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Varicella zoster virus (VZV) infection is a common infection in children and adolescents. In most of the cases it is a self limiting disease without any complications. In Armed Forces this infection is important because troops stay in close proximity to each other, so there is increased chance of person to person spread. We present a case of chicken pox manifesting with multi-organ life threatening complications successfully managed at a peripheral hospital.
A 34 year old male presented to the medical inspection (MI) room with high grade, continuous fever of two days and rash of one day duration. Rash started on the face and spread over to the trunk and limbs. He was diagnosed as case of chicken pox, isolated and started on oral acyclovir. After two days, the patient developed increasing cough and dyspnoea for which he was transferred to our hospital.
On arrival, he was severely dyspnoeic and unable to maintain oxygen saturation in room air. He had tachycardia, fever, a petechial rash all over the body and large haemorrhagic bullae surrounded by an area of erythema, centripetal in distribution (Fig. 1). Respiratory examination revealed bilateral crackles all over lung fields. Examination of other systems was unremarkable. Ryle's tube aspirate consisted of fresh blood and he had frank haematuria.
He was a smoker and there was history of household contact with a case of chicken pox. He had a past history of tubercular meningitis and was on anti tubercular drugs for last 10 months. He had no known immunocompromised disease and had not received steroids or immunosuppressive drugs in the recent past.
Investigations showed thrombocytopenia, deranged liver functions, renal functions and coagulopathy (Table 1). Chest radiograph revealed bilateral reticulo-nodular opacities with sparing of apices (Fig. 2). Electrocardiograph (ECG) showed sinus tachycardia. Arterial blood gas showed acute respiratory acidosis with a pH of 7.21, pO2 of 50 mm of Hg, pCO2 of 76 mm of Hg and HCO3 of 28 mEq/l.
A diagnosis of VZV infection with complications of varicella pneumonia (VP) leading to adult respiratory distress syndrome (ARDS), disseminated intravascular coagulation (DIC) and hepatitis was made. The patient was ventilated with lung protective strategy using a low tidal volume (TV) of 6ml/kg and a high positive end expiratory pressure (PEEP) of 10 cm of H2O. Controlled ventilation with paralysis and sedation with vecuronium and propofol was administered to the patient. Intravenous acyclovir in doses of 10 mg/kg 8th hourly was instituted. Broad spectrum antibiotics meropenem and teicloplanin were also added for possible bacterial infection. Transfusion support with random donor platelets (RDP), fresh frozen plasma (FFP) and whole blood were given as patient had significant upper gastro intestinal (UGI) bleed and haematuria.
In the first 48 hours of hospitalization he required 12 units of RDP, 12 units of FFP and four units of whole blood transfusion. He also developed oral, nasal and endotracheal bleeding. Radiographic opacities increased by the second day. PEEP and pressure support were increased to 15 cm of H2O and TV decreased to 4 ml/kg. Steroids were added after 48 hours to counter ARDS. Varicella serology, sent after five days of onset of rash, was positive (23 units/ml). Active bleeding decreased after day three of hospitalization. His haematological parameters gradually improved and by third day he did not require component support, however four more units of whole blood were given over two days to replace the blood loss. Biochemical parameters gradually normalized.
On day five patient developed bradycardia when heart rate reduced to 40–50 beats per minute. ECG showed Mobitz type 1, 2° heart block. Heart block reversed with atropine bolus injection. Subsequently, over the next two days he continued to have intermittent episodes of heart block, which did not require any specific therapy. This transient ECG change was attributed to myocarditis due to varicella infection.
Weaning trials were started by sixth day and he was extubated by eighth day of hospitalization. Antibiotics and acyclovir were continued for a total of ten days. Skin lesions healed and chest radiograph also normalized by tenth day of therapy (Fig. 3, Fig. 4). ECG reverted back to normal. He was discharged after he was restored to good health and all laboratory data normalized.
This patient when presented to our hospital, had fever with rash. He had a large number of petechiae present all over the body and haemorrhagic bullae, which had characteristic distribution of a varicella rash. A diagnosis of VZV infection with complications was considered due to the characteristics of the rash.
VP is the commonest complication of VZV infections in adults; its incidence has been estimated to be 2.3 in 400 cases . Risk factors for VP are smoking, immunocompromised adults, severity of skin rash and chronic obstructive lung disease . Our patient was a smoker and had a severe rash. Treatment of VP consists of early institution of acyclovir therapy and aggressive mechanical ventilation . Acyclovir was started on admission in this patient. The use of steroids has been studied in a trial and has been found to significantly reduce hospital and intensive care unit (ICU) stay and moderately decrease mortality . Respiratory acidosis with hypercapnia in this patient was possibly because of respiratory muscle fatigue as he was dyspnoeic for more than 24 hours when he presented to us. Haemorrhagic manifestations in varicella are a rare
complication and not even a single case was seen in two large case series of varicella related complications [5, 6]. In one case report, an immunocompetent male with varicella infection with ARDS and DIC was successfully managed with acyclovir, mechanical ventilation, steroid pulse therapy hemofiltration and component support . Varicella serology is not routinely used in uncomplicated cases, however in complicated cases like these, where lesions of chicken pox do not appear to be classic due to haemorrhagic manifestations, this diagnostic test can be of great help. Immunoglobulin M (IgM) in this patient was positive and confirmed our diagnosis.
To conclude, this was a case of varicella infection with severe, rare complications of DIC, ARDS, myocarditis and hepatitis managed successfully with acyclovir, mechanical ventilation and component support at a peripheral hospital.