Tracheal stenosis and failure to wean from mechanical ventilation due to herpetic tracheitis

A 64-year-old man with chronic obstructive pulmonary disease presented with pneumococcal pneumonia that progressed to respiratory failure within one week, requiring mechanical ventilation. Despite a low minute ventilation and clear chest roentgenogram, multiple weaning attempts failed. Bronchoscopy revealed significant narrowing of the distal trachea with erythema, edema, and ulceration of the mucosa. Cytology of tracheal washings was consistent with herpes simplex virus, and the patient was successfully extubated following treatment with intravenous acyclovir. Bronchoscopy following acyclovir therapy demonstrated resolution of the inflammation and narrowing. Herpetic tracheitis is a rarely recognized reversible cause of tracheal stenosis, especially in a nonimmunocompromised patient. It should be suspected in patients without an obvious cause of failure to wean from mechanical ventilation, and can be successfully treated with acyclovir.