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Varicella Pneumonia

Chickenpox Pneumonitis

Varicella pneumonia, caused by the varicella-zoster virus, is a rare form of viral pneumonia. Immunocompromised individuals and pregnant women are at a higher risk of acquiring this condition, although it has been reported in immunocompetent persons too. The diagnosis of the disease is based on history, physical exam, radiological studies, and identification of viral DNA.


Presentation

Varicella-zoster virus (VZV) causes chickenpox, the infectious disease which usually has a self-limiting course, especially in children. Varicella pneumonia is a complication of chickenpox seen more frequently in immunocompromised adults and pregnant women and is associated with a significant rate of morbidity and mortality [1]. The frequency of varicella pneumonia has been reported to be 1 case in 400 patients with chickenpox infection, although it is difficult to provide an exact incidence since most published reports are about a small series of patients [2] [3].

The clinical manifestations of varicella pneumonia can range from mild to severe and their onset is up to six days after the appearance of the chickenpox rash. While some patients can be asymptomatic, the majority of patients present with clinical manifestations such as fever, malaise, dyspnea, tachypnea, dry cough, and occasionally with pleuritic chest pain, hemoptysis, and cyanosis. One study amongst military personnel showed that 25% of patients presented with a cough while 10% had tachypnea [4]. Patients presenting with hypoxemia and severe respiratory distress usually require mechanical ventilation [5]. Pleural effusion and peripheral lymphadenopathy are other manifestations in these cases. Some patients may rapidly deteriorate and the reported mortality rate in varicella pneumonia is 10-33% and can be as high as 50% in patients which require mechanical ventilation [6] [7].

Several risk factors have been suggested for the development of varicella pneumonia: immunocompromised status, chronic pulmonary diseases, smoking [8] [9], positive history of a contact with a patient suffering from chickenpox, being in the third trimester of pregnancy [9], and increased severity of the rash.

