Case Presentation: A 52 year old African American male presented to the ED complaining of dyspnea that started 1 day prior. He denied having a fever, cough, or sick contacts. On presentation the patient appeared to be in respiratory distress. Initial vital signs: Temp 98.1, HR 105, SpO2 71% on room air, RR 36, and BP 86/59. On examination the patient was found to have labored respirations, bibasilar crackles and a diffuse vesicular rash in various stages of development that had started 3 days prior. A chest x-ray showed diffuse lung infiltrates throughout both lung fields. He was resuscitated with IV fluids and stabilized with non-invasive ventilation. He was also started on empiric antibiotic therapy and later was started on IV Acyclovir. A diagnostic workup for a differential that included Atypical and Viral Pneumonia, Vasculitis, Sarcoidosis, and a possible Immunologic process was perfomed. Lab tests for HIV and Atypical Pneumonia pathogens were negative. ACE and ANCA levels, ANA panel and RF were within normal levels. A Respiratory Virus Panel was negative. Varicella Zoster IGG and IGM were both positive. The patient’s clinical status improved significantly and he was weaned off supplemental oxygen and his respiratory symptoms improved. Antibiotic therapy was deescalated and he was ultimately discharged home to complete a course of antiviral therapy with Valacyclovir. A VZV PCR was performed from the fluid of a vesicle prior to discharge and returned positive.
Discussion: Varicella Zoster Virus is commonly known to cause Varicella infection in children and Herpes Zoster infection in adults. It has generally been thought that a second episode of Varicella infection in an immunocompetent individual is rare but surveillance programs suggest that the incidence is increasing. The patient in this case reported having Varicella infection as a child but was unsure about having received a vaccine. Varicella infections are clinically diagnosed based on the presence of a characteristic rash and generally have a benign course. However, Varicella infection can be a severe disease and Varicella Pneumonia accounts for the majority of morbidity and mortality seen in adults with Varicella infection. In immunocompetent adults, Varicella Pneumonia has a mortality rate between 10-30%; the mortality rate approaches 50% in patients with respiratory failure requiring mechanical ventilation despite aggressive treatment. Timely administration of IV Acyclovir has been associated with clinical improvement and resolution of Varicella pneumonia.
Conclusions: This was a case of an adult patient with a second episode of Varicella infection who subsequently developed Varicella Pneumonia as a complication. It highlights the need for high clinical suspicion for Varicella infection in patients presenting with a characteristic diffuse vesicular rash and respiratory distress given that Varicella Pneumonia accounts for the majority of morbidity and mortality seen in Varicella infections.
