Herpes Simplex Virus: Bystander or Villain? Fatal Necrotizing HSV Pneumonia in a Healthy Host

Introduction: Herpes simplex virus (HSV) infection is a known cause of widespread disease in immunocompromised and critically ill hosts. Clinically significant lower respiratory infection from HSV is rare in immunocompetent hosts; its isolation is sometimes treated as incidental and non-pathogenic. We present a case of a healthy, immunocompetent patient who succumbed to necrotizing HSV pneumonia.


Description: A 22 year-old previously healthy male presented to the emergency department with acute onset chest pain. History was notable for daily vaping, recent binge-drinking, and 2 days of flu-like symptoms. He was diagnosed with a STEMI based on ECG and underwent emergent angiography which showed an isolated LAD occlusion, presumed to be embolic. Aspiration thrombectomy and Impella placement was performed resulting in improvement in symptoms with EF of 25-30%. Due to worsening respiratory status and cardiogenic shock, he was cannulated for VVA ECMO. Despite improvement in cardiovascular status and decannulation from the arterial limb, he had worsening respiratory failure with increasingly dense pulmonary consolidation on imaging. Multiple bronchoscopies and bronchoalveolar lavages did not elucidate a cause of respiratory failure. Unfortunately, he had an abrupt drop in ECMO flow and systolic pressure and pneumothorax. Despite emergent thoracostomy tube placement and recannulation for VAV ECMO, he developed DIC with massive biventricular thrombi and acute occlusion of the ECMO circuit. The patient was pronounced dead after multidisciplinary discussion which concluded no further feasible options existed. Autopsy showed profound necrotizing HSV bronchopneumonia and necrotizing HSV esophagitis, deemed his cause of death.


Discussion: This patient’s hypercoagulability may have been due to acute HSV infection. In vitro data demonstrates induction of a prothrombotic state by HSV, though no direct causal relationship has been definitively established in humans. Some case reports have linked HSV esophagitis in immunocompetent hosts with vaping. Further investigation into risk factors of HSV infection is necessary to improve diagnosis and treatment. HSV pneumonia should be considered in respiratory failure of unclear etiology despite its rarity in immunocompetent individuals.