HSV-1 pneumonia; acyclovir; anesthesia; cardiac surgery; cardiopulmonary bypass; herpes simplex; intensive care.