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

  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]

  Conclusions: Varicella zoster pneumonia should be considered in patients with prolonged fever and accompanying cough in patients having chicken pox. [mona.uwi.edu]

  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]

  ( A78 ) rheumatic fever ( I00 ) schistosomiasis ( B65.0- B65.9 ) Type 1 Excludes candidial pneumonia ( B37.1 ) chlamydial pneumonia ( J16.0 ) gonorrheal pneumonia ( A54.84 ) histoplasmosis pneumonia ( B39.0- B39.2 ) measles pneumonia ( B05.2 ) nocardiosis [icd10data.com]

  A30-year-old woman presented with a 3-day history of fever, chills, cough, chest pain on coughing and deep breathing, and shortness of breath on exertion. She also had a vesicular skin rash that had started a week before her presentation. [cmaj.ca]

• 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]

  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]

  The exanthem is frequently accompanied by fever, malaise, headache, and anorexia. [mdedge.com]

• Falling

  Infectivity is from a few days before the onset of the lesions until the crusts fall off. It is not possible to catch shingles from chickenpox, as the former represents a resurgence of a dormant virus. [patient.info]

  The crusts typically fall off in 1 to 2 weeks and often leave an area of hypopigmentation.4 The lesions tend to be concentrated on the trunk and face and appear in crops, with lesions present at the various stages of disease progression. [mdedge.com]

  […] fever with renal syndrome), Rift Valley fever virus, and Crimean-Congo hemorrhagic fever virus, it has failed to show any efficacy in HPS, perhaps because death typically occurred within 24-48 hours of hospitalization. [71] Prevention Influenza Annual fall [emedicine.medscape.com]

• 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]

• Cough

  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]

  Symptoms start as a non-productive cough, which can rapidly progress to respiratory failure within 36–48 hours. The cough becomes increasingly productive, with tachypnoea, dyspnoea, cyanosis and chest pain. < Previous | Contents | Next > [books.mcai.org.uk]

  Diagnosis is based on the usual criteria for varicella in association with signs and symptoms of respiratory distress: dyspnea, tachypnea, cough, chest pain, and hemoptysis, with characteristic x-ray findings. [ncbi.nlm.nih.gov]

  A30-year-old woman presented with a 3-day history of fever, chills, cough, chest pain on coughing and deep breathing, and shortness of breath on exertion. She also had a vesicular skin rash that had started a week before her presentation. [cmaj.ca]

  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]

• 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]

  Fever and cough are two primary symptoms that develop in varicella pneumonia. It is then followed with difficulty in breathing and shallow breathing. Chest pain, productive or dry cough, is common clinical symptoms of symptoms. [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]

• Skin Rash

  The occurrence of congenital varicella is unpredictable, but an infant born within four days of the mother's development of the varicella skin rash is at high risk, with the outcome being fatal in five percent of cases. [ncbi.nlm.nih.gov]

  She also had a vesicular skin rash that had started a week before her presentation. Her 10-year-old daughter had been diagnosed with mild chickenpox 3 weeks earlier, at which time our patient had taken prophylactic acyclovir for 5 days. [cmaj.ca]

  We diagnosed varicella pneumonia based on the presence of a typical skin rash, pulmonary symptoms, and contact with a child with chickenpox, confirmed by positive serology of VZV. [omicsonline.org]

  The clinical picture was associated with an infectious syndrome, severe respiratory distress and a scattered skin rash of macules, vesicles, and scabs suggestive of varicella. Chest Radiography showed diffuse interstitial opacities in both lungs. [jmscr.igmpublication.org]

• Cutaneous Manifestation

  Viral syndromes can present with various cutaneous manifestations, from the morbilliform eruption of measles to the papular lesions of molluscum. [ncbi.nlm.nih.gov]

  Cutis. 2008 December;82(6):399-402 Viral syndromes can present with various cutaneous manifestations, from the morbilliform eruption of measles to the papular lesions of molluscum. [mdedge.com]

• Cerebellar Ataxia

  The most common complications from varicella are bacterial infections of the skin and soft tissues in children pneumonia in adults Severe complications caused by varicella include cerebellar ataxia, encephalitis, viral pneumonia, and hemorrhagic conditions [cdc.gov]

  Other CNS complications - eg, benign cerebellar ataxia, myelitis, vasculitis causing strokes (may occur several months after the chickenpox). [ 2 ] Other infections - eg, osteomyelitis, sepsis, otitis media. [patient.info]

  Acute cerebellar ataxia in a 41 year old woman. Lancet Neurol 2006; 5:984-8. [P ubMed] 8 0. Mouly F, Mirlesse V, Meritet JF, Rozenberg F, Poissonier MH, Lebon P, Daffos F. [antimicrobe.org]

• Ataxia

  The most common complications from varicella are bacterial infections of the skin and soft tissues in children pneumonia in adults Severe complications caused by varicella include cerebellar ataxia, encephalitis, viral pneumonia, and hemorrhagic conditions [cdc.gov]

  Other CNS complications - eg, benign cerebellar ataxia, myelitis, vasculitis causing strokes (may occur several months after the chickenpox). [ 2 ] Other infections - eg, osteomyelitis, sepsis, otitis media. [patient.info]

  Acute cerebellar ataxia in a 41 year old woman. Lancet Neurol 2006; 5:984-8. [P ubMed] 8 0. Mouly F, Mirlesse V, Meritet JF, Rozenberg F, Poissonier MH, Lebon P, Daffos F. [antimicrobe.org]

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 Infiltrates

  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 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]

A high dose acyclovir treatment was effective, but recurrences occurred twice when the treatment was discontinued. [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]

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]

A one-year prospective study of infectious etiology in patients hospitalized with acute exacerbations of COPD and concomitant pneumonia. Respir Med. 2008 Aug. 102(8):1109-16. [Medline]. [emedicine.medscape.com]

Etiology of community-acquired pneumonia: increased microbiological yield with new diagnostic methods. Clin Infect Dis. 2010;50(2):202–9. View Article PubMed Google Scholar Widmer K, Zhu Y, Williams JV, et al. [ccforum.biomedcentral.com]

Importantly, these patients experienced symptoms, signs and laboratory abnormalities characteristic of giant cell arteritis (GCA), a vasculitis of unclear etiology that is treated with corticosteroids. [antimicrobe.org]

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]

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]

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]

Prevention and other disease-modifying therapy are also discussed. [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]

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3. Mohsen AH, McKendrick M. Varicella pneumonia in adults. Eur Respir J. 2003;21:886–891.
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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.