Postintubation Tracheal Rupture in a Patient With Herpes Simplex Virus Type 1 (HSV-1) Tracheitis

Herpes simplex virus type 1 (HSV-1) can cause a range of infections, including orolabial herpes and, in rare cases, tracheobronchitis, especially in immunocompromised patients. Inflammation from such infections might increase the risk of postintubation tracheal rupture, a serious complication characterized by subcutaneous and mediastinal emphysema and pneumothorax. This case report presents a rare instance of tracheal rupture following intubation in a patient with HSV-1 tracheitis. A 70-year-old woman with diabetes mellitus presented to the hospital with altered mental status after drinking a bottle of Coke. She was diagnosed with diabetic ketoacidosis, and multifocal pneumonia which were treated with insulin, antibiotics, and supportive care. She was also intubated for airway protection. After a few days of treatment, her mental status and medical condition improved warranting extubation. Post-extubation, she developed stridor that did not respond to medical treatment. In concerns for airway compromise, an attempt of re-intubation was complicated with hypoxemia, subcutaneous face and chest emphysema, pneumoperitoneum, and bilateral pneumothoraces leading to cardiopulmonary arrest. Cardiopulmonary resuscitation was started, and return of spontaneous circulation was achieved after one minute. She was eventually intubated with a smaller endotracheal tube, and bilateral chest tubes were placed. Bronchoscopy revealed tracheal injury and whitish growth around the endotracheal tube. A biopsy of the latter growth was consistent with HSV-1 infection, prompting antiviral therapy. The patient ultimately recovered and was discharged after tracheostomy placement. This case represents a rare instance of iatrogenic tracheal injury associated with HSV-1 tracheitis. Diagnosis of tracheal injury hinges on clinical suspicion and is confirmed through radiologic imaging and bronchoscopy. Treatment varies based on injury severity, with our patient's level II injury managed conservatively with antiviral therapy and tracheostomy, resulting in a favorable outcome.