Abstract Introduction Herpes simplex virus 1 and 2 (HSV-1, HSV-2) of the Herpesviridae family are known to cause mucosal infections; however, HSV infection can rarely lead to severe, life-threatening infections. HSV pseudotumor is a rare presentation of HSV infection with formation of tumor-like masses instead of typical blisters or ulcers, seen largely in immunocompromised individuals. Case A 58-year-old male with human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) and inconsistent antiretroviral use presented with two months of shortness of breath, cough, and right-sided chest pain. Computed tomography (CT) of the chest revealed an obstructive right-sided endobronchial mass, with bronchoscopy revealing necrotic material completely obstructing the right upper lobe. The patient underwent cryo-debulking and was discharged on Biktarvy, doxycycline, cefpodoxime, dapsone, and fluconazole. Bronchoalveolar lavage (BAL) was positive for HSV-2; the patient completed a course of treatment dose valacyclovir for HSV-2 pneumonia with subsequent transition to suppressive therapy. Despite strict adherence to medications, he was readmitted two months later with recurrent complete obstruction of the right mainstem bronchus. He underwent two additional debulkings with cryotherapy and argon plasma coagulation (APC) for worsening symptoms and persistent occlusion on CT imaging, with pathology confirming HSV on a background of necrosis concerning for HSV pseudotumor. He was discharged on a course of intravenous (IV) acyclovir. Over the next two months, the patient was readmitted multiple times for persistent symptoms despite therapy with IV acyclovir followed by oral valacyclovir and required three additional debulkings with cryotherapy and APC for bronchial obstruction. He also completed a course of prednisone due to concern for possible immune reconstitution inflammatory syndrome. Five months from initial presentation, the patient was transitioned to foscarnet due to concern for resistance to acyclovir and valacyclovir, with clinical improvement and improvement of pseudotumor burden on repeat bronchoscopy. Discussion HSV pseudotumor is an atypical presentation of HSV infection typically seen in immunocompromised patients, particularly those with uncontrolled HIV. Endobronchial pseudotumors are exceedingly rare with less than ten cases reported in the current literature. Pseudotumor resulting in near or complete obstruction should be treated aggressively with debulking and antiviral therapy, with close clinical and radiographic monitoring to ensure treatment efficacy. Although HSV resistance to antivirals such as acyclovir are low in immunocompetent individuals, resistance is significantly higher in immunocompromised patients and should be considered for patients who do not improve despite prolonged treatment with first-line antivirals. This abstract is funded by: None
Shieh et al. (Fri,) studied this question.