Pulmonary Procedures |

Postobstructive Pneumonia With an Interesting Twist FREE TO VIEW

Matthew Hammar, DO; Jan Silverman, MD; Uma Krishnamurti, MD; Mark Lega, MD
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Allegheny General Hospital, Pittsburgh, PA

Chest. 2014;145(3_MeetingAbstracts):469A. doi:10.1378/chest.1807539
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SESSION TITLE: Bronchology Case Report Posters

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Pseudotumors of the lung are uncommon and include organizing pneumonia, nodular lymphoid hyperplasia, apical scarring, rounded atelectasis, hyalinizing granuloma, etc… We report a herpetic pseudotumor which is quite rare, especially in an immunocompetent individual.

CASE PRESENTATION: A 53-year-old Caucasian male with no HIV risk factors and a history of tobacco dependence presented with altered sensorium. The patient was intubated for hypoxemic respiratory failure in the setting of pneumonia with sepsis. CXR revealed a dense left sided infiltrate concerning for a post-obstructive process. CT findings demonstrated an endobronchial mass and left hilar adenopathy. Bronchoscopic evaluation confirmed a polypoid endobronchial mass partially occluding the entrance of the left upper lobar bronchus. Multiple biopsies were obtained. Cytologic and histologic examination revealed a herpetic infection. The patient was treated with a 2-week course of valcyclovir. Repeat CT scan demonstrated complete resolution of the herpetic pseudotumor.

DISCUSSION: Herpes infection of the respiratory tract, either initial or reactivation, has been well established since 1949. Herpes simplex virus (HSV) I & II, herpesvirus 6 & 8, and varicella-zoster virus can all cause pneumonia. To our knowledge, there are only three other cases of HSV endobronchial pseudotumor. In all reported cases the symptom duration was less than 4 weeks suggesting rapid pseudotumor formation. All three previously reported cases had partial or complete obstruction of the lower respiratory tract. Our patient had near complete obstruction of the left upper lobar bronchus. Two of the three previously reported cases were in the setting of HIV/AIDS. Both of these patients developed HSV-II pseudotumors and had resolution with 2-weeks of acyclovir. The third case involved an HSV-1 pseudotumor and did not comment on HIV status. Reportedly, this third patient died from a pulmonary embolus. The endobronchial biopsy from our patient revealed HSV prompting antiviral therapy. Our patient had clinical and radiographic resolution following 2-weeks of valganciclovir treatment. Herpetic pseudotumor, although rare, should be considered in the differential diagnosis for obstructing endobronchial lesions. Moreover, diagnosis of herpetic pseudotumor can occur in immunocompetent patients.

CONCLUSIONS: In the setting of an endobronchial lesion, consider HSV endobronchial pseudotumor in the differential diagnosis regardless of immunocompetence.

Reference #1: Armbruster, C., Drlicek, M. Herpes simplex virus type II infection as an exophytic endobronchial tumor. Wein Klin Wochenschr 1995; 107:344-346.

Reference #2: Plowman, G., Watson, M., D’Souza, H., Thomas, M. Obstructive endo-bronchial pseudotumor due to herpes simplex type 2 infection in an HIV-infected man. Int J STD AIDS 2009; 20:737-738.

Reference #3: Upadya, A., Tilluckdharry, L., Nagy, C., Ravichandran, P., Manthous, C. Endobronchial pseudo-tumor caused by herpes simplex. Eur Respir J 2005; 25:1117-1120.

DISCLOSURE: The following authors have nothing to disclose: Matthew Hammar, Jan Silverman, Uma Krishnamurti, Mark Lega

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