Lung Pathology: Student/Resident Case Report Poster - Lung Pathology I |

A Case of Deadly Varicella Pneumonia in an Immunosuppressed Patient FREE TO VIEW

Biplab Saha, MD; Kristin Fless, MD; Paul Yodice, MD; Nirav Mistry, MD; Fariborz Rezai, MD; Vagram Ovnanian, MD
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Saint Barnabas Medical Center, West Orange, NJ

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):805A. doi:10.1016/j.chest.2016.08.901
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SESSION TITLE: Student/Resident Case Report Poster - Lung Pathology I

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Varicella is a mild and self-limited disease in children, but in immunocompromised individuals and pregnant women, it is associated with significant morbidity and mortality. Pneumonia is the most worrisome complication of adult varicella infection with a mortality rate ranging between 10-50%.

CASE PRESENTATION: A 58 year old male with relapsed CLL on chemotherapy, presented with cough, progressive shortness of breath on minimal exertion, chest tightness, fever, malaise, myalgia and worsening disseminated rash for 5 days. He was a former heavy smoker and had chickenpox in childhood.No recent known contact with anyone with chickenpox. Vital signs demonstrated tachycardia (117 bpm), temperature 103F, respiratory rate of 35 and SpO2 of 88% on room air. Physical exam revealed a generalized rash at various stages of healing and small ulcers in the oral cavity. Disseminated Varicella infection was diagnosed. Initially oxygen saturation remained 95-100% on 2L/min via nasal cannula. Subsequently he developed progressive tachypnea and hypoxia and the patient was intubated after an unsuccessful trial of non-invasive positive pressure ventilation. CT chest revealed diffuse bilateral centrilobular nodules in a random pattern and bronchoalveolar lavage was negative for viral inclusions. He was started on Acyclovir, Varicella Zoster Immunoglobulin, Vancomycin and Meropenem. Despite adequate treatment the patient died within 24 hours after admission. VZV DNA by polymerase chain reaction of blood revealed >2000000 copies.

DISCUSSION: More than 90% of adult cases of varicella pneumonia occur in patients with lymphoma or other immunocompromising conditions. Risk factors include impaired immune status, chronic lung diseases,and smoking. Smoking renders human alveolar macrophages more susceptible to viral infection. Evidence is lacking which demonstrates mortality benefit of antiviral treatment.

CONCLUSIONS: Although rare, systemic Varicella infection is associated with a mortality rate as high as 50%. Absence of typical skin rash and specific antibodies might make the early diagnosis challenging. Acyclovir, Vidarabine and interferon have been used for the treatment of cutaneous and visceral varicella in immunocompromised patients but little is known about their efficacy in varicella pneumonia.

Reference #1: Kim E.A., Lee K.S., Primack S.L., et al. Viral pneumonia in adults: radiologic and pathologic findings. RadioGraphics 2002;22:S137-49.

DISCLOSURE: The following authors have nothing to disclose: Biplab Saha, Kristin Fless, Paul Yodice, Nirav Mistry, Fariborz Rezai, Vagram Ovnanian

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