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Correspondence |

Chickenpox in Unexplained Pulmonary Necrotizing GranulomasPulmonary Chickenpox FREE TO VIEW

Giulio Rossi, MD; Paolo Graziano, MD; Alberto Cavazza, MD
Author and Funding Information

From the Unità Operativa di Anatomia Patologica (Drs Rossi and Cavazza), Azienda Ospedaliera Arcispedale Santa Maria Nuova/Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS); and Unità Operativa di Anatomia Patologica (Dr Graziano), Casa Sollievo della Sofferenza/IRCCS, San Giovanni Rotondo.

Correspondence to: Giulio Rossi, MD, Unità Operativa di Anatomia Patologica, Azienda Ospedaliera Arcispedale Santa Maria Nuova/IRCCS; viale Risorgimento, 80 - 42123 - Reggio Emilia, Italy; e-mail: giurossi68@gmail.com


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(2):433-434. doi:10.1378/chest.13-2394
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To the Editor:

We read with interest the recent work by Mukhopadhyay et al1 in CHEST (September 2013). The authors reviewed a large series of pulmonary necrotizing granulomas and were able to find a cause in 60% of the cases in which a cause was not evident at the time of initial histologic evaluation. Importantly, in 40% of the cases, the granulomas remained unexplained even after extensive histologic, clinical, radiologic, laboratory, and molecular investigations. Here we aim to point out a possible cause of some apparently unexplained pulmonary necrotizing granulomas that, in our practice, is not so exceptional: chickenpox infection.

Among necrotizing granulomas of unknown cause, we previously identified eight adult patients with chickenpox granulomas of the lung that were clinically misdiagnosed as metastatic disease.2 When questioned, all patients confirmed a previous history of chickenpox infection, with a mean of 18.6 months (range, 8-37 months) from the clinical manifestations to the discovery of the lung nodules.

Pulmonary chickenpox has been previously described in the literature,3 but it is still underrecognized by clinicians, radiologists, and pathologists. Despite the unknown incidence, pulmonary involvement of chickenpox has a significantly higher incidence in adulthood, and some risk factors have been suggested, such as smoking history, pregnancy, underlying chronic lung diseases, or immunodeficiency.4,5 At imaging, the chickenpox granulomas are well defined, tiny (< 1 cm), dense nodules; randomly distributed; and bilaterally involving the lungs, with a tendency to calcify and to persist over time. Histology, although not pathognomonic, is quite characteristic, showing small, rounded, subcentimetric nodules centered by deeply eosinophilic necrosis and surrounded by a wall of dense fibrosis with a chronic infiltrate with or without scattered giant cells. Unusual cases simulating rheumatoid nodules may occur (Fig 1). Molecular analysis of paraffin-embedded lung tissue including granulomas is a very sensitive and specific tool in disclosing varicella-zoster virus DNA.2

Figure Jump LinkFigure 1. A tiny, rounded, necrotizing chickenpox granuloma with peripheral histocytic palisading mimicking a rheumatoid nodule (hematoxylin and eosin, original magnification × 100).Grahic Jump Location

While the discovery of chickenpox granulomas in the lung is insignificant on a therapeutic level, the correct recognition of this lesion may be very helpful to prevent future misdiagnoses in cases of subsequent imaging studies of the lungs. Based on our experience, it seems important to take into account this not-exceptional occurrence as another possible cause of unexplained pulmonary necrotizing granulomas with indolent course in adulthood.

References

Mukhopadhyay S, Wilcox BE, Myers JL, et al. Pulmonary necrotizing granulomas of unknown cause: clinical and pathologic analysis of 131 patients with completely resected nodules. Chest. 2013;144(3):813-824. [CrossRef] [PubMed]
 
Rossi G, Cavazza A, Gennari W, et al. Chickenpox-related pulmonary granulomas in immunocompetent adults: clinicopathologic and molecular features of an underrated occurrence. Am J Surg Pathol. 2012;36(10):1497-1502. [CrossRef] [PubMed]
 
Weber DM, Pellecchia JA. Varicella pneumonia: study of prevalence in adult men. JAMA. 1965;192(6):572-573. [CrossRef] [PubMed]
 
Mohsen AH, McKendrick M. Varicella pneumonia in adults. Eur Respir J. 2003;21(5):886-891. [CrossRef] [PubMed]
 
Dehecq C, Wibaux A, Valette M, et al. Retrospective study of 106 cases of varicella in immunocompetent adults. Parameters associated with varicella pneumonia [in French]. Med Mal Infect. 2009;39(2):101-107. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1. A tiny, rounded, necrotizing chickenpox granuloma with peripheral histocytic palisading mimicking a rheumatoid nodule (hematoxylin and eosin, original magnification × 100).Grahic Jump Location

Tables

References

Mukhopadhyay S, Wilcox BE, Myers JL, et al. Pulmonary necrotizing granulomas of unknown cause: clinical and pathologic analysis of 131 patients with completely resected nodules. Chest. 2013;144(3):813-824. [CrossRef] [PubMed]
 
Rossi G, Cavazza A, Gennari W, et al. Chickenpox-related pulmonary granulomas in immunocompetent adults: clinicopathologic and molecular features of an underrated occurrence. Am J Surg Pathol. 2012;36(10):1497-1502. [CrossRef] [PubMed]
 
Weber DM, Pellecchia JA. Varicella pneumonia: study of prevalence in adult men. JAMA. 1965;192(6):572-573. [CrossRef] [PubMed]
 
Mohsen AH, McKendrick M. Varicella pneumonia in adults. Eur Respir J. 2003;21(5):886-891. [CrossRef] [PubMed]
 
Dehecq C, Wibaux A, Valette M, et al. Retrospective study of 106 cases of varicella in immunocompetent adults. Parameters associated with varicella pneumonia [in French]. Med Mal Infect. 2009;39(2):101-107. [CrossRef] [PubMed]
 
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