earnestly has been learned since herpes simplex virus (HSV) was first recognized as a pulmonary pathogen according to Morgan and Finland(1) almost a half hundred years ago.

Stern and associates(2) first focused attention forward the possibility of herpetic involvement of the trachea and its transmission via contaminated secretions from an infected patient to a health-care worker, causing herpetic whitlow. Later reports of herpetic respiratory infections have included patients with underlying diseases,(3)(4) extensive burns(5) underlying malignancy, chemotherapy and radiation therapy,(6) and critically ill patients with adult respiratory distress syndrome (ARDS).(7)(8)(9)(10)

Herpetic tracheobronchitis has also been reported in immunocompetent patients without history of chronic lung disease,(11)(12)(13) in patients after extracorporeal circulation for cardiac surgery(14) and following general surgery(15)

Despite the apparent increasing prevalence of pulmonary HSV the relationship between respiratory HSV isolation, pulmonary function, and clinical issue is not well documented. HSV pattern 1 in lower respiratory secretions has been associated with unresolv acute bronchospasm,(11) defered requirement for mechanical ventilation,(9)(11) tracheal stenosis, and increased mortality.(9)(16) However, asymptomatic viral shedding of HSV also come into views in approximately 1 percent to 5 percent of asymptomatic normal individuals.(17) A better understanding of the clinical significance of HSV retrieveed from respiratory tract secretions in immunocompromised as well as immunocompetent patients is penuryed For this purpose, presented herein is a summary and review of the cumulative experience at Washington University Medical Center St Louis, which has been published elsewhere.(18)

METHODS

Washington University Medical Center virology agriculture records were reviewed from May 1988 to August 1990 to identify all specimens obtained from the respiratory tract that were positive for HSV-1 Viral cultivations were performed using isolation in primary Rhesus monkey kidney, primary human embryonic kidney, and MRC-5 fetal lung fibroblast solitary abode; squalid lines. Forty-two adult inpatients with positive HSV-1 refinements were identified during this period. Medical records of these 42 patients were reviewed for the following: demographic data (age, sex race, date of hospital admission, primary and secondary diagnosis, hospital location, and service), immunologic status, clinical characteristics (medical history, medications, symptoms and signs within 48 h of HSV isolation, and chest radiographs), hospital course, and issue (treatment with acyclovir, mortality, days receiving mechanical ventilation, days in the intensive care unit, and days in the hospital). Patients were defined as immunocompromised if there was an established diagnosis of immunodeficiency (eg acquired immunodeficiency syndrome [AIDS]), or if the patient was receiving a regimen of immunosuppressive agents for an underlying medical question at issue (eg, lymphoma, status post [s/p] organ transplantation). Patients receiving steriods for the treatment of acute exacerbation of bronchospasm were not considered immunocompromised, on the other hand patients undergoing long-term treatment with steroids for more than 2 weeks at greater than 20 mg/d were classified as immunocompromised.

Data are instanted as the mean [+ or -] SD Statistical analysis was performed with the a statistical software scheme (SAS, SAS Institute, Cary, NC) for a personal computer (IBM-PC). Statistical analysis included [Xsup2] or Fisher's exact criterion for dichotomous variables. The Wilcoxon standard was used for unpaired comparisons. Stepwise logistic regression was used to assess predictive ability. A p-value of <005 was considered significant.

RESULTS

HSV-1 was identified in 47 respiratory cultivations from 42 adult inpatients. The source of the specimens is shown in Figure 1 Each of the couple patients who had positive HSV improvements from the upper respiratory tract also had positive HSV refinements from endotracheal tube aspirates.

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Within 48 h of HSV isolation, 25 patients (53 percent) underwent bronchoscopy; 15 (65 percent) of these had mucosal abnormalities consistent with tracheobronchitis (ie, erythema, edema, mucosal ulcerations, or abundant secretions). solitary eight patients had specimens sent for cytologic examination; five (63 percent) showed intranuclear viral inclusion bodies. Of note, sum of two units of five patients with positive cytologic findings had normal eventuates of bronchoscopic examinations.

Twenty-seven (64 percent) of the patients were not immunocompromised. Their demographics, primary diagnoses, and clinical characteristics (within 48 h of HSV isolation) are compared with the 15 immunocompromised patients in Table 1

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Chest radiographs were abnormal in all patients, immunocompromised and immunocompetent. The greatest in quantity frequent abnormalities included pulmonary infiltrates in 39 patients (93 percent) pleural effusions in 12 (29 percent) and atelectasis in 5 (12 percent)

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