PMC10407726_01
Time course of skin rash. On the day of admission, papular skin rashes were observed. (A). The day after admission, the papules changed to vesicles. (B). On the fourth day of admission, most of the skin lesions were crusted (C). On the 12th day of admission, her skin rashes became more pigmented (D). On the 34th day of admission, the skin rashes had almost disappeared (E).
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A 66-year-old female was admitted to our hospital with papules on her face, anterior chest, and groin along with dyspnea (Fig. 1 A). Additionally, vesicular rashes appeared throughout the body, including the head (Fig. 1B). The time course of the skin rashes is shown in Fig. 1. On the day of admission, papular skin rashes were observed. (Fig. 1A). The day after admission, the papules changed to vesicles. (Fig. 1B). On the fourth day of admission, majority of the skin lesions appeared crusted (Fig. 1C). On the 12th day of admission, her skin rashes became more pigmented (Fig. 1D). On the 34th day of admission, the skin rashes had almost disappeared (Fig. 1E).
Time course of chest computed tomography findings. Granular infiltrates, micronodules, and ground-glass opacities were observed on the day of admission (A). Worsening ground-glass opacities and coalescence of the nodular lesions were observed the day after admission (B). On the fourth day of admission, most of the lung fields were filled with ground-glass opacities and infiltrating shadows (C). However, as the disease improved, the ground-glass opacities and infiltrating shadows disappeared, and only small nodules remained on the 12th day of admission (D). On the 34th day of admission, the nodules had shrunk but persisted (E).
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Chest CT revealed granular infiltrates, micronodules, and ground-glass opacities (Fig. 2A). Chest CT at that time showed worsened ground-glass opacities and coalescence of nodular lesions, which are considered characteristic of VZV pneumonia (Fig. 2B). The time course of chest CT findings is shown in Fig. 2. Granular infiltrates, micronodules, and ground-glass opacities were observed on the chest CT at the time of admission (Fig. 2A). The day after admission, worsening of ground-glass opacities and coalescence of nodular lesions were observed (Fig. 2B). On the fourth day of admission, most of the lung fields were filled with ground-glass opacities and infiltrating shadows (Fig. 2C). Only small nodules remained on the CT on the 12th day of admission (Fig. 2D). On the 34th day of admission, the nodules had shrunk in size but remained intact. (Fig. 2E).
Clinical course of this case. ABPC/SBT: ampicillin/sulbactam, Cre: creatinine, mPSL: methylprednisolone, NC: nasal cannula, P/F ratio: a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen. Ampicillin/sulbactam was administered upon admission. However, the day after admission, she was diagnosed with VZV pneumonia and treated with acyclovir (14 days) based on the typical skin rash and chest CT findings. Her condition worsened and she developed multiple organ failure. The patient was intubated; ventilator management was initiated; and steroids (10 days), noradrenaline (3 days), vasopressin (2 days), along with heparin (10 days) were administered. After continued treatment with drug adjustments based on the renal function, the patient's respiratory condition and cardiovascular system gradually improved. The patient was extubated on the 11th day and discharged on the 19th day of admission.
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The clinical course of this case is summarized in Fig. 3.
Time course of polymerase chain reaction of varicella-zoster virus and human herpesvirus 6 and titers of IgM and IgG of varicella-zoster virus. DNA: deoxyribonucleic acid, HHV-6: human herpesvirus 6, PCR: polymerase chain reaction, VZV: varicella-zoster virus. A total of 8.65 x 105 copies/ml of VZV DNA and 1.04 x 105 copies/ml of HHV-6 DNA were detected on the day of admission in the blood samples. VZV DNA was detected at 2.71 x 104 copies/ml on the 8th day and 196 copies/ml on the 15th day, but disappeared on the 34th day of admission. On the other hand, HHV-6 DNA was not detected after the 8th day of admission. In sputum samples, VZV and HHV-6 DNA were detected at 2.27 x 104 copies/well and 3.31 x 103 copies/well, respectively, on the 6th day of admission. VZV DNA was detected at 50 copies/well on the 18th day and 27 copies/well on the 34th day of admission. In contrast, HHV-6 DNA was not detected after the 18th of admission. The titers of both VZV-IgM and VZV-IgG showed little increase upon admission. The titer of VZV-IgM increased initially and then decreased, whereas that of VZV-IgG increased and then remained persistently high.
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Multiplex real-time polymerase chain reaction for simultaneous detection of VZV, HHV-6, and herpes simplex virus was performed using blood and sputum samples (Fig. 4). VZV-IgM and IgG levels were also measured over the time (Fig. 4).