Journal of Clinical Virology 56 (2013) 360–364 Contents lists available at SciVerse ScienceDirect Journal of Clinical Virology jo u r n al hom epage: www.elsevier.com/locate/jcv Case report Bronchial ulceration as a prognostic indicator for varicella pneumonia: Case report and systematic literature review Ryota Inokuchi a,∗ , Kensuke Nakamura a , Hajime Sato b , Kazuaki Shinohara c , Yuta Aoki a , Kent Doi a , Masataka Gunshin a , Takeshi Ishii a , Takehiro Matsubara a , Takahiro Hiruma a , Susumu Nakajima a , Naoki Yahagi a a Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan b Department of Health Policy and Technology Assessment, National Institute of Public Health, 2-3-6 Minami, Wako, Saitama 351-0197, Japan c Department of Emergency and Critical Care Medicine, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, Koriyama, Fukushima 963-8558, Japan a r t i c l e i n f o Article history: Received 23 August 2012 Received in revised form 31 October 2012 Accepted 10 December 2012 Keywords: Varicella zoster Chickenpox Pneumonia Viral Ulceration Bronchoscopy a b s t r a c t Adult varicella pneumonia is a common and serious complication of varicella zoster virus (VZV) infection in pregnant woman and immunocompromised individuals, with mortality rates of 30–50%. The poor prognosis is attributable to very aggressive disease progression and delayed onset of treatment. Here, we present a case of varicella pneumonia in a 69-year-old woman following long-term immunosuppressive treatment for kidney transplant. Respiratory failure developed within 3 d after admission for skin rash, and the patient died 28 d later despite acyclovir and foscarnet treatment. The autopsy showed extensive mucosal airway ulcerations from the pharynx to the main bronchi and numerous VZV-infected cells. We searched PubMed, Web of Science, and EMBASE (1980 through February 2012), as well as several medical report databases created by Japanese healthcare professionals, for all reported cases of varicella pneumonia for which bronchoscopy findings were documented. Twenty-four cases were included and we found that patients with limited or shallow ulcers had favorable outcomes, whereas patients with vast and deep ulcerations had fatal outcomes. These findings indicate that bronchoscopy findings, particularly those showing bronchial involvement, may be useful for evaluating varicella pneumonia. © 2012 Elsevier B.V. All rights reserved. 1. Why this case is important? Pneumonia, the most frequent complication of adult varicella often develops insidiously, with mortality rates ranging from 10% to >50% 1 and evolves rapidly; fatality is difficult to avoid once mechanical ventilation is required. Varicella pneumonia is usually detected within 6 d of rash onset and is associated with tachypnea, chest tightness, cough, dyspnea, fever, and occasionally, pleuritic chest pain and hemoptysis. However, these signs appear too late to constitute early biomarkers and are poor indicators of disease severity. 2 Moreover, polymerase chain reaction (PCR)-based diag- nosis using bronchial lavage (BAL) for disseminated varicella zoster virus (VZV) 3 infection does not allow early detection, cannot reli- ably measure disease severity, or serve as a prognostic indicator. Here, we have presented a fatal case of varicella pneumonia in an immunocompromised patient and discussed the relationship between bronchoscopic findings, disease severity, and progno- sis. ∗ Corresponding author. Tel.: +81 3 5800 8681; fax: +81 3 3814 6446. E-mail address: inokuchir-icu@h.u-tokyo.ac.jp (R. Inokuchi). 2. Case description A 69-year-old Japanese female nonsmoker was admitted to the University of Tokyo Hospital 1 month after kidney transplantation. She had developed end-stage renal failure 20 years earlier due to nephrosclerosis and was being treated with dialysis. She had con- comitant hepatitis C and transient atrial fibrillation. She complained of oral pain and a generalized rash on the day of admission. She had no headache, chest pain, or dyspnea, and her vital signs were stable. Varicella was diagnosed based on cutaneous findings, and 500 mg/d valacyclovir therapy was initiated. However, she developed fever, respiratory failure, and destabilized circulatory dynamics 3 d after admission and was transferred to the intensive care unit. Multiple mouth ulcers were noted, and cutaneous findings showed substantial generalized bullous lesions or pustules with a bright red halo. Mechani- cal ventilation and cardiovascular management for septic shock were initiated. After mechanical respiration, BAL was performed, and the sample was used for VZV-DNA real time PCR, which yielded positive results (>5.0 × 10 7 copies/ml; unmeasurable level). Bronchoscopy showed deep ulcerations from the trachea to the bronchi. 1386-6532/$ – see front matter © 2012 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.jcv.2012.12.013