A 52-year-old man with fever, diffuse vesicular rash, hypoxia, and pulmonary infiltrates was diagnosed with varicella pneumonia and treated with intravenous acyclovir.
Researchers described a single-patient case of a seasonal agricultural worker without prior varicella immunity who presented with 2 days of cough, dyspnea, and fever, followed by a rapidly spreading pruritic rash. On presentation, oxygen saturation was 88% on room air, and examination showed vesicular lesions on the trunk and buccal mucosa with bilateral crackles. Laboratory findings included elevated C-reactive protein, leukopenia, and liver enzyme levels. Chest imaging demonstrated bilateral micronodules and ground-glass opacities, predominantly in the lower lobes. Polymerase chain reaction testing of vesicular fluid confirmed varicella zoster virus.
The patient received intravenous acyclovir with supportive care, resulting in resolution of respiratory symptoms and normalization of oxygenation by hospital discharge, with complete resolution of skin lesions within 2 weeks.
The report highlights that the combination of generalized vesicular rash, fever, hypoxia, and pulmonary infiltrates is characteristic of varicella pneumonia in adults. Imaging findings supported the diagnosis.
The report also notes that varicella pneumonia typically develops within the first week after rash onset and occurs more commonly in adults without prior immunity. In cited data, 71% of immunocompetent adults with primary varicella had imaging findings of pneumonia, and the lungs were the most commonly affected organ in disseminated infection. Among hospitalized patients, mortality rates range from approximately 13.6% to 24%, particularly in those requiring intensive care or mechanical ventilation.
Because confirmatory testing may take 24 to 48 hours, treatment should be initiated based on clinical suspicion. Early initiation of intravenous acyclovir within 24 hours of rash onset is associated with faster recovery and reduced risk of respiratory failure and mortality. Intravenous antiviral therapy is recommended; oral therapy may be used after clinical improvement, and corticosteroids are not routinely recommended. Varicella zoster immune globulin is reserved for postexposure prophylaxis.
This report is limited by its single-case design and lack of comparative data, which limits generalizability and does not allow estimation of treatment effects. Management recommendations reflect established clinical guidance rather than outcomes tested within the report.
The findings highlight the importance of recognizing varicella pneumonia in adults with compatible dermatologic and respiratory features and initiating prompt treatment. As Paul Bellmann, MD, of Medical University Innsbruck, and colleagues wrote, “intravenous antiviral therapy is recommended for treatment of varicella pneumonia.”
Disclosures: The researchers reported no conflicts of interest.
Source: JAMA Clinical Challenge
