A 29 year old man presents to the Emergency Department with a 2 day history of shortness of breath and hallucinations and one week history of a rash. Examination reveals that he is febrile (40.9oC), tachypnoeic (44 breaths per minute) and hypoxic on room air (SpO2 92%), tachycardic (120 beaths per minute) and hypotensive (90/45mmHg). He is resuscitated and transferred to intensive care:

 

 

 

a).What  is the likely pathogen  for the rash?

b) What specific treatment can be used?

c) What are the risk factors for developing a pneumonia from this pathogen?

d) What superimposed infection is likely?

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College Answer

a).What  is the likely pathogen  for the rash?
Varicella Zoster Virus

 

b) What specific treatment can be used?
Acyclovir, famciclovir or valaciclovir

 

c) What are the risk factors for developing a pneumonia from this pathogen? 
Smoker, contact with index case, >100 spots, duration of fever, chronic lung disease, 3rd trimester pregnancy, immunosuppression

 

d) What superimposed infection is likely?
Staphylococcal Aureus

 

Discussion

 

a) This looks like the rash of Varicella zoster.

 

b) Aciclovir or famciclovir are the treatment of choice.Valaciclovir is an oral pro-drug of aciclovir, and one would probably be wanting to use the high-potency IV forms in this disease.

 

c)The following are known risk factors for Varicella pneumonia:

  • Immunocompromise
  • Pregnancy
  • Chronic lung disease
  • Adults (greater risk compared to children)
  • Smoking
  • Number of spots - over 100 (yes, somebody counted them)

Contact with an infected person is also mentioned. In one case series, such contact was mentioned by 16 of the varicella pneumonia patients, and only by 10 of the non-pneumonia patients.

 

d) Staphylococcal superinfection of the wounds classically follows the resolution of chickenpox, and can lead to some nasty complications.

 

 

References

References

Gogos, C. A., H. P. Bassaris, and A. G. Vagenakis. "Varicella pneumonia in adults, A review of pulmonary manifestations, risk factors and treatment."Respiration 59.6 (1992): 339-343.

 

Mohsen, A. H., and M. McKendrick. "Varicella pneumonia in adults." European Respiratory Journal 21.5 (2003): 886-891.

 

Ellis, M. E., K. R. Neal, and A. K. Webb. "Is smoking a risk factor for pneumonia in adults with chickenpox?." British medical journal (Clinical research ed.) 294.6578 (1987): 1002.

 

Mohsen, A. H., et al. "Lung function tests and risk factors for pneumonia in adults with chickenpox." Thorax 56.10 (2001): 796-799.

 

Fleisher, Gary, et al. "Life-threatening complications of varicella." American Journal of Diseases of Children 135.10 (1981): 896-899.