Viral ventilator-associated pneumonia (VAP) has recently been recognised as a true disease in non-immunosuppressed patients. Viral VAP is typically due to latent viruses that are reactivated in critically ill individuals. Herpes simplex virus (HSV)-1 and cytomegalovirus (CMV) are the main viruses responsible for viral VAP. HSV-1 is frequently recovered from the upper and lower respiratory tract of intensive care unit (ICU) patients. In some patients, true VAP (HSV bronchopneumonitis) can occur. The clinical diagnosis is not specific, but patients frequently have herpes labialis or gingivostomatitis. If HSV bronchopneumonitis is suspected, bronchoalveolar lavage (BAL) can be performed to detect HSV and HSV-specific inclusions in cells recovered in BAL fluid. Whether or not a specific treatment is useful in this setting remains to be determined.
CMV is less frequently recovered from the lower respiratory tract of ICU patients, but can be classed as true CMV pneumonia in some cases. Diagnosis is not easy and often requires lung biopsy. Whether or not noninvasive testing (CMV in BAL or blood) is useful in the diagnosis of CMV pneumonia, remains to be seen. To date, a specific treatment cannot be recommended.