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 Table of Contents  
Year : 2022  |  Volume : 11  |  Issue : 3  |  Page : 274-276

Rash with atypical pneumonia: Varicella pneumonia in a young immunocompetent male

Department of General Medicine, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India

Date of Submission03-Apr-2022
Date of Decision01-Jun-2022
Date of Acceptance02-Jun-2022
Date of Web Publication28-Jul-2022

Correspondence Address:
Dr. Syed Mudasir Qadri
Department of General Medicine, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijrc.ijrc_70_22

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Varicella pneumonia is a serious complication of varicella infection. It occurs more often in adults than in children, although it is now infrequently seen since the introduction of the chickenpox vaccines. In immunocompetent adults, varicella pneumonia has a reported incidence of about 1 in 400 cases of varicella infection and it also carries significant mortality. Here, we report a case of varicella pneumonia in a young male who was immunocompetent and had no comorbidities. This case teaches us to be always careful and thorough with our clinical assessment and to think about the alternative etiologies for the cause of atypical pneumonia even during the times of the COVID-19 pandemic and not get swayed by the sheer numbers of coronavirus infections.

Keywords: Acyclovir, atypical pneumonia, chickenpox, herpes zoster, varicella pneumonia

How to cite this article:
Shah SH, Qadri SM, Koul AN, Bagdadi FS, Mantoo S, Sheikh AR, Najar ZA, Bhat SA. Rash with atypical pneumonia: Varicella pneumonia in a young immunocompetent male. Indian J Respir Care 2022;11:274-6

How to cite this URL:
Shah SH, Qadri SM, Koul AN, Bagdadi FS, Mantoo S, Sheikh AR, Najar ZA, Bhat SA. Rash with atypical pneumonia: Varicella pneumonia in a young immunocompetent male. Indian J Respir Care [serial online] 2022 [cited 2022 Aug 11];11:274-6. Available from: http://www.ijrc.in/text.asp?2022/11/3/274/352649

  Introduction Top

Varicella-zoster virus (VZV) belongs to the family Herpesviridae and causes two distinct clinical syndromes. The first is varicella (chickenpox) and the second is herpes zoster (shingles). Initial infection with VZV causes varicella which is usually a benign disease of childhood characterized by an exanthematous vesicular rash. After many years following the initial infection, VZV can be reactivated endogenously and presents as a dermatomal vesicular rash known as herpes zoster. Pneumonia is a rare but serious complication of varicella infection. It is now infrequently seen due to the introduction of the chickenpox vaccines (60 per 10000 cases).[1],[2] In immunocompetent adults, pneumonia has a reported incidence of about 1 in 400 cases of varicella infection[3],[4],[5] and carries overall mortality of 10%–30%.[6],[7]

  Case Report Top

Amid the COVID-19 pandemic, soon after the second wave, we received a 32 years aged male with no known comorbidities and fully vaccinated against COVID-19. He presented with a 7-day history of fever, malaise, and body aches. A vesicular type of rash had started on the 2nd day of illness that gradually involved the whole body. The patient had also developed a cough with shortness of breath, 3 days after the appearance of the rash. On examination, he was found to have tachypnea, tachycardia, hypoxia, and auscultation revealed bibasal coarse crackles. The skin examination was deemed remarkable for a vesicular maculopapular rash over an erythematous base in the different stages of eruption mainly involving the trunk areas, although most of the lesions had already crusted [Figure 1]. His laboratory findings included thrombocytopenia, acute kidney injury, and mild transaminitis. On imaging, there was evidence of infiltrates in bilateral lower zones on the chest X-ray [Figure 2] and a high-resolution computed tomography (CT) chest revealed bilateral lower lobe consolidation patches (atypical pneumonia) with infective bronchiolitis [Figure 3]. Tzanck smear of the scraping of the lesions was negative. PCR of the blood showed the presence of VZV DNA. Nasopharyngeal swabs for reverse transcription–polymerase chain reaction (RT-PCR) and Rapid Antigen Test (RAT) for COVID-19 were negative.
Figure 1: Varicella rash in different stages of evolution

