Original article
Varicella-zoster virus pneumonia in adults: report of 14 cases and review of the literature

https://doi.org/10.1016/j.ejim.2004.04.016Get rights and content

Abstract

Background

The aim of this retrospective study was to determine the clinical, laboratory, and radiological features of all adult patients with varicella-zoster virus pneumonia (VZVP) treated in our departments during the last 5 years. Important therapeutic and evolutionary features are also reported.

Methods

Fourteen patients (11 males and 3 females, mean age OF 36.4 and 34.3 years, respectively), diagnosed as suffering from VZVP, were included in this study. The antecedents of previous contact with patients with varicella, smoking, pregnancy, and underlying diseases were evaluated. In all cases, the diagnosis of pneumonia was established by clinical and radiological criteria in the course of varicella infection.

Results

All but one patient had had previous contact with a varicella patient. Eleven of them (78.57%) were smokers. None of the patients was immunocompromised. All patients had the characteristic rash of the disease, fever, and cough. Only six (43%) had bilateral sparse rales on auscultation. Arterial blood gas analysis at the onset of VZVP revealed hypoxemia in seven patients (50%) and hypocapnia in six (43%). Mean PaO2 was 55 mmHg (range of 42–68 mmHg) and mean PaCO2 was 34 mmHg (range of 27–36 mmHg). Chest radiographs showed ill-defined nodular or reticular densities of various sizes scattered throughout both lung fields. A CT scan of the chest, performed in seven patients (50%), confirmed the radiological findings and marked out patchy ground-glass attenuation in three patients and coalescence of lesions in two others. After diagnosis, all patients were immediately started on acyclovir 5–10 mg/kg every 8 h. Five patients (36%) were admitted to the ICU due to acute hypoxemic respiratory failure. Two patients received noninvasive positive pressure ventilation via a facemask and the other three patients with a clinical diagnosis of ARDS were intubated and ventilated mechanically. The duration of patient hospitalization was 16±10 days. One patient (8%) died in the ICU on the third day after admission due to multiple organ dysfunction (MOF). All of the other patients recovered completely without any sequelae.

Conclusions

Adult patients with severe VZVP must be admitted and treated in the ICU. The use of intravenous acyclovir may be lifesaving, preventing progressive respiratory failure and reducing the high mortality rate of the disease.

Introduction

Varicella, more commonly known as chickenpox, is due to varicella-zoster virus. It is usually a mild childhood disease with most cases occurring in children below 13 years of age [1]. Less than 20% of all cases of VZV infection occurs in adults [2]. Adult morbidity and mortality are 10–20 times more common than in children because the otherwise healthy adults have a 20-times higher risk of complications [3], [4]. A serious and life-threatening complication is the development of varicella-zoster virus pneumonia (VZVP), which occurs most often in adults and in the immunocompromised host. The incidence of VZVP in otherwise healthy adults has been estimated to range from 0.3% to 50% [5], [6], [7], [8]. VZVP has a reported mortality of between 2.15% and 20% in the general population, but in pregnancy, it may be as high as 41% [5], [9], [10], [11], [12], [13], [14], [15], [16], [17].

In this retrospective study, we determine the clinical, laboratory, and radiological features of all adult patients with VZVP treated in our departments during the last 5 years. Important therapeutic and evolutive features are also reported.

Section snippets

Materials and methods

In this retrospective study, we examined all medical records of adult patients with a diagnosis of varicella who had been hospitalized in our two hospitals during the last 5 years. The medical records were obtained for those with a varicella diagnosis that could include VZVP. We defined the diagnosis of VZVP as a patient with a typical clinical history of varicella, a positive chest X-ray consisting mainly of ill-defined nodular or reticular densities of various sizes scattered throughout both

Results

A total of 92 adults were admitted to our hospitals because of varicellla-zoster virus (VIZ) infection during the last 5 years. Of these, 14 had a clinical diagnosis of VZVP (Table 1). Eleven (77%) were males (mean age of 36.4 years, range of 22–66 years) and three (23%) were females (mean age of 34.3 years, range of 17–61 years). In only three of our patients had the clinical diagnosis of VZV infection been confirmed serologically, and in only one was VZV DNA detected in the serum by the

Discussion

VZVP is the most common severe complication of VZV infection and sometimes leads to death. It is estimated that VZVP is the cause of hospitalization in at least 1 of 400 cases of this infection [24], with a reported mortality ranging from 2.15% to 50% [5], [9], [10], [11], [12], [13], [14], [15], [16], [17]. Reported incidences of VZVP have varied from 5% to as much as 50% [5], [7], [8], [19], [20], [21]. However, other studies suggest that the incidence in adults may be much lower: 5% or less

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