Luis Shimose, MD
Assistant professor
University of Mississippi (UMMC), United States
Disclosure information not submitted.
Title: Varicella zoster tracheitis in an immunocompromised patient with renal transplant
Case Report Body
Introduction: Varicella-zoster virus(VZV) and cytomegalovirus(CMV) are common infections seen in immunocompromised patients. VZV reactivation can have variety of presentation including localized vesicular rash, generalized vesicular rash, and tissue invasive disease. We are presenting a rare case of disseminated VZV with tracheitis and CMV co-infection.
Description: 58-year-old male who presented with confusion and altered mental status, following flu-like symptoms 3 weeks before admission. He also noted a disseminated vesicular rash. He has a medical history significant for renal transplant in 2013 and diabetes. He was on tacrolimus, mycophenolate and prednisone. Patient was VZV IgG and CMV IgG positive at time of transplant. Donor serologic status was unknown. On arrival patient was found to be hypoxic, and CT chest showed diffuse nodular and ground glass opacities(figure 1). He was intubated. On exam, he was noted to have diffuse vesicular rash all over his body including head, neck, extremities and torso. Punch biopsy of the lesions revealed positive direct fluorescent antibody (DFA) for VZV. Lumbar puncture also confirmed presence of VZV by PCR in CSF. Due to respiratory failure, he underwent bronchoscopy with BAL that showed multiple vesicular lesions similar to those on his skin in the distal trachea, and main right and left bronchi (Figure 2). Bronchoalveolar lavage was positive for VZV by PCR and was also positive for CMV by PCR with 206,000 copies.His serum CMV PCR showed 106 copies. He was treated with ganciclovir for 4 weeks with significant improvement. He was extubated and transferred to rehab facility.
Discussion: VZV tracheitis is a rare manifestation of varicella virus infection. It has been reported in children but not in adults to our knowledge. One should be aware of pulmonary CMV and VZV co-infection in immunosuppressed patients.