VARICELLA PNEUMONIA IN AN IMMUNOCOMPETENT ADULT WITH INTERSTITIAL LUNG DISEASE (ILD) REQUIRING VENO-VENOUS EXTRACORPOREAL MEMBRANE OXYGENATION (VV-ECMO)

Abstract

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Pulmonary involvement of varicella-zoster virus (VZV) is uncommon in immunocompetent adults but is associated with up to a 24% mortality rate. In this report, we present a case of primary VZV pneumonia causing severe acute respiratory distress syndrome (ARDS) ultimately requiring veno-venous ECMO (VV-ECMO). CASE PRESENTATION: A 37-year-old male with a history of ILD, noncompliant with immunosuppression regimen, presented with fever and cough for one week. He was discharged on levofloxacin for presumed community-acquired pneumonia. Two days later, he developed dyspnea and a diffuse vesicular rash concerning for chicken pox and was admitted. He developed worsening tachypnea and hypoxemia requiring endotracheal intubation. Subsequent bronchoscopy revealed normal mucosa. Empiric antibiotics and acyclovir were started for presumed VZV pneumonia given the rash. Arterial blood gas on a FiO2 of 70% was pH 7.38, PCO2 51, and PaO2 80 (PaO2:FiO2 114). Varicella IgM was positive, and a culture of his skin lesion grew VZV. CT chest revealed diffuse ground-glass opacities (Fig 1). Despite heavy sedation, paralytics and prone positioning, he developed increasing oxygen requirements, higher plateau pressures and a worsening respiratory acidosis. The patient was placed on VV-ECMO for respiratory support. Repeat bronchoscopy revealed new diffuse, endobronchial vesicular lesions (Fig 2,3). Despite more than two weeks on ECMO, he remains on ECMO due to poor lung compliance and gas exchange. His circuit was changed to include two oxygenators in parallel to improve gas exchange and CO2 removal, which allowed him to be extubated and communicate with his family. DISCUSSION: VZV pneumonia is becoming an increasingly recognized cause of ARDS in adults. Risk factors for the development of VZV pneumonia include an immunocompromised state, male sex, smoking history and prior lung disease. Our patient was never vaccinated against VZV and did not have the infection as a child. His course echoes what is described in the literature - pneumonia-like symptoms prior to development of skin lesions followed by ARDS. The underlying ILD likely predisposed him to a more severe course despite being immunocompetent otherwise. The finding of vesicular lesions on upper airways is classic of VZV pneumonia. Interestingly, the development of airway lesions occurred after skin lesions in our patient, which may explain why there are varying bronchoscopy findings reported in the literature. The mainstays of treatment include IV acyclovir and respiratory support. CONCLUSIONS: VZV pneumonia should be on the differential for patients with a diffuse rash and pneumonia given its high mortality rate. VV-ECMO may offer further supportive options since these patients are often younger and healthier, thus having a higher likelihood of recovering. The various configurations of VV-ECMO can allow prolonged lung rest to promote healing in these patients. Reference #1: Mirouse, A. et. al. Severe varicella-zoster virus pneumonia: a multicenter cohort study. Crit Care. 2017 Jun 7;21(1):137. Reference #2: John, K.G., et. al. The outcome of severe varicella pneumonia with respiratory failure admitted to the intensive care unit for mechanical ventilation. Eur Respir J. 2018 Jul 4;52(1). DISCLOSURES: No relevant relationships by Lisa Chen, source=Web Response No relevant relationships by Jonathan Gong, source=Web Response stock relationship with Pfizer Please note: $1001 - $5000 Added 03/11/2019 by Zubair Hasan, source=Web Response, value=stock stock relationship with Stryker Please note: $1001 - $5000 Added 03/11/2019 by Zubair Hasan, source=Web Response, value=stock stock relationship with United Health Group Please note: $1001 - $5000 Added 03/11/2019 by Zubair Hasan, source=Web Response, value=stock No relevant relationships by Ayelet Hilewitz, source=Web Response No relevant relationships by Seth Koenig, source=Web Response No relevant relationships by Peter Nauka, source=Web Response