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Bilateral Pneumothroax in a Varicella Blizzard FREE TO VIEW

Yathreb Alaali, MD; Aymen Bukannan, MD; Gul Sachwani-Daswani, MD; Erin Field, MD; Robert Pompa, MD
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Henry Ford Hospital, Dearborn, MI

Chest. 2015;148(4_MeetingAbstracts):886A. doi:10.1378/chest.2229612
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SESSION TITLE: Pulmonary Manifestations of Systemic Disease Student/Resident Case Report Posters II

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Disseminated Varicella infection usually occurs in an immunocompromised host. We report the first case presenting with esophageal rupture and bilateral pneumothoraces in an immunocompetent host.

CASE PRESENTATION: 39 year old inmate with no significant medical history was transferred to Henry Ford Hospital ICU for escalation of care. He had presented with a rash and dyspnea of 3 days duration. He denied any sick contacts, vomiting, trauma, or ingestion of caustic material. He was febrile, tachypnic and tachycardic and was intubated for respiratory distress. He had generalized vesicular rash at different stages of healing over his trunk, extremities and oral mucosa. EKG showed diffuse ST segment elevations deemed secondary to acute pericarditis. Significant laboratory findings included elevated WBC and lactate, creatinine of 4.22, troponin of 36, positive (VZV) IgM and IgG, positive VZV PCR and negative HSV 1&2 PCR. Chest x-ray revealed bilateral pneumothoraces and pneumo-mediastinum, prompting bilateral chest tube placement. Acyclovir and broad-spectrum antibiotics were initiated. CT thorax was suspicious for a ruptured distal esophagus. Upon transfer, a CT of the chest and abdomen with gastrograffin resulted in drainage of the gastrograffin into the chest tube. It showed gas near the distal esophagus and pleural effusion. EGD was performed which showed erythematous mucosa in the mid and distal esophagus with fibrinous exudate, and a defect noted at 39 cm from incisors. Multiple clean-based non-bleeding ulcers were noted in the proximal stomach, duodenal bulb, and second part of the duodenum. An esophageal stent was successfully deployed traversing the defect. Pleural fluid analysis was consistent with empyema and cultures growing Staphylococcus Aureus and Streptococcus Salivarius (oral flora). He underwent left (VATS) with total pulmonary decortication and pericardial window with drainage of 70 cc of clear fluid. Pathology described acute inflammation of pericardial fibrous tissue. He was continued on acyclovir for 21 days and antibiotics for 4 weeks for treatment of empyema.

DISCUSSION: Disseminated VZV usually occurs in an immunocompromised host. HIV testing in this patient was negative. Other potential etiologies of patient’s presentation were ruled out including negative AFB, anti treponemal antibody, hepatitis B &C serology and negative autoimmune workup. Few case reports described pneumotharx as a presentation of esophageal rupture, none presented with bilaterally and none in an immunocompetent host with acute Varicella infection.

CONCLUSIONS: VZV can affect multiple organs, including the lungs and esophagus and may result in esophageal rupture and pneumothorax. It is imperative to include viral syndromes in the differential diagnosis of a multi-organ process.

Reference #1: F Moretti,C Uberti-Foppa, Oesophagobronchial fistula caused by varicella zoster virus in a patient with AIDS: a unique case,J Clin Pathol 2002;55:397-398

DISCLOSURE: The following authors have nothing to disclose: Yathreb Alaali, Aymen Bukannan, Gul Sachwani-Daswani, Erin Field, Robert Pompa

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