Treatment of a large area perioral viral herpes infection following noninvasive ventilation: A case report

Abstract

BACKGROUND

Alphaherpesvirus belongs to the Herpesviridae family and has large, monopartite double-stranded linear DNA. It mainly infects the skin, mucosa, and nerves, and can affect various hosts, including humans and other animals. Here, we present a case of a patient seen by the gastroenterology department at our hospital who experienced an oral and perioral herpes infection following treatment with a ventilator. The patient was treated with oral and topical antiviral drugs, furacilin, oral and topical antibiotics, local epinephrine injection, topical thrombin powder, and nutritional and supportive care. A wet wound healing approach was also implemented with good response.

CASE SUMMARY

A 73-year-old woman presented to the hospital with a chief complaint of "abdominal pain for 3 d with dizziness for 2 d." She was admitted to the intensive care unit for septic shock and spontaneous peritonitis secondary to cirrhosis and was given antiinflammatory and symptomatic supportive treatment. A ventilator was used to assist breathing for acute respiratory distress syndrome, which developed during her admission. A large area of herpes infection appeared in the perioral region 2 d following noninvasive ventilation. The patient was transferred to the gastroenterology department, at which time she had a body temperature of 37.8 C and a respiratory rate of 18/min. The patient's consciousness was intact, and she no longer had abdominal pain or distension, chest tightness, or asthma. At this point, the infected perioral region changed in appearance and was now accompanied by local bleeding with crusting of blood at the wounds. The surface area of the wounds measured approximately 10 cm × 10 cm. A cluster blisters appeared on the patient’s right neck, and ulcers developed in her mouth. On a subjective numerical pain scale, the patient reported a pain level of 2. Overall, her diagnoses other than the oral and perioral herpes infection included: (1) Septic shock; (2) spontaneous peritonitis; (3) abdominal infection; (4) decompensated cirrhosis; and (5) hypoproteinemia. Dermatology was consulted regarding the treatment of the patient’s wounds; they suggested treatment with oral antiviral drugs, an intramuscular injection of nutritious nerve drugs, and the application of topical penciclovir and mupirocin around the lips. Stomatology was also consulted and suggested the use of nitrocilin in a local wet application around the lips.

CONCLUSION

Through multidisciplinary consultation, the patient’s oral and perioral herpes infection was successfully treated with the following combined approach: (1) Application of topical antviral and antibiotic treatments; (2) keeping the wound moist with a wet wound healing strategy; (3) systemic use of oral antiviral drugs; and (4) symptomatic and nutritional supportive care. The patient was discharged from the hospital after successful wound healing.

Key Words: Ventilator, Viral herpes, Nursing care, Case report

Core Tip: Herpes simplex virus can be latent in the sensory ganglia of the host and reactivate periodically, resulting in recurrent herpes infection. The patient presented in this case report achieved good recovery after multidisciplinary consultation, treatment of the viral infection with oral and topical administration of antiviral drugs, the anti-inflammatory effect of furacilin, hemostasis with local epinephrine injection and application of thrombin lyophilized powder, and the use of a wet wound healing approach.

INTRODUCTION

Alphaherpesvirus belongs to the Herpesviridae family, and has a relatively large, monopartite, double-stranded linear deoxyribonucleic acid (DNA). It mainly infects the skin, mucosa, and nerves, and can affect various hosts including humans and other animals. Here, we present the case of a patient seen by the gastroenterology department at our hospital who experienced an oral and perioral herpes infection following noninvasive ventilation during admission to the intensive care unit (ICU)[1]. The patient was treated with topical and oral antiviral and antibacterial drugs, uracil, hemostatic measures, and nutritional and supportive care[2,3]. A wet wound healing approach was also implemented with good results.

CASE PRESENTATION

Chief complaints

Following noninvasive ventilation in the ICU, a 73-year-old female patient developed an oral and perioral herpes infection.

History of present illness

A large wound developed around the patient’s lips and in her mouth 2 d after noninvasive ventilation during admission to the ICU for management of decompensated cirrhosis complicated by abdominal infection, spontaneous peritonitis, hypoproteinemia, acute respiratory distress syndrome (ARDS) and septic shock.

History of past illness

The patient initially presented to the hospital with a 3-d history of abdominal pain accompanied by 2 d of dizziness. She was admitted to the ICU, where she was found to have decompensated cirrhosis complicated by abdominal infection, spontaneous peritonitis, hypoproteinemia, ARDS, and septic shock. She was treated with noninvasive ventilation for management of ARDS.

Personal and family history

The patient did not have any pertinent personal or family medical history.

Physical examination

The patient was transferred to the gastroenterology department for further management. At this point, her consciousness was intact and she had no ongoing abdominal pain or distension, no chest tightness, and no asthma. The perioral wound progressed to exhibit local bleeding with crusting of blood, and measured approximately 10 cm × 10 cm.

Laboratory examinations

The following laboratory values were observed in the patient at the time of transfer to gastroenterology: Prothrombin time 15.9 sec; partial thromboplastin time 34.5 sec; albumin 27.9 g/L; alanine aminotransferase 56 U/L; total bilirubin 129.4 μmol/L; neutrophils 79.2%; hemoglobin 87 g/L; platelet count 48 × 10⁹/L; and high sensitivity C-reactive protein 77 mg/L.

