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Weekly Chest CasesArchive of Old Cases

Case No : 1109 Date 2019-01-28

  • Courtesy of Yoon Joo Shin, Kyung Won Lee / Seoul National University Bundang Hospital
  • Age/Sex 24 / M
  • Chief Complaintcough, blood tinged sputum and skin rash
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5

Diagnosis With Brief Discussion

Diagnosis
Varicella-zoster pneumonia
Radiologic Findings
Initial chest plain radiograph shows multiple nodular patchy infiltration in both lungs, especially at LLLF.
Serial non-contrast chest CT scan demonstrated multiple randomly distributed small sized, ill-defined nodules with surrounding halo of ground-glass opacity in both lungs. Focal ill-defined GGO/consolidation in the LUL lingula division.
The patient showed skin rash as shown as figure, and serum IgM of Varicella-zoster was positive. After treating with IV acyclovir 10mg/kg for 4 days and PO gangiclovir for 3 days, symptom and chest plain radiograph of the patient was much improved.
Brief Review
Varicella virus (varicella-zoster virus) is a double-stranded DNA virus and a member of the Herpesviridae family. Varicella (chickenpox) is a common contagious infection in childhood, with increasing frequency in adults . Pneumonia, although rare, is the most serious complication affecting adults with chickenpox. Varicella pneumonia is estimated to occur in one of every 400 cases of adulthood chickenpox infections, being more common in pregnant and immunosuppressed patients .
Predisposing conditions include underlying leukemia and lymphoma and other causes of immunodeficiency. Patients with human immunodeficiency virus or acquired immunodeficiency syndrome (AIDS) with chickenpox are at high risk for developing varicella pneumonia .
Symptoms of pneumonia develop within a few days after the skin rash appears and include cough, dyspnea, hemoptysis, tachypnea, pleuritic chest pain, cyanosis, and fever. Analysis of case series suggests that mortality due to varicella pneumonia has declined with the advent of acyclovir, although it remains as high as 22% in immunocompromised hosts.
The thin-section CT appearances in varicella pneumonia largely reflect the multicentric hemorrhage and necrosis centered on airways . Common findings include numerous nodular opacities measuring 5–10 mm in diameter, some with a surrounding halo of ground-glass opacity (halo sign), patchy ground-glass opacities, and coalescence of nodules . A miliary distribution may also occur. After antiviral chemotherapy, imaging findings disappear concurrently with healing of skin lesions. Occasionally, lesions may calcify and persist as numerous, well-defined, randomly scattered, 2–3-mm densely calcified nodules.
References
1. Tomas Franquet, Imaging of pulmonary viral pneumonia, Radiology 2011; 260:18– 39
2. Kim JS, Ryu CW, Lee SI, Sung DW, Park CK. High-resolution CT findings of varicella-zoster pneumonia. AJR 1999;172:113-116
Please refer to
Case 79 Case 328 Case 917
Keywords
Lung, Viral infection,

No. of Applicants : 70

▶ Correct Answer : 24/70,  34.3%
  • - Ishikawa Matto Central Hospital , Japan MANABU AKIMOTO
  • - Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
  • - Kinki University Faculty of Medicine, , Japan MITSURU MATSUKI
  • - Niigata University , Japan ATSUSHI UEHARA
  • - The University of Tokyo Hospital , Japan MASAFUMI KAIUME
  • - Higashi-Ohmi General Medical Center , Japan AKITOSHI INOUE
  • - Chonbuk National University Medical School , Korea (South) HYEJIN YANG
  • - Chonbuk National University Hospital , Korea (South) MINGI SHIN
  • - NIMS, HYDERABAD , India BHASKAR K
  • - Ondokuz Mayis University , Turkey CETIN CELENK
  • - Other , Korea (South) SEONGSU KANG
  • - Cabinet Capricorne, clinique sainte-clotilde , Reunion FABIEN HO
  • - Gifu University Hospital , Japan Yo Kaneko
  • - CLINIQUE STE CLOTILDE , Reunion PATRICK MASCAREL
  • - Azienda Ospedaliera di Cremona , Italy Pietro Sergio
  • - Chonbuk National University Hospital , Korea (South) KUM JU CHAE
  • - , Korea (South) SEUNGYOON CHAE
  • - Kizawa Memorial Hospital , Japan Shoji Okuda
  • - Kyoto Prefectural University of Medicine , Japan TADASHI TANAKA
  • - Ichinomiya Nishi Hospital , Japan Takao Kiguchi
  • - Private sector , Greece VASILIOS TZILAS
  • - , Japan YUMI MAEHARA
  • - Hamamatsu University Hospital , Japan YUKI HAYASHI
  • - Seoul Veterans Hospital , Korea (South) HYUN JUNG YOON
▶ Correct Answer as Differential Diagnosis : 6/70,  8.6%
  • - Vita Hospital , Brazil DIOGO LAGO PINHEIRO
  • - , Korea (South) JUNGHWAN KIM
  • - Narayana Multispeciality Hospital Jaipur Rajasthan , India JAINENDRA JAIN
  • - Teikyo University Hospital , Japan KAORU SUMIDA
  • - the first affiliatited hospital of nanjing medical univercity , China HAI XU
  • - Jiangsu province hospital , China WANGJIAN ZHA
▶ Semi-Correct Answer : 5/70,  7.1%
  • - Affilitated Hospital of Jining Medical University , China HUA SHENG JIANG
  • - Seoul National University Hospital , Korea (South) Ju Gang Nam
  • - Qatif Central Hospital , Saudi Arabia HANI MAKKY ALSALAM
  • - Onomichi municipal hospital , Japan Hirofumi Mifune
  • - Seoul National University Hospital , Korea (South) JI HEE KANG
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Current Editor : Sung Shine Shim, MD, PhD. Email : sinisim@ewha.ac.kr

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