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Figure 2: Chest X-ray demonstrating few infiltrates in right and left lower zone (Arrows)

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Figure 3: HRCT scan cuts mainly showing lower and basal areas. There are few patches of consolidation bilaterally (white arrows), with well-defined margins. At few places in the background a halo of ground-glass attenuation can also be seen (red arrows). HRCT=High-resolution computed tomography

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The diagnosis of varicella pneumonia was made based on the characteristics of the rash, chest symptoms, CT evidence of interstitial pneumonia, and detection of VZV DNA by PCR of the blood specimen. The patient was managed with oxygen inhalation and IV acyclovir for 1 week. He was discharged on low flow oxygen and reported back for follow-up to the outpatient clinic after 1 week. He had already turned off the oxygen support a few days before the follow-up visit and recovered fully without any complications [Figure 4].
Figure 4: Chest-X ray on follow-up showing complete clearance of the bilateral infiltrates

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  Discussion Top

A member of the virus family Herpesviridae, VZV causes many other manifestations such as postherpetic neuralgia, vasculopathy, myelopathy, retinal necrosis, and cerebellitis[8] apart from the two distinct clinical syndromes, i.e., varicella (chickenpox) and herpes zoster (shingles). The initial infection usually occurs in childhood where it causes “varicella,” usually a benign disease characterized by an exanthematous vesicular rash. After the initial episode, the virus becomes latent in the cranial nerve roots, the dorsal nerve roots, and the autonomic ganglia.[9] After many years following the initial infection, the virus can get reactivated endogenously and presents as a vesicular rash distributed in a dermatomal fashion also known as herpes zoster. The risk of transmission of the virus and so the VZV infection is higher with exposure to primary varicella compared to herpes zoster with secondary attack rates in susceptible contacts, especially the close contacts and the people in the household range from 60% to more than 90% in varicella and about one-fifth of this in herpes zoster.[10] The period of contagiousness during primary varicella begins 1–2 days before the appearance of rash till the lesions are crusted and that is typically 4–7 days after the rash has appeared.[11] VZV is often transmitted by infected secretions of the nasopharyngeal mucosa through droplets deposited onto the mucosal surfaces of nasal or oral passages or conjunctiva. It can also be transmitted through direct contact with vesicular fluid containing the virus or rarely through the airborne spread of the virus. The usual incubation period of varicella in an adult is 2 weeks but can be prolonged for as long as 28 days after receipt of varicella-zoster immune globulin and it may be shortened in immunocompromised patients.[10]

Varicella pneumonia is one of the most serious complications following varicella. It is more common in adults than in children and is particularly severe in pregnant women. In an immunocompetent adult, varicella pneumonia carries overall mortality of 10%–30%.[6],[7] However, for patients with respiratory failure requiring mechanical ventilation, the mortality approaches 50% despite aggressive management and supportive measures.[12],[13],[14] Risk factors that may lead to the development of varicella pneumonia include male sex, cigarette smoking, immunosuppression, and pregnancy.[4],[6],[15],[16],[17],[18] Pneumonia due to VZV typically develops insidiously over 2 − 6 days after the onset of rash with symptoms of progressive dyspnea, fever, and dry cough.[19] Pleuritic chest discomfort and hemoptysis have been occasionally reported.[7] Patients demonstrate progressive hypoxemia because of impaired gas exchange. Chest radiographs typically reveal bilateral diffuse infiltrates and interstitial pneumonitis. There is a simultaneous resolution of pneumonia along with the skin rash; however, patients may persist with fever and compromised pulmonary function for many weeks. Prompt administration of antivirals (IV acyclovir) has been associated with significant clinical improvement and resolution of pneumonia in selected series.[7],[13],[20] The role of corticosteroids in varicella pneumonia remains controversial and usually correlates with shorter hospital and intensive care unit stay.[21] Patients should be actively screened by primary health-care providers for the evidence of varicella immunity and vaccination should be provided to those without evidence of immunity as primary care prevention decreases the incidence of the disease and its complications.[1] Although preexposure vaccination is the best salvage strategy, as per the recent evidence, postexposure vaccination within 72 h and up to 5 days after exposure is also effective in modifying the severity of varicella infection, so it is recommended for healthy individuals without evidence of immunity against the disease.[1],[19]

