INTRODUCTION:Acute chest syndrome is the leading cause of death and hospitalization among patients with sickle cell disease. In the majority of cases, a cause cannot be identified. Fat embolism and bacterial infection are amongst its leading identifiable causes. Rarely, viruses have been reported as an etiologic agent. We report a case of acute chest syndrome secondary to Herpes Simplex Virus (HSV) pneumonitis.
CASE PRESENTATION:An 18 year old female with past medical history of sickle cell disease (SC) presented with complaints of chest pain, back pain and fever for 4 days. She was admitted with a diagnosis of sickle cell crisis. On her initial evaluation, she was found to have a urinary tract infection for which she was started on Ciprofloxacin. During her hospital stay, she became increasingly dyspneic and hypoxemic. This required transfer to the intensive care unit. Her initial workup included a CT scan which revealed bilateral nodular and ground glass opacities as well as dense consolidation. She was treated with broad spectrum antibiotics which included vancomycin, cefepime and azithromycin. Due to her worsening oxygenation, she was initiated on mechanical ventilation. She underwent a bronchoscopy with bronchoalveolar lavage and specimens were collected for serologic and microbiologic testing. She continued to have persistent hypoxemia which eventually required inverse ratio ventilation. In addition, she required exchange transfusion. Her hemoglobin S level decreased from 30% to 8% after the transfusion. Despite this, she continued to require high amounts of oxygen. In the interim, viral culture from the bronchoalveolar lavage came back positive for herpes simplex virus. She was then started on acyclovir. Within 48 hours, she became afebrile. Her oxygenation improved and she was subsequently weaned off the mechanical ventilator. An HIV test was negative. She received acyclovir for a total of 2 weeks. Follow up chest X-Ray showed resolving pulmonary infiltrates. She was subsequently discharged to rehabilitation facility leading to complete recovery.
DISCUSSIONS:Acute chest syndrome is a frequent and potentially life threatening complication of sickle cell disease. Its pathogenesis is poorly understood. Vasocclusive crises in the setting of hypoxia, leading to inflammatory response and eventual lung injury is thought to be responsible. Its management largely involves supportive care including treatment of the underlying causes. Infections are known to be a predisposing factor. The most common infectious agents are bacterial pathogens including Chlamydia pneumoniae and Mycoplasma pneumoniae. Among viruses, the most commonly reported are respiratory syncytial virus and parvovirus. Only a few cases have been reported of herpes simplex pneumonitis leading to acute chest syndrome. This case suggests that HSV should be considered as a potential pathogen in sickle cell disease, which can lead to pneumonitis and acute chest syndrome.
CONCLUSION:Herpes Simplex Virus infection is a rare but potentially treatable cause of acute chest syndrome. Initial diagnostic evaluation should consider this pathogen as a causative agent and appropriate work up should be undertaken to identify this agent.
DISCLOSURE:Dashant Kavathia, No Financial Disclosure Information; No Product/Research Disclosure Information