Itching from the Skin to the Lungs

October 2015, Vol 148, No. 4_MeetingAbstracts

Chest Infections | October 2015

Itching from the Skin to the Lungs Bravein Amalakuhan, MD; Phoebe King, MD; Jay Peters, MD; Adriel Malave, MD University of Texas Health and Science Center at San Antonio, San Antonio, TX Chest. 2015;148(4_MeetingAbstracts):164A. doi:10.1378/chest.2246918

Abstract SESSION TITLE: Infectious Diseases Cases I SESSION TYPE: Affiliate Case Report Slide PRESENTED ON: Tuesday, October 27, 2015 at 07:30 AM - 08:30 AM INTRODUCTION: Varicella pneumonia (VP) is a rare but increasingly frequent complication of varicella zoster (VZ) infections, estimated to occur once every 400 cases. Of these cases, there are even fewer reports of VP presenting with endobronchial vesicles. To our knowledge, we present the first reported case of VP with diffuse endobronchial “bullae”.

CASE PRESENTATION: A 28 year old man with no significant past medical history, presented to an outpatient clinic with a three-day history of dyspnea and a worsening diffuse pruritic papular rash. He received diphenhydramine for an allergic skin reaction and was discharged. He developed facial swelling and progressive dyspnea over the next 2 days causing him to seek medical attention. Upon presentation in the E.D., he was hemodynamically stable, but febrile to 101°and severely hypoxic (RA saturation 85%). A chest x-ray revealed bilateral patchy infiltrates. The patient deteriorated and was placed on mechanical ventilation. A CT scan of the chest showed diffuse bilateral nodular ground-glass opacities. An HIV screen returned positive (CD4-54; viral load of 424,000 copies/ml). He was started on empiric antibiotics with Vancomycin, Piperacillin/Tazobactam, Azithromycin, Acyclovir, Trimethoprim/Sulfamethoxazole (TMP/SMX) and intravenous corticosteroids. A diagnostic bronchoscopy showed scattered 4cm “bullous” lesions throughout the bronchial tree. Bronchoscopic alveolar lavage was positive for VZ by polymerase chain reaction, with negative cultures for other viruses, bacteria, mycobacterial species and fungi. On Day 4, the patient was extubated and discharged home on a 14-day course of Valacyclovir, a corticosteroid taper and TMP/SMX. HIV therapy was planned as an outpatient.

DISCUSSION: Over the last 10 years, VP is increasing in incidence with mortality rates approaching 50% for those requiring mechanical ventilation. This is the first report of endobronchial bullae related to VP, and may be a valuable sign for early diagnosis and initiation of antiviral therapy. Early antiviral therapy for VP has been shown to decrease mortality rates to approximately10%. CONCLUSIONS: Endobronchial bullae are rare, and may be a sign of VP prompting early diagnostic tests for VZ infections even in the absence of a classic papular-vesicular rash.

Reference #1: Mohsen AH, McKendrick M. Varicella pneumonia in adults. The European respiratory journal. 2003;21(5):886-891. Reference #2: dos Santos MC, Alecrim MGC. Varicella Pneumonia in an Adult. New England Journal of Medicine.2010;362(13):1227-1227.

DISCLOSURE: The following authors have nothing to disclose: Bravein Amalakuhan, Phoebe King, Jay Peters, Adriel Malave No Product/Research Disclosure Information