Fever
  • Thus, early institution of acyclovir therapy is associated with reduction in fever and tachypnea and improvement in oxygenation in otherwise healthy adults with varicella pneumonia.[ncbi.nlm.nih.gov]
  • DATA EXTRACTION: Diagnosis of varicella pneumonia was made by history of recent exposure to chickenpox, progressive dyspnea, fever, a characteristic diffuse, vesicular rash, and a supporting chest roentgenogram.[ncbi.nlm.nih.gov]
  • Conclusions: Varicella zoster pneumonia should be considered in patients with prolonged fever and accompanying cough in patients having chicken pox.[mona.uwi.edu]
  • Since the child had no more fever spikes, he was discharged home the following day on oral clindamycin, as a reasonable choice for both conditions. He had no more fevers and was essentially well on follow-up 48 hours later.[healio.com]
  • Other symptoms include Fever Headache Tiredness Loss of appetite Chickenpox is usually mild and lasts 5 to 10 days. Calamine lotions and oatmeal baths can help with itching. Acetaminophen can treat the fever.[icdlist.com]
Malaise
  • While some patients can be asymptomatic, the majority of patients present with clinical manifestations such as fever, malaise, dyspnea, tachypnea, dry cough, and occasionally with pleuritic chest pain, hemoptysis, and cyanosis.[symptoma.com]
  • The exanthem is frequently accompanied by fever, malaise, headache, and anorexia.[mdedge.com]
  • In healthy children, varicella is generally mild, with an itchy rash, malaise, and temperature up to 102 F for 2 to 3 days.[cdc.gov]
  • Prodromal symptoms: fever, malaise, anorexia, mild headache Malaise, muscle aches, arthralgias, and headache are more common in adults.[5minuteconsult.com]
  • Headache, malaise and abdominal pain may be reported. Crops of vesicles appear over the course of 3-5 days - mostly on the head, neck and trunk and very sparse on the limbs (may also occur in the mouth and oropharynx).[patient.info]
Collapse
  • Fulminant respiratory collapse often ensues and is associated with greater than 40% mortality. We successfully treated three patients for varicella pneumonia in pregnancy.[ncbi.nlm.nih.gov]
  • Show conditions that may occur with pneumonia, such as fluid in the chest cavity or a collapsed lung. Reveal another condition, such as heart failure, lung cancer, or acute bronchitis.[northshore.org]
Hodgkin's Disease
  • [Varicella pneumonia in a patient with Hodgkin's disease]. Radiologe 1987 ; 18 : 398 –400. Raidt H, Gottschalk D, Krummenerl T, et al. Acyclovir bei schwerer Varizellapneumonie und bei Herpes ophthalmicus.[erj.ersjournals.com]
Dry Cough
  • While some patients can be asymptomatic, the majority of patients present with clinical manifestations such as fever, malaise, dyspnea, tachypnea, dry cough, and occasionally with pleuritic chest pain, hemoptysis, and cyanosis.[symptoma.com]
  • The Merck Manual notes that coughs due to pneumonia produce mucous or phlegm in older children and adults, while younger children, infants and the elderly usually have dry coughs.[livestrong.com]
  • Symptoms These include: Dry cough Fever Chills Shortness of breath Pain in your chest when you cough or breathe Rapid breathing If you have any of these symptoms, call your doctor.[webmd.com]
  • Chest pain, productive or dry cough, is common clinical symptoms of symptoms. Some patients may develop fluid in the lining of lungs which is called pleural effusion. Patient with pleural effusion experience sharp stitching pain in lungs.[tandurust.com]
  • cough, associated orthopnea, with legs pain and swelling, decreased exercise tolerance from 3 blocks to 1, and a week of pruritic rash.[consultant360.com]
Liver Dysfunction
  • A chest radiograph showed diffuse, bilateral airspace consolidation; additional complications included liver dysfunction and thrombocytopenia. However, treatment with intravenous acyclovir and gamma-globulin improved his clinical symptoms and signs.[ncbi.nlm.nih.gov]
Thrombosis
  • Two men with varicella pneumonia who had profound lower extremity ischemia caused by thrombosis of the profunda femoris and tibial arteries are reported.[ncbi.nlm.nih.gov]
  • Thrombosis associated with varicella zoster in an adult.. Int J Infect Dis 13 :, 498– – 500. [CrossRef] [Google Scholar] Massano J., Ferreira D., Toledo T., Mansilha A., Azevedo E., Carvalho M.. ( 2008 ; ).[jmmcr.microbiologyresearch.org]
Spontaneous Rupture of Membranes
  • Cesarean section was performed 9 days later after spontaneous rupture of membranes with excellent outcome. The same approach is suggested for similar cases.[ncbi.nlm.nih.gov]
Cesarean Section
  • Cesarean section was performed 9 days later after spontaneous rupture of membranes with excellent outcome. The same approach is suggested for similar cases.[ncbi.nlm.nih.gov]
  • The patient required intubation, early treatment with acyclovir (700 mg/IV every eight hours), as well as the extraction of the fetus by cesarean section before the time gestation was completed.[ncbi.nlm.nih.gov]

Workup

The workup includes a detailed history, clinical examination, radiological studies, and confirmation with molecular biological tests. A history of contact with an index case is a clue to the diagnosis. Physical examination will reveal the characteristic rash in various stages. In addition, occasional pulmonary wheezes and rhonchi may be found on pulmonary auscultation. Laboratory studies may show elevated lactate dehydrogenase levels (LDH) [5]. Confirmation of hypoxemia requires pulse oximetry in all patients and arterial blood gases analysis in patients with severe disease [5].

Findings on plain chest X-ray frequently include round, 5-10 mm in size, confluent nodules that resolve within seven days after resolution of the cutaneous changes. However, they may persist and calcify over months, appearing as well-defined calcifications which are 2-3 mm in size. Pleural effusion may be present in some patients. Computed tomography (CT) scan shows diffusely scattered pulmonary nodules with a surrounding "ground-glass" halo.

A sample of respiratory secretions, cerebrospinal fluid (CSF), and vesicular secretions can be used to isolate the varicella-zoster virus. Multinucleated giant cells with eosinophilic intranuclear inclusions can be seen on Tzanck smear but are not specific for a varicella-zoster virus as they are also seen with a herpes simplex virus.

