Case Presentation: 65-year-old female who presented to the emergency department with diffuse abdominal pain persisting for one week. Her medical history is significant for diffuse large B-cell lymphoma, for which she had undergone chimeric antigen receptor (CAR) T-cell therapy six months prior to her presentation. Upon evaluation, she exhibited elevated liver function tests (LFTs), elevated lipase levels, electrolyte abnormalities, and thrombocytopenia. Initial abdominal imaging suggested acute cholecystitis, cholangitis, or pancreatitis; however, further investigation, including a HIDA scan and an MRCP, returned negative results. The patient was initially treated for suspected cholangitis, leading to the placement of a cholecystectomy tube. During her hospital stay, she developed scattered hemorrhagic lesions throughout her body and progressive respiratory distress. A chest radiograph revealed diffuse bilateral pulmonary infiltrates. As her condition deteriorated, she developed septic shock and required intubation and vasopressor support.A respiratory pathogen PCR panel returned negative, but CMV PCR was positive, as was VZV PCR from vesicular fluid. A thorough medication reconciliation revealed noncompliance with outpatient Acyclovir prophylaxis. Consequently, she was switched from broad-spectrum antibiotics to intravenous Acyclovir for 21 days and was placed on Atovaquone for PCP prophylaxis due to high-dose glucocorticoid therapy. Her hospital course was complicated by encephalopathy, with imaging suggestive of atypical posterior reversible encephalopathy syndrome (PRES). An EEG demonstrated right temporal sharp waves, leading to the initiation of anticonvulsant therapy. After 18 days of intubation, she underwent tracheostomy. Over the following weeks, her respiratory status gradually improved, resulting in decannulation 45 days post-tracheostomy, and her mental status returned to baseline with a repeat MRI showing no significant changes. Ultimately, she was discharged from the hospital.
Discussion: This case underscores the critical risks associated with VZV pneumonitis in immunocompromised patients, particularly those undergoing innovative therapies like CAR-T cell therapy. Mortality rates can approach 50% for this patient population. The patient’s symptoms progressed rapidly, highlighting the challenges in managing complications arising from immunosuppression. The successful identification of VZV through PCR testing and subsequent administration of appropriate antiviral therapy illustrates the importance of timely diagnostics and targeted treatment in these complex cases. Moreover, the development of encephalopathy and PRES demonstrates the multifaceted complications that can arise in severely immunocompromised patients, necessitating vigilant monitoring and comprehensive supportive care.
Conclusions: This case illustrates the potentially fatal complications of VZV pneumonitis in patients receiving immunosuppressive therapies, especially CAR-T cell therapy, where the mortality risk is significantly elevated. It also emphasizes the necessity of thorough history-taking and meticulous medication reconciliation, as neglecting these practices can lead to dire consequences. Effective management of immunocompromised patients requires an interdisciplinary approach, highlighting the importance of prompt diagnosis, appropriate therapy, and continuous monitoring to improve patient outcomes.