An Atypical Presentation of Disseminated Varicella Infection

We present the case of a 61-year-old woman with a medical history of rheumatoid arthritis on immunosuppressive therapy who presented with generalized weakness, progressive dry cough, and dyspnea. She rapidly progressed to profound acute hypoxemic respiratory failure prompting initiation of mechanical ventilatory support. She was subsequently discovered to have diffuse vesicular rash about her abdomen without respect for dermatome borders that disseminated to her back and neck. Diagnostic testing confirmed varicella zoster virus with concomitant varicella pneumonia. Disseminated varicella infection is not uncommon and most frequently affects those with immunosuppression, but cases have been documented somewhat regularly in those without overt immunosuppression. Of the complications associated with disseminated varicella infection, varicella pneumonia is the most deadly. Mortality rate for disseminated varicella infection with varicella pneumonia ranges from 10% to 30%. However, for those with extreme respiratory failure requiring mechanical ventilation, mortality can reach as high as 50%. The most common presentation is a patient with cutaneous eruption that does not follow dermatomal distribution; this is followed by the onset of pulmonary symptoms within 2 to 5 days of rash. However, our case contributes another example of a rare presentation of varicella pneumonia, that being a case wherein the viral exanthem was preceded by the onset of respiratory failure. Recognizing the possibility of respiratory symptoms preceding the classic cutaneous manifestations of disseminated varicella infection is an important lesson, as it will allow for earlier detection and initiation of therapy. The profound mortality associated with varicella pneumonia is justification for further dedicated research into improved prevention and treatment, and increasing physician awareness of this clinical entity will be beneficial to that end.