Direct immunofluorescence of scrapings obtained from cutaneous lesions will help to rapidly identify the varicella-zoster virus. Results of viral culture can take a long time and are not practical. Gene fragments amplification with polymerase chain reaction (PCR) and reverse-transcriptase polymerase chain reaction (RT-PCR) are the most sensitive methods to detect the varicella-zoster virus.

Rarely, a transbronchial pulmonary biopsy may be required in seriously ill, immunocompromised patients, to confirm the etiology. Histopathological examination of the lung tissue is likely to show consolidation, intranuclear inclusions, focal necrosis, and a mononuclear infiltrate.

Pulmonary Infiltrate
  • A follow-up chest radiograph 1 week later (Figure 2) revealed nearly total resolution of pulmonary infiltrates. Pneumonia is a serious complication of VZV infection and occurs primarily in adults.[nzma.org.nz]
  • All patients had bilateral pulmonary infiltrates documented on chest radiographs. Other noted complications included renal failure, myocarditis, pancreatitis and disseminated intravascular coagulation.[aafp.org]
  • Pulmonary infiltrates in non-HIV immunocompromised patients: a diagnostic approach using non-invasive and bronchoscopic procedures. Thorax 2001; 56 (5) 379-387 16 Solé Violán J, Fernández JA, Benítez AB, Cardeñosa Cendrero JA, Rodríguez de Castro F.[thieme-connect.com]
Bilateral Pulmonary Infiltrate
  • pulmonary infiltrates and microbiological confirmation is not usually necessary in typical cases. 2,3 The most common radiological pattern observed is bilateral reticulonodular pattern followed by patchy airspace consolidations. 2,3 After the introduction[nzma.org.nz]
  • All patients had bilateral pulmonary infiltrates documented on chest radiographs. Other noted complications included renal failure, myocarditis, pancreatitis and disseminated intravascular coagulation.[aafp.org]
Alveolar Consolidation
  • The initial chest radiograph showed bilateral reticulonodular infiltrates, which quickly evolved to diffuse alveolar consolidations. Arterial blood gas analysis revealed a ratio of arterial partial pressure to fraction of inspired oxygen of 87.[ncbi.nlm.nih.gov]
Pseudomonas
  • One of the deaths was from progressive right heart failure secondary to pulmonary hypertension and the other death was from overwhelming Pseudomonas sepsis.[ncbi.nlm.nih.gov]

Treatment

  • A high dose acyclovir treatment was effective, but recurrences occurred twice when the treatment was discontinued.[ncbi.nlm.nih.gov]
  • Our study supports treatment using a combination of acyclovir and corticosteroids.[ncbi.nlm.nih.gov]
  • Abstract Extracorporeal membrane oxygenation is the recommended treatment for fulminant pulmonary failure due to varicella pneumonia.[ncbi.nlm.nih.gov]
  • Early treatment with acyclovir has improved hope for these patients.[ncbi.nlm.nih.gov]
  • Treatment has included respiratory support and prophylactic antibiotics. Acyclovir has been prescribed with the intent to decrease the impact of the infection. It was added to the treatment protocol of two cases of varicella pneumonia in pregnancy.[ncbi.nlm.nih.gov]

Prognosis

  • Prognosis is favorable with complete recovery.[ncbi.nlm.nih.gov]
  • The poor prognosis is attributable to very aggressive disease progression and delayed onset of treatment. Here, we present a case of varicella pneumonia in a 69-year-old woman following long-term immunosuppressive treatment for kidney transplant.[ncbi.nlm.nih.gov]
  • 2% Differential Diagnosis Histoplasmosis Alveolar microlithiasis Treatment Supportive care Respiratory isolation until skin lesions heal, Acyclovir Complications Secondary bacterial infections Encephalitis Hepatitis Reye syndrome (with aspirin use) Prognosis[learningradiology.com]
  • Based on the available data, we attempt to discuss the main aspects of diagnosis, treatment, prevention, and prognosis of this pulmonary complication of varicella.[thieme-connect.com]
  • The prognosis was clearly extremely poor at presentation. The illness could have been prevented by varicella vaccination.[mja.com.au]

