Severe type Ⅰ herpes virus pneumonia diagnosed by mNGS: 4 cases reports and literature review

doi:10.16138/j.1673-6087.2024.01.08

Abstract

Abstract:

Objective To explore the diagnosis and treatment of severe type Ⅰ herpes virus (HSV-1) pneumonia patients with normal immune function. Methods Four patients admitted to Ruijin Hospital of Shanghai Jiao Tong University School of Medicine from April 2021 to December 2021 who were diagnosed as severe HSV-1 pneumonia were enrolled, and their clinical data and the relevant domestic and foreign literatures were reviewed. All 4 patients were male, and their age was between 72 and 89 years. Results The main symptoms were fever, cough, expectoration (some patients had bloody sputum), asthma and dyspnea. All patients developed severe type Ⅰ respiratory failure. The infection indicators of all four patients increased, along with a relative decrease in lymphocyte counts, and a significant increase in CD3, CD4, and CD8 absolute counts after treatment. HSV-1 was detected in respiratory specimen using metagenomic next generation sequencing (mNGS) in them. After receiving early antiviral and hormonal anti-inflammatory therapy and respiratory support, the conditions in all four patient improved, and three of them were cured and discharged from the hospital. A total of 26 cases of HSV-1 pneumonia with low immunity and 3 cases with normal immune function were found in the literature, and most of cases lacked specific clinical symptoms and signs. As anti-bacterial or fungal treatment failed, most of them received the etiological examination of alveolar lavage fluid and was confirmed HSV-1 infection. The patients were given acyclovir antiviral therapy, and some patients also got hormone therapy. Three cases with normal immune function and 22 of 26 cases with low immunity showed improved condition, while 4 cases died. Conclusions The clinical symptoms of severe HSV-1 pneumonia lacked specificity and the diagnosis was difficult in elderly patients. mNGS of respiratory secretions combined with routing laboratory tests is helpful to identify the pathogen and make early diagnosis of the disease. The disease can be effectively treated through early recognition of the disease, administration of antiviral drugs, and a short-term treatment of glucocorticoid.

Key words: Type Ⅰ herpes virus, Severe pneumonia, Next generation sequencing

CLC Number:

R563.1

ZHANG Lili, XIE Simin, FENG Yun, $\boxed{\hbox{CHEN Hong}}$. Severe type Ⅰ herpes virus pneumonia diagnosed by mNGS: 4 cases reports and literature review[J]. Journal of Internal Medicine Concepts & Practice, 2024, 19(01): 43-50.

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病例	血常规			CRP（mg/L）	PCT（μg/L）	氧合指数（PaO₂/FiO₂表示）
	WBC (×10⁹/L)	NEU	LYM
	WBC (×10⁹/L)	[×10⁹/L（%）]	[×10⁹/L（%）]
1	7.64	6.80（89.0）（↑）	0.55（7.2）（↓）	103（↑）	1.1（↑）	72.7
2	15.39（↑）	14.60（94.8）（↑）	0.23（1.5）（↓）	99（↑）	8.13（↑）	97.5
3	8.32	7.52（90.5%）（↑）	0.53（6.4）（↓）	78（↑）	1.28（↑）	90
4	26.67（↑）	26.01（97.5）（↑）	0.23（0.9）（↓）	101（↑）	0.2（↑）	66

病例	性别	年龄（岁）	基础病	病程（d）	常见症状				常见体征
病例	性别	年龄（岁）	基础病	病程（d）	发热	咳嗽	咳痰	气喘	口唇疱疹	肺部啰音
1	男	72	溃疡性结肠炎阵发性房颤脊髓型颈椎病外伤后高位截瘫	7	+	+	粉红色脓痰	+	+	+
2	男	89	陈旧性脑梗死慢性阻塞性肺疾病慢性肺源性心脏病	3	+	+	黄白色黏痰	+	-	+
3	男	78	冠状动脉性心脏病 PCI术后	2	+	+	偶咳白黏痰	+	-	+
4	男	82	高血压病陈旧性脑梗死	21	+	+	黄白色脓痰，偶呈粉红色	+	+	+

病例	常规病原学检查			mNGS
	病毒		细菌	mNGS
	抗HSV-1 IgM	抗HSV-1 IgG	痰	痰	血
1	阴性	阳性	aba kpn sau	aba（序列数：216 758） pma（序列数：130 574） sau（序列数：69 077） HSV-1（序列数：126）	ND
2	阴性	阴性	pma	cor（序列数：856 235） hpi（序列数：8 232） efa（序列数：668） HSV-1（序列数：2 109）	ND
3	阴性	阳性	-	cal（序列数：752） HSV-1（序列数：125）	EBV（+）
4	阳性	阴性	-	efa（序列数：42 067） ctr（序列数：4 076） HSV-1（序列数：9 183）	ND

病例	CD3绝对计数		CD4绝对计数		CD8绝对计数
病例	治疗前	治疗后	治疗前	治疗后	治疗前	治疗后
1	394(↓)	734	244(↓)	408	153(↓)	342
2	62(↓)	912	35(↓)	519	32(↓)	519
3	335(↓)	941	241(↓)	771	101(↓)	184(↓)
4	114(↓)	1129	58(↓)	609	57(↓)	520

病例	呼吸支持方式	俯卧位	抗病毒		激素（甲泼尼龙）		增强免疫力		预后
病例	呼吸支持方式	俯卧位	药物及剂量	疗程（d）	是否使用	剂量及疗程	免疫球蛋白	胸腺肽类	预后
1	IMV	-	阿昔洛韦 0.4 g 鼻饲tid	14	+	40 mg ×10 d	+	-	好转
2	HFNC/NIV交替	-	伐昔洛韦 0.3 g鼻饲 bid	7	-	-	-	+	痊愈出院
3	HFNC	-	阿昔洛韦 0.4 g口服 tid	14	+	40 mg ×9 d	-	-	痊愈出院
4	IMV	+	伐昔洛韦 0.3 g鼻饲q12 h	45	+	120 mg ×3 d 80 mg ×14 d	+	-	痊愈出院