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A Rare Recovery: A Favorable Outcome in Disseminated VZV and ARDS in a Transplant Patient With CF FREE TO VIEW

Geoffrey Bass, BA; William Healy, MD; Stephen Kirkby, MD; Amy Pope-Harman, MD
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The Ohio State University College of Medicine, Columbus, OH

Chest. 2014;146(4_MeetingAbstracts):461A. doi:10.1378/chest.1968120
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SESSION TITLE: Miscellaneous Student/Resident Case Report Posters I

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Disseminated varicella zoster virus (VZV) infection with visceral involvement in lung transplant patients is a rare entity with high morbidity and mortality. VZV reactivation occurs in the presence of cellular immunosuppression.1 Severe disease presents in the transplant population with much of the mortality arising from pulmonary graft dysfunction.2 We present a case of disseminated VZV in a patient with double lung transplant notable for favorable return to function after multi-system organ failure (MSOF) and acute respiratory distress syndrome (ARDS).

CASE PRESENTATION: Our patient is a 44-year-old male with cystic fibrosis, 19 years status post double lung transplant, who presented with right upper quadrant abdominal pain and rash. Physical exam revealed a crusting, vesicular rash on his face, trunk, and abdomen and abdominal tenderness. Initial laboratory studies revealed leukocytosis, thrombocytopenia, hyponatremia, acute kidney injury complicating underlying chronic kidney disease, and elevated transaminases. Portable chest x-ray at this time was unremarkable.

DISCUSSION: Given evidence of evolving MSOF, he was admitted to our medical intensive care unit. He was started on broad-spectrum antibiotics and high dose acyclovir, along with varicella immunoglobulin. The patient developed worsening respiratory distress and altered mental status attributed to acyclovir-induced encephalopathy and uremia and was mechanically ventilated. Bronchoscopy was performed, revealing only scant petechiae without endobronchial ulcerations. Chest CT identified diffuse bilateral airspace disease consistent with ARDS. The patient required renal replacement therapy. After nearly one month of hospitalization, the patient was discharged home. He will continue on lifelong oral acyclovir for viral suppression.

CONCLUSIONS: This case highlights a uniquely favorable outcome in a patient with remote double lung transplant with disseminated VZV with visceral involvement. Recovery of graft function from ARDS was notable. Bronchoscopy did not show bronchial ulcerations. Interestingly, ulcerations have been suggested by a case series to be an indicator of more advanced varicella pneumonitis.3 The case further confirms the role of intravenous acyclovir, intravenous immunoglobulin, and early intensive care unit transfer in the pulmonary transplant patient with disseminated VZV.

Reference #1: Fuks L, Shitrit D, Fox BD, et al. Herpes zoster after lung transplantation: Incidence, timing, and outcome. Ann Thorac Surg. 2009 Feb; 87(2): 423-6.

Reference #2: Partridge DG and McKendrick MW. The treatment of varicella-zoster virus infection and its complications. Expert Opin Pharmacother. 2009 Apr; 10(5): 797-812.

Reference #3: Inokuchi R, Nakamura K, Sato H et al. Bronchial ulceration as a prognostic indicator for varicella pneumonia: Case report and systematic literature review. J Clin Virol. 2013 Apr;56(4): 360-4.

DISCLOSURE: The following authors have nothing to disclose: Geoffrey Bass, William Healy, Stephen Kirkby, Amy Pope-Harman

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