CME INDIA Case Presentation by Dr. R K Gupta, Consultant Physician, Yamuna Nagar, Haryana.
CME INDIA Case Study
How Presented on 24/02/2022?
- 25 yrs. old male came with 4-5 days h/o fever with shivering and rash. The rash was generalized and pruritic. It progressed rapidly from macular to papular to vesicular lesions before crusting. Lesions were typically present in all stages of development at the same time. The rash appeared first on the chest, back, and face, then spreads over the entire body. The lesions were usually most concentrated on the chest and back.
- Dry cough 4-5 days.
- Temperature up to 102°F lasted for 2 to 3 days.
- Looks very much like Chicken Pox.
- TLC 11200, DLC P-70, L-25, ESR-12 mm 1st hr.
Did X-ray look like Miliary Mottling?
- X-ray below gives impression of bilateral extensive Miliary Tuberculosis?
- My question is can we explain X-ray findings with Chicken Pox?
CME INDIA Case Discussion:
Dr. Arun Kedia, Diabetologist, Raipur:
- HIV?
Dr. Aakash R. Doshi, MD, Rajkot:
- Saturation level.
- Prior history if patient remembers.
- Adults r more at risk for viral ARDS with severe chicken pox.
- HRCT should be done.
- What is the profession? To rule out occupational lung diseases.
Dr. R. K. Gupta, Yamuna Nagar:
- Spo2 60% on presentation.
- Now on Oxygen Spo2 83% after 2 hrs. 2L/Minutes.
- Profession – Fruit seller.
- HIV Negative.
- Started with Inj Acyclovir I/V TDS.
- INJ Dexamethasone, 4 mg, TDS.
- INJ Amoxiclav, 1.2 G BD.
Dr. Venktesgh Moilio, Internist, Goa:
D/D of such Mottling
- Infections: TB, Coccidiomycosis, Blastomycosis, Histoplasmosis, Chickenpox.
- Drug Inhalation: Tin, Barium.Beryllium, Silicosis, Coal miner’s pneumoconiosis.
- Bronchiolitis obliterans.
- Alveolar microlithiasis.
- Hyaline membrane disease.
- Metastases.
- Histiocytosis X.
- Sarcoidosis.
- Secondary hyperthyroidism.
- Amyloidosis.
Dr. S. K. Gupta, Senior Consultant Physician, Delhi:
- Increase Oxygen
Dr. Ranjeet, Internist, Ramgarh, Jharkhand:
- This is Varicella Pneumonia.
Dr. Nishith Kumar, Pulmonologist, Ranchi:
- 👍🏻varicella pneumonia in adults is characterised by multiple small ill-defined nodules which usually resolve within a week after the disappearance of the skin lesions but in certain instances the nodules may persist for months & may calcify.
Dr. Ravishankar Dwivedi, Dermatologist, Ranchi:
- Just to add a note, Steroid should never be given in varicella as it may increase viremia and lead to other complications like neurological involvement.
Dr. Keyur Acharya, Intensivist, UK:
- Agree. Steroids are not being studied in varicella pneumonia. Especially when PCP has not been ruled out. At least B glucan can be done (indirectly will rule in or out PCP) if Bronchoscopy cannot be done.
Dr. Devi Jyoti Dash, Pulmonologist, Raipur:
- Very interesting case Sir. I have seen only one case of varicella pneumonia till date. A few things I would like to point out.
- The shadows here are bigger than miliary (classically 1-2 mm), thus are micronodular.
- Kindly search for any cause of immunodeficiency as more than 90 percent cases associated with malignancy or immunodeficiency.
- Send for sputum PCR for varicella, if possible.
- Please use steroids judiciously as May increase viremia. Also, a study had showed that patients of varicella pneumonia who were given steroids, had longer ICU stay with no mortality benefit.
- If found to be positive for varicella, kindly publish as very few reported cases.
Dr. Murali Mohan, Pulmonologist, Bengaluru:
- Yes – nodular opacities of different sizes are more typical of varicella pneumonia than miliary TB where they are typically fairly uniform.
- Other differentials of extensive nodular opacities should be considered but the rash is strongly suggestive. I’d also suggest looking for causes of immunocompromised states.
Dr. Manoj Rawal, MD Paediatrics, Hod Paediatrics, Bps GMCH, Kanpur Kalan, Sonepat:
- Why Dexamethasone Sir? Chickenpox can flare up with steroids.
Dr. Atri Gangopadhyay, Pulmonologist, Ranchi:
- No steroid in varicella pneumonia.
- Only oxygen, bronchodilator.
- Post varicella bacterial pneumonia can be very severe, so give good broad-spectrum antibiotic.
- A bronchoscopy in current described condition would do more harm than good, so hold until not improving.
- Varicella pneumonia can occur in severe immunodeficiency, so antifungal and PCP treatment to be given concurrently.
- I have seen only two cases until now, both didn’t survive unfortunately.
- I have seen few cases in paediatrics patient of varicella pneumonia. Gram positive bacteria like staphylococcus aureus are more commonly associated.
Dr. Devi Jyoti Dash, Pulmonologist, Raipur:
- I also want to point out that Steroid in varicella pneumonia is not absolutely contraindicated. There are a few studies where they have been shown to be beneficial.