Etiology

  • Rarely, a transbronchial pulmonary biopsy may be required in seriously ill, immunocompromised patients, to confirm the etiology.[symptoma.com]
  • Etiology, prognosis, and treatment. Am Rev Respir Dis 1990; 142 (2) 369-373 23 Sörensen J, Forsberg P, Håkanson E, et al. A new diagnostic approach to the patient with severe pneumonia.[thieme-connect.com]

Epidemiology

  • This review discusses the epidemiology, pathogenesis, pulmonary manifestation, morbidity, long-term clinical consequences and current state of management of Varicella pneumonia in adults.[ncbi.nlm.nih.gov]
  • The epidemiology of varicella and its complications. J. Infect. Dis. , 172 , 706–712. PubMed Google Scholar Cutts, F. T., & Markowitz, L. E. (1994). Successes and failures in measles control. J. Infect. Dis. , 170 (Suppl. 1), S32–S41.[link.springer.com]
  • Methods All relevant published articles relating to the epidemiology, natural history and treatment of Varicella pneumonia since 1964 were identified.[erj.ersjournals.com]
  • Epidemiology and prognostic factors. Am Rev Respir Dis 1991; 144 (2) 312-318 25 Torres A, el-Ebiary M. Invasive diagnostic techniques for pneumonia: protected specimen brush, bronchoalveolar lavage, and lung biopsy methods.[thieme-connect.com]
  • Epidemiology Varicella infection is more common during the late winter and early spring. The disease also is more prevalent in temperate areas than in tropical climates.[pedsinreview.aappublications.org]
Sex distribution
Age distribution

Prevention

  • Prevention and other disease-modifying therapy are also discussed.[ncbi.nlm.nih.gov]
  • Varicella-related deaths are preventable by vaccine. To prevent complications and lethal outcome of varicella as reported here, the recommendations concerning vaccination against varicella must be taken into account in paediatric practice.[ncbi.nlm.nih.gov]
  • Preventing pneumonia is always better than treating it. Vaccines are available to prevent pneumococcal pneumonia and the flu. Other preventive measures include washing your hands frequently and not smoking.[icdlist.com]
  • The importance of the vaccine for preventable infectious diseases is stressed in this paper, in which we present a case of death in an unvaccinated cardiopathic child with Down Syndrome affected by varicella.[moh-it.pure.elsevier.com]
  • Prevention The same steps you would take to try to prevent the flu also help lower your chance of pneumonia. Wash your hands often. Scrub them with soap and water for at least 20 seconds before you eat or prepare food.[webmd.com]

References

Article

  1. Choo WP, Donahue GJ, Manson EJ, Platt R. The epidemiology of varicella and its complications. J Infect Dis. 1995;172:706–712.
  2. Mandell GL, Douglas GR, Bennett JE. Principal and practice of infectious diseases. 5th ed. Philadelphia: Churchill Livingston; 2000; 1582.
  3. Mohsen AH, McKendrick M. Varicella pneumonia in adults. Eur Respir J. 2003;21:886–891.
  4. Weber DM, Pellecchia JM. Varicella Pneumonia: Study of Prevalence in Adult Men. JAMA. 1965;10:192:572-3.
  5. Avnon LS, Smolikov A, Almog Y. Varicella pneumonia in southern Israel: Clinical characteristics, diagnosis, and therapeutic considerations. IMAJ. 2009;11:261-265
  6. Centers for Disease Control and Prevention (CDC) Varicella-related deaths among adults-United States, 1997. MMWR Morb Mortal Wkly Rep. 1997;46:409–12.
  7. Feldman S. Varicella zoster virus pneumonitis. Chest. 1994;106:22s–7s.
  8. Ellis ME, Neal KR, Webb AK. Is smoking a risk factor for pneumonia in adults with chickenpox? BMJ. 1987; 294:1002.
  9. Mohsen AH, Peck RJ, Mason Z, Mattock L, McKendrick MW. Lung function tests and risk factors for pneumonia in adults with chicken pox. Thorax. 2001;56:796–799.

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Last updated: 2018-06-22 03:56