A Fatal Case of Varicella

A case of adult chickenpox in which the patient developed a fatal pneumonia in the presence of preexisting idiopathic pulmonary hypertension is presented.

DEBA P. SARMA, MD New Orleans

. Ithough childhood A ideaths due to chickenpox are rare, adult fatalities due to chickenpox pneumonia are not uncommon. This is a report of a case of adult chickenpox in which the patient developed a fatal pneumonia in the presence of preexisting idiopathic pulmonary hypertension.

Report of a Case
A 42-year-old man came to the hospital in December, 1976, with a three-day history of shortness of breath and skin eruptions. He had been recently exposed to his daughter who was recovering from chickenpox. Since 1972 the patient had been followed for idiopathic pulmonary hypertension with polycythemia. On admission, there were extensive vesicular eruptions of the skin of the face, eyelids, neck, chest, abdomen, and anterior surfaces of the tower extremities. Vesicles were present in the mouth and oropharynx ranging in size up to 4 mm in diameter. Some were ruptured. No pustules were noted, nor were hemorrhagic changes found in any lesions. The patient appeared desperately ill with an oral temperature of 101F; a blood pressure of 80/0 mm Hg; pulse rate of 160 per minute; and a respiration rate of 52 per minute. Bilateral basilar rales were heard on auscultation. Roentgenogram of the chest revealed bilateral nodular densities. Laboratory studies yielded the following values: hematocrit, 76.2%; hemoglobin,

Fig. 1 Vesicular lesion of skin showing acantholytic and multinudeated

epidermal cells (hematoxylineosin, X60).

Associate Professor of Pathology, LSU School of Medicine; and Staff Pathologist, \ Medical Center, New Orleans, La.

25.2 gm/100 ml; red blood cells, 8,960,000/cu mm; WBCs, 12,.200/cu mm, with 30% aeutrophilic bands, 40% neutrophils, 10% lymphocytes, and 3% monocytes; serum sodium, 134 mEq/liter; serum potassium, 5.1 mEq/liter; serum chloride, 97 mEq /liter; and serum crea tinine, 3.8 ing/100 ml. Values of arterial blood gases were: serum pH, 7.40; Poz, 58; and Pcoz, 10. A diagnosis of varicella pneumonia was made. Management included oxygen inhalation and maintenance of fluid balance by intravenous infusions. Steroids, antiviral and antibacterial agents were not administered. The patient expired due to respiratory failure within 24 hours of admission. At autopsy, the skin vesicles showed typical histopathologic features of chickenpox (Fig. 1). The intradermal

vesicles contained desquamated epidermal cells showing enlargement, vacuolization, and multinucleation. Lungs were heavy (each weighed 1100 g). All lobes were subcrepitant, dark red, fleshy and rubbery. Red frothy fluid was noted on cut surface. On microscopic examination (Fig. 2) there was extensive sloughing of the respiratory epithelium of the bronchioles and alveoli. An interstitial pneumonitis was noted throughout the entire lung. Predominantly mononuclear cells with few neutrophils infiltrated the wails of bronchi, bronchioles, and alveoli. In some of the alveoli the exudate contained red cells, mononuclear cells, and large alveolar macrophages showing prominent nuclei with eosinophilic inclusion bodies (Fig. 2, inset) surrounded by clear haloes. Other organs, including the brain, did not show any evidence of varicella

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Journal of the Louisiana State Medical Society

October, 1981 - Volume 133, No. 10

VARICELLA - SARMA

infection. The heart was enlarged (700 g) as a result of long-standing idiopathk pulmonary hypertension.

Comment
Varicella pneumonia is rare in childhood, as noted by Builowa and Wishick, 1 who observed an incidence of pneumonia in 0.8% cases among 2,534 hospitalized children with varicella. However, among adults the incidence of pneumonia is about 15%.i3 The mortality among adult patients with varicella pneumonia is usually secondary to respiratory insufficiency. I feel that the preexisting idiopathk pulmonary hypertension and respiratory impairment in this patient were important factors in his rapid demise following varicella infection. Other factors increasing the mortality in these patients include steroid therapy, adminstration of antimetabolites and immunosuppressive drugs; malignant diseases, especially leukemias and lymphomas; and pregnancy.3

Fig. 2 Lung showing interstitial inflammation and alveolar exudate containing mononuclear cells (hematoxylin-eosin, X60). Intranuclear inclusion body in a

mononudear cell is seen (arrow) which is shown at high magnification in the inset (hematoxylin-eosin, X240).

References
1

Builowa JGM, Wishick SM: Complications of varicella: their occurrence among 2,534 patients. Am J Dis Child 49:923-

926, 1935 Weber DM, Pellecchia JA: VaricelL pneumonia. Study of prevalence in adult men. JAMA 192:228-229, 1965 Tribwasser JH, Harris RE, Bryant RE, et al: Varicella pneumonia in adults. Medicine 46:409-423, 1967

Sarma DP (1981): A fatal case of varicella. J La State Med Soc 133:152-153. PMID: 7338672 [PubMed - indexed for MEDLINE