- But a recent multi-centre cohort study in more than 100 patients have found steroids to be harmful.
- Sharing a few articles:
Update on 28/02/2022, Dr. R K Gupta, Yamuna Nagar:
- Clinically patient is much better.
- Now he is on 1 L oxygen Spo2 92%.
- Skin rash is much better.
- Now eating well.
- Improving very good.
- I will post all the Xray’s after 3-4 days.
- No fever now.
- No cough, no Dyspnoea.
Dr. Devi Jyoti Dash, Pulmonologist, Raipur:
- Did you give steroids?
Dr. R. K. Gupta, Yamuna Nagar:
Continuing with:
- Inj Acyclovir 500 mg I/V TDS.
- Inj Dexamethasone 4 mg I/V TDS-It was continued as with c/o fever Rash all over the body of 4-5 days, he had severe breathing difficulty. (Spo2 65%).
- Inj Piperacillin (4000mg) + Tazobactam (500mg) I/V TDS.
Scan Serial Chest X-ray
Patient was discharged on 4/3/22 without Oxygen support.
- Spo2 97%.
- Lesions during discharge:
Dr. S. K. Gupta, Senior Consultant Physician, Delhi:
- Deserve big applause.
Dr. Anupama Ramkumar, Phys Clinical Researcher, Ahmedabad:
- Super!
CME INDIA Learning Points
- The varicella virus can be spread in many ways. Mostly transmission of VZV is airborne via respiratory droplets. Other ways the virus can be spread is through direct contact with conjunctival fluid, saliva, or fluid from a vesicle of an infected individual. Spread can occur beginning 2 days prior to outbreak of lesions (varicella exanthema).
- Approximately 5% to 15% cases of adult varicella will have a type of respiratory complication.
- Progression to pneumonia risk factors:
- Pregnancy.
- Age.
- Smoking.
- Chronic obstructive pulmonary disease.
- Immunosuppression.
- The present case report illustrates severe varicella pneumonia in a previously healthy, young adult without any history of immunosuppression.
- Varicella pneumonia usually presents 1–6 days after the onset of the rash.
- It is associated with tachypnoea, chest tightness, cough, dyspnoea, fever and occasionally with pleuritic chest pain and haemoptysis.
- Chest symptoms may start before the appearance of the skin rash.
- Physical findings are usually minimal.
- Chest radiographs typically reveal nodular or interstitial pneumonitis.
- The presence of new chest symptoms has been shown to be strongly associated with the documentation of radiological pneumonia.
- With the exception of hypoxia, physical signs are a poor guide of severity.
- The risk of developing respiratory failure requiring artificial ventilation is difficult to predict early in the disease.
- Remember, Varicella pneumonia can progress rapidly to fulminant respiratory failure despite maximum conventional support; this type of respiratory failure is potentially refractor.
- Infection with varicella during pregnancy:
- In the first and second trimesters, can cause a significantly worse varicella infection in infants.
- Pregnancy can also place women at risk for significant complications if infected with varicella.
- Incidence of varicella-associated pneumonia increases particularly from week 28 of pregnancy to delivery.
- The mortality rate of varicella pneumonia increases from 11% in healthy adults to just under 50% in pregnant women. (Due to the increased prevalence of respiratory failure in pregnant women).
- Management:
- Treatment is a 7-day course of intravenous acyclovir for varicella pneumonia.
- Early intervention may modify the course of this complication.
- The antiviral agents licensed for treatment of VZV include acyclovir, valaciclovir and famciclovir.
- With serious illness, such as pneumonia, it is important to appreciate the necessity to use i.v. therapy (by slow i.v. infusion).
- The earlier in the illness the agent is given, the greater the likely benefit.
- Role of Steroids: One very small old study found Steroid useful in management in respect of significantly shorter hospital and ICU stays, and no mortality. (Ref-1) (In the present case dexamethasone was used).
- Use of extracorporeal membrane oxygenation/life support (ECMO/ECLS), have been shown to be beneficial in selected cases.
CME INDIA Tail Piece
“Breakthrough varicella”
“It is less severe because it occurs in patients who have been immunized against the virus. This means that individuals will have significantly less vesicular lesions and a smaller chance of complications than their nonimmunized counterparts.”
References:
- Mer M, Richards AG. Corticosteroids in life-threatening varicella pneumonia. Chest 1998;114:426–431.
- Varicella pneumonia in adults.A.H. Mohsen, M. McKendrickEuropean Respiratory Journal 2003 21: 886-891; DOI: 10.1183/09031936.03.00103202
- Denny JT, Rocke ZM, McRae VA, Denny JE, Fratzola CH, Ibrar S, Bonitz J, Tse JT, Cohen S, Mellender SJ, Kiss GK. Varicella Pneumonia: Case Report and Review of a Potentially Lethal Complication of a Common Disease. J Investig Med High Impact Case Rep. 2018 Apr 18;6:2324709618770230. doi: 10.1177/2324709618770230. PMID: 29707592; PMCID: PMC5912273.
- Alanezi M. Varicella pneumonia in adults: 13 years’ experience with review of literature. Ann Thorac Med. 2007;2:163-165.
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