Case Presentation:

A 36‐year‐old man with a history of congenital obstructive uropathy status post cadaveric renal transplant in 2006 presented with fever, shortness of breath, and cough for 3 days. He had had a recent kidney biopsy because of worsening creatinine and was started on an increased dose of prednisone for acute interstitial nephritis versus rejection. Chest exam revealed diffuse wheezing with crackles at the bases. Chest CT showed multilobar pneumonia. The patient was started on vancomycin, moxifloxacin, and cefepime initially for health care–associated pneumonia. He was continued on reduced doses of prednisone and Progaf for immunosuppression but his Cellcept was stopped given the infection. His clinical conditioned continued to worsen despite antibiotics, so his antimicrobial coverage was broadened to include ganciclovir and micafungin. Legionella, RSV antigens, and cytomegalovirus polymerase chain reaction and fungal serologies were negative. He underwent a bronchoscopy, which showed pearly white plaques on the bronchial mucosa and purulent sputum. Viral culture from the bronchoalveolar lavage was positive for herpes simplex virus (HSV)–1. All other cultures were negative. Patient clinically improved after initiation of the antiviral agent. The patient was discharged on acyclovir and cefpodoxime.


Herpes simplex virus is a rare cause of pneumonia and is primarily seen in severely immunocompromised patients such as organ transplant patients. HSV‐1 pneumonia is a rare complication in renal transplant patients, occurring in only 1.5%. Despite its relative infrequency, if left untreated in an immunocompromised patient, HSV pneumonia has a very high mortality rate, 80%. Treatment of choice is acyclovir along with concomitant antibacterial therapy to cover superimposed bacterial pneumonia.


HSV pneumonia is a rare but deadly infection seen in immunocompromised patients including renal transplant patients. Therefore, we must have a high index of suspicion in transplant patients with pneumonia who are not clinically improving and consider empiric therapy for viral pneumonia and early bronchoscopy for viral cultures including herpes simplex.


P. Desa ‐ none; R. Poteet ‐ none