Hepatitis and Respiratory Compromise after Uneventful Subglottic Stenosis Correction Surgery

Abbreviations: HSV-1 - Herpes simplex virus type 1

Case presentation: A one-year-old girl with a history of subglottic stenosis due to previous intubation for respiratory distress and prematurity admitted electively to our hospital for removal of a subglottic cyst.

Three days after the uneventful surgery, she was readmitted complaining of high fever, stridor, dyspnea, and desaturation; she was re-intubated and admitted to the pediatric intensive care unit. On admission, laboratory tests showed elevated liver enzymes (ALT 405 U/L, AST 514U/L, GGT 651U/L) with normal bilirubin levels and elevated inflammatory indices (WBC and CRP); due to the unexplained fever and elevated liver enzymes, further investigations were performed, including HSV-1 blood PCR and serology (IgM), which were later positive. Due to the difficulty in assessing the patient`s neurological status and ruling out HSV encephalitis, a lumbar puncture was performed, which also revealed a positive HSV-1 PCR with normal CSF white blood cell, glucose and protein levels; Later, a flexible bronchoscopy revealed scattered ulcerations in the airways, where HSV-1 PCR was also positive. She was treated with Acyclovir for twenty-one days, which resulted in a good clinical response.

Case discussion: In unexplained respiratory deterioration after airway surgery, viral infections, including HSV, should be part of the differential diagnosis; hepatitis, unexpected respiratory compromise, airway ulceration are important clinical keys to an appropriate diagnosis.

Conclusion: HSV infection requires a high index of suspicion in unexplained respiratory failure and airway obstruction after airway surgery, antiviral therapy and airway protection should be considered.