Patel- Viral Infections & the ICU: a deadly combination!

Dr Devang Patel is a member of the Institute of Human Virology (IHV) in the Division of Infectious Diseases at the University of Maryland School of Medicine and works currently as the Chief of Service for the MICU ID team. In addition to his vast expertise in the developed world, Dr. Patel has worked with the University of Zambia to develop a residency program in HIV Medicine for Zambian physicians and has been working to bring a similar program to Port au Prince in Haiti. Over the next 55 minutes Dr Patel will take you on a whirlwind tour of ICU virology and give you tips and tricks that just might save your patient’s life. This is a talk that you cannot afford to miss!

Pearls

1) HSV

  • Either HSV-1 or HSV-2 can lead to genital infections, with >90% of the population HSV-1 positive by age 50
  • Atypical infections
    • HSV anogenital infection + immunosuppression= a “burn” like presentation with HUGE insensible losses
    • Aseptic menigitis: HSV-2>HSV-1; normal infectious complication, but can be recurrent with every outbreak (Mollaret’s Menigitis)
    • HSV encephalitis– 70% mortality
      • In the immunocompetent pt: 90% caused by nasolabial reactivation of HSV-1
      • Hallmark: aphasia due to temporal lobe necrosis
      • LP: dx by ↑ protein and RBCs
      • Treat: IV Acyclovir (watch for crystallization in renal tubules  AKI)
    • HSV pneumonitis– rare unless immunocompromised (transplant pts)
      • Characterized by diffuse infiltrates, lobular necrosis, and DAH

2) EBV (HHV-4)

  • 90-95% of the world population have antibodies
  • Immune response drives the SERIOUS adverse reactions:
    • Autoimmune hemolytic anemia
    • Thrombocytopenia
    • Splenic rupture (highest in 2nd or 3rd week)
    • Neuro complications: GBS, Encephalitis
    • Progressive Outer Retinal Necrosis (PORN)

3) CMV

  • Resembles EBV mononucleosis ( LFTs, malaise), but no pharyngeal exudates
  • When combined with HIV infection:
    • CMV retinitis: most common AIDS ophtho complication; leads to blindness
    • CMV encephalitis: classic is periventricular enhancement on MRI
    • CMV colitis, esophagitis, gastritis: can lead to massive insensible losses, ulcerations, and malnutrition
    • CMV pneumonitis: RARE, but when CMV is found in the lungs of immunocompetent individuals it is a marker of illness severity (↑ morbidity)
      • Most common life threatening infection in stem cell transplant patients
      • Most common cause of death in first 14 weeks s/p liver transplant

4) Respiratory Viruses

  • Influenza
    • Only agent with an annual epidemic
    • Different regions of the world are affected at different times, be wary of traveling patients
    • High mortality in the pregnant population
    • Complications (10% of individuals in epidemics have pulm complications, BUT pt’s >70 yo have pulm complications in 73% of cases)
      • Primary PNA → ARDS → Death
      • Secondary bacterial PNA: 4-14 days s/p flu virus; often due to pneumococcus, Staph, H flu
      • Non-pulmonary: GBS, myositis, Reye’s syndrome, meningitis
  • Adenovirus
    • Deadly cause of PNA in transplant patients
    • Can also lead to intractible diarrhea
  • RSV
    • BMT/solid organ transplant patients have a similar mortality to influenza
  • MERS-CoV
    • Classic: fever + cold symptoms + diarrhea in an otherwise immunocompetent person
Suggested Readings

  1. Harper SA, Bradley JS, Englund JA, File TM, Gravenstein S, Hayden FG, McGeer AJ, Neuzil KM, Pavia AT, Tapper ML, Uyeki TM, Zimmerman RK; Expert Panel of the Infectious Diseases Society of America. Seasonal influenza in adults and children–diagnosis, treatment, chemoprophylaxis, and institutional outbreak management: clinical practice guidelines of the Infectious Diseases Society of America. Clin Infect Dis. 2009 Apr 15;48(8):1003-32. [PDF]
  2. Razonable RR, Humar A, and the AST Infectious Diseases Community of Practice. Cytomegalovirus in Solid Organ Transplantation. American Journal of Transplantation 2013; 13:93–106. [PDF]

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