  Conclusion Top

Varicella pneumonia is not a common occurrence and we received this patient with bilateral lower lobe atypical pneumonia during the COVID-19 pandemic. He could have easily been labeled as RTPCR-negative COVID pneumonia. The diagnosis of varicella pneumonia is made by a good history, a thorough physical examination, and a high clinical suspicion supported by relevant investigations. Acknowledging the fact that the disease is highly unpredictable, it is very important to diagnose it early and start the treatment, especially antivirals, of which acyclovir is the drug of choice. Hence, it is very important to keep our eyes open and do a thorough clinical assessment to reach the correct diagnosis.

Declaration of patient consent

The authors confirm that they have obtained the appropriate consent from the patient to publish the case report. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that their names and initials will not be published and due efforts will be made to conceal their identity.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Marin M, Watson TL, Chaves SS, Civen R, Watson BM, Zhang JX, et al. Varicella among adults: data from an active surveillance project, 1995-2005. J Infect Dis 2008;197 Suppl 2:S94-100.  Back to cited text no. 1
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Lopez A, Harrington T, Marin M. Pinkbook: Varicella | CDC. Available from: https://www.cdc.gov/vaccines/pubs/pinkbook/varicella.html. [Last accessed on 2022 Feb 26].  Back to cited text no. 10
Marin M, Leung J, Lopez AS, Shepersky L, Schmid DS, Gershon AA. Communicability of varicella before rash onset: A literature review. Epidemiol Infect 2021;149:e131.  Back to cited text no. 11
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Haake DA, Zakowski PC, Haake DL, Bryson YJ. Early treatment with acyclovir for varicella pneumonia in otherwise healthy adults: Retrospective controlled study and review. Rev Infect Dis 1990;12:788-98.  Back to cited text no. 13
Mer M, Richards GA. Corticosteroids in life-threatening varicella pneumonia. Chest 1998;114:426-31.  Back to cited text no. 14
Fairley CK, Miller E. Varicella-zoster virus epidemiology – A changing scene? J Infect Dis 1996;174 Suppl 3:S314-9.  Back to cited text no. 15
Ellis ME, Neal KR, Webb AK. Is smoking a risk factor for pneumonia in adults with chickenpox? Br Med J (Clin Res Ed) 1987;294:1002.  Back to cited text no. 16
Esmonde TF, Herdman G, Anderson G. Chickenpox pneumonia: An association with pregnancy. Thorax 1989;44:812-5.  Back to cited text no. 17
Fleisher G, Henry W, McSorley M, Arbeter A, Plotkin S. Life-threatening complications of varicella. Am J Dis Child 1981;135:896-9.  Back to cited text no. 18
Mohsen AH, McKendrick M. Varicella pneumonia in adults. Eur Respir J 2003;21:886-91.  Back to cited text no. 19
Wilkins EG, Leen CL, McKendrick MW, Carrington D. Management of chickenpox in the adult. A review prepared for the UK Advisory Group on Chickenpox on behalf of the British Society for the Study of Infection. J Infect 1998;36 Suppl 1:49-58.  Back to cited text no. 20
Adhami N, Arabi Y, Raees A, Al-Shimemeri A, Ur-Rahman M, Memish ZA. Effect of corticosteroids on adult varicella pneumonia: Cohort study and literature review. Respirology 2006;11:437-41.  Back to cited text no. 21


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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