Visceral infections

HSV infection of visceral organs usually results from viremia, and multiple organ involvement is common. Occasionally, however, the clinical manifestations of HSV infections may involve only the esophagus, lung, or liver. HSV esophagitis may result from direct extension of oral-pharyngeal HSV infection into the esophagus or may occur de novo by reactivation of HSV and spread of virus to the esophageal mucosa via the vagus nerve. The predominant symptoms of HSV esophagitis are odynophagia, dysphagia, substernal pain, and weight loss. Endoscopically there are multiple oval ulcerations on an erythematous base with or without a patchy white pseudomembrane. The distal esophagus is most commonly involved, but with extensive disease diffuse friability of the entire esophagus may ensue. Neither endoscopic nor barium examination can differentiate HSV from Candida esophagitis, or from esophageal ulcerations due to thermal injury, radiation, and corrosives. Endoscopically obtained secretions for cytologic examination and culture provide the most accurate material for diagnosis. While controlled trials have not been conducted, anecdotal observations suggest resolution of the symptoms of HSV esophagitis with systemic antiviral chemotherapy.
HSV pneumonitis is uncommon except in severely immunosuppressed patients. Among bone marrow transplant recipients HSV pneumonitis appears to account for approximately 6 to 8 percent of cases of biopsy- or autopsy-proven interstitial pneumonia. HSV-1 infection of the lower respiratory tract may occur from extension of herpetic tracheobronchitis into lung parenchyma. Focal necrotizing pneumonitis usually results. Hematogenous dissemination of virus from oral or genital mucocutaneous disease may also occur, and produce a bilateral interstitial pneumonitis. Concomitant bacterial, fungal, and parasitic pathogens are common in HSV pneumonitis. As the mortality of HSV pneumonia in immunosuppressed patients is high (>80 percent), these patients should be candidates for antiviral chemotherapy. HSV has also been isolated from the lower respiratory tract of persons with acute respiratory distress syndrome (ARDS). However, the relationship between isolation of HSV and the pathogenesis of the respiratory distress syndrome is unclear.

HSV is an uncommon cause of hepatitis in immunocompetent patients. HSV infection of the liver is associated with fever, abrupt elevations of the bilirubin and serum transaminases, and leukopenia (white blood cells <4000 per cubic millimeter). Disseminated intravascular coagulation may also be present.

Other isolated but reported complications of HSV include monoarticular arthritis, adrenal necrosis, idiopathic thrombocytopenia, and glomerulonephritis. Disseminated HSV infection in the immunocompetent patient is rare. In immunocompromised, burn, or malnourished patients, dissemination of HSV to other visceral organs such as adrenal glands, pancreas, small and large intestine, and bone marrow may occur occasionally. Rarely, primary HSV infection in pregnancy may disseminate and may be associated with mortality in both mother and fetus. This, however, is an uncommon event and is usually associated with acquisition of primary infection in the third trimester.