MULTIDISCIPLINARY EXPERT CONSULTATION

Dermatology was consulted regarding treatment of the patient’s perioral wounds; they suggested treatment with oral antiviral drugs, intramuscular injection of nutritious nerve drugs, and application of topical penciclovir and mupirocin around the lips. Stomatology was also consulted, and they suggested wet application of topical nitrocilin around the lips.

FINAL DIAGNOSIS

Perioral herpes infection secondary to noninvasive ventilation.

TREATMENT

The patient achieved good recovery after multidisciplinary consultation and treatment including oral and topical antiviral and antibiotic administration, nutritional and symptomatic supportive care, the anti-inflammatory effect of furacilin, hemostasis with local epinephrine injection and application of topical thrombin lyophilized powder, and the use of a wet wound healing approach.

OUTCOME AND FOLLOW-UP

Following treatment, the patient’s wound fully healed and she was discharged from the hospital. The perioral wound before and after treatment is depicted in Figure 1.

Figure 1 Perioral wound due to herpes infection, before and after treatment. A-B: Herpes infection causing large wound around the lips before (A) and after (B) medical treatment and wet wound care.

DISCUSSION

Herpes simplex virus (HSV) can be latent in the sensory ganglia of the host and reactivate periodically, resulting in recurrent infection. Herpes infection is characterized histologically by epidermal blistering and necrosis and the presence of multinucleated epithelial giant cells, eosinophilic intranuclear inclusions, and significant neutrophilic and lymphocytic inflammatory infiltrate[4]. An immune response can be stimulated immediately by HSV infection, and, if so, lesions are typically limited to the skin surface and mucous membranes. However, when HSV infection occurs in newborns with immature immune function or people with immune deficiency (i.e. in the settings of organ transplantation, immunosuppressant use, or anti-tumor treatment), herpes can spread throughout body to infect the brain, liver, lung, eye, adrenal gland, skin and mucous membranes, and other various sites. Herpes infection in an immunocompromised setting is serious and carries a high mortality rate[5-7]. When the skin has extensive damage, such with eczema or burns, HSV often manifests as generalized infection of skin the and mucous membranes and can cause disseminated lesions. The patient in the present report had a large perioral wound measuring 10 cm × 10 cm accompanied by bleeding, difficulty opening the mouth, pain, and changes in self-image. After consultation, the cause of the patient’s wound was identified as herpes infection. The wound was effectively managed with antiviral treatment, the anti-inflammatory effect of furacilin, and local hemostatic therapy. Additionally, a wet wound healing approach was implemented, and, through keeping the wound moist, healing was achieved.

One of the antiviral medications used in the management of the patient’s perioral herpes infection was topical penciclovir. Penciclovir is a nucleoside antiviral drug that inhibits HSV types I and II and can be administered topically with a cream. The antibacterial medication mupirocin is suitable for skin infection caused by Gram-positive cocci, and is used to treat primary skin infections, pustulosis, furuncle, folliculitis, and infections secondary to eczema[8,9]. Furacilin can interfere with bacterial glucose metabolism and the oxidase function to cause bacteriostasis or sterilization[10]. This drug has a broad spectrum of antibacterial activity, and is effective against various Gram-positive and anaerobic pathogenic bacteria; however, it not as effective in the treatment of infections caused by Pseudomonas aeruginosa, Proteus spp., or Pneumococcus spp.[11,12]. It is also ineffective against fungi and molds, but it is still effective against bacterial infections secondary to mold[13].

Epinephrine injection can cause constriction of small arteries with a less potent effect on veins, and is especially effective on the small vessels of the skin and mucosae. Lyophilized thrombin powder is also used for hemostasis of small blood vessels, gastrointestinal bleeding, and traumatic bleeding that is not amenable to surgical ligation. Epinephrine and lyophilized thrombin powder can function well in achieving local hemostasis, and according to the wet healing theory, this combination is more likely to reduce the potential cost associated with the use of advanced wound dressings. This is accomplished via the promotion of wound healing by keeping the wound wet and has been associated with faster healing rates[14]. In the present case, we used a nitrofurazone dressing with regular dressing change. Also, a gentle dressing change technique was used to prevent injury to the healing skin.

Finally, with respect to the psychology of the patient and her family, we used a gradual communication strategy. This strategy facilitated cooperation between the patient and her family and medical staff, which we believe improved the treatment outcome and promoted her ongoing rehabilitation.

CONCLUSION

This case report shares valuable experience in the clinical management of perioral herpes infection following noninvasive ventilation. There are few reports in the literature describing an effective treatment plan with respect to such a case. In the present case, the patient's wound healed after administration of oral and topical antiviral medications, furacilin, local epinephrine and topical thrombin powder, and a wet wound healing approach with no observed adverse reactions or toxic side effects. In patients managed with noninvasive ventilation, nursing and supportive staff should be aware of the signs of perioral herpes infection, including unusual pain with or without associated wounds of the skin around the mouth. The treatment regimen described in this case report was effective in accelerating the wound healing process and eradicating local herpes infection. Therefore, in patients who develop HSV infection following noninvasive ventilation, the authors suggest that the pharmacological and wound care measures applied here should be pursued.