DOI:10.2214/AJR.05.0850
AJR 2007; 188:W557-W559
© American Roentgen Ray Society
CT Findings of Varicella Pneumonia After Lung Transplantation
Toby M. Maher1,
Narainder K. Gupta2,3,
Margaret M. Burke4 and
Martin R. Carby5
1 Department of Respiratory Medicine, Royal Brompton Hospital, Sydney St.,
London SW3 6NP, United Kingdom.
2 Department of Radiology, Harefield Hospital, Harefield, Middlesex, United
Kingdom.
3 Present address: Department of Radiology, University of Pennsylvania,
Philadelphia, PA.
4 Department of Pathology, Harefield Hospital, Harefield, Middlesex, United
Kingdom.
5 Cardiothoracic Transplant Unit, Harefield Hospital, Harefield, Middlesex,
United Kingdom.
Received May 19, 2005;
accepted after revision July 10, 2005.
Address correspondence to T. M. Maher.
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Keywords: chest imaging • lung cancer • lung transplantation • pneumonia • varicella pneumonia
Introduction
Varicella pneumonia is a serious complication of chickenpox infection that
in immunosuppressed individuals has a mortality rate of more than 20%
[1]. The radiographic and
high-resolution CT appearances of varicella pneumonia have been described and
include 1- to 10-mm pulmonary nodules; hilar lymphadenopathy; ground-glass
attenuation; consolidation; and, less commonly, pleural effusions
[2–5].
This case report represents, to the best of our knowledge, the first
description of the CT findings of varicella pneumonia occurring in a lung
transplant recipient. The CT appearances in this case of varicella pneumonia
differ from those previously reported in either immunocompetent or
immunosuppressed individuals.
Case Report
A 31-year-old man who had undergone double lung transplantation 6 months
earlier because of cystic fibrosis presented with a 2-day history of pyrexia,
rigors, and wide-spread vesicular rash. A clinical diagnosis of primary
chickenpox infection was made and was later confirmed serologically. At
presentation, immunosuppression was being maintained with cyclosporine
(Neoral, Novartis), azathioprine (Imuran, GlaxoSmithKline), and prednisolone.
After the diagnosis of chickenpox, both prednisolone and azathioprine were
stopped, and treatment with high-dose IV acyclovir (10 mg/kg every 8 hours)
commenced. Immunosuppression was maintained with cyclosporine alone.
Over the subsequent 6 days, the patient became dyspneic and hypoxic,
requiring supplemental oxygen therapy. Chest radiograph, which had been clear
on admission, showed bilateral pulmonary infiltrates with moderatesized
pleural effusions. High-resolution CT of the chest revealed bilateral hilar
soft-tissue masses, thickening of the bronchovascular bundles, multiple lowe r
lobe pulmonary nodules, thickened interlobular septa, prominent mediastinal
adenopathy, and bilateral effusions (Figs.
1A,
1B,
1C,
1D).
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Fig. 1A —31-year-old man with varicella pneumonia after having
undergone double lung transplantation. CT scan at level of aortic arch shows
interlobular septal thickening (arrows) and scattered pulmonary
nodules.
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Fig. 1B —31-year-old man with varicella pneumonia after having
undergone double lung transplantation. CT scan at level of main carina shows
prominent soft-tissue densities at both hila, diffuse ground-glass
attenuation, and bilateral effusions.
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Fig. 1C —31-year-old man with varicella pneumonia after having
undergone double lung transplantation. CT scan through lung bases reveals
bilateral pleural effusions, prominent interlobular septal thickening, and
multiple pulmonary nodules (arrows).
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At this point, our differential diagnosis included varicella pneumonia,
acute allograft rejection, or secondary bacterial pneumonia. We were concerned
that mediastinal adenopathy might represent a second condition, such as
posttransplantation lymphoproliferative disease.
At fiberoptic bronchoscopy, the bronchial tree was found to be mildly
erythematous. Bacterial and fungal cultures of bronchial washings were
negative. Transbronchial biopsies showed interstitial pneumonitis, sparse
perivascular infiltrates, and prominent type II pneumocytes. One free-lying
intraalveolar cell contained a viral inclusion body (inset of
Fig. 1E). Treatment was
augmented with the administration of pooled human immunoglobulin
(Sandoglobulin, ZLB Bioplasma).
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Fig. 1E —31-year-old man with varicella pneumonia after having
undergone double lung transplantation. Photomicrograph of sample obtained at
transbronchial biopsy shows interstitial pneumonitis with viral inclusion body
in intraalveolar cell (inset). (H and E, original magnification, x200;
inset, x400)
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Over the subsequent 10 days, our patient made a full recovery. All
radiographic changes resolved. Thoracic CT repeated 14 days after the initial
scan showed that all of the previously noted abnormalities including the
mediastinal adenopathy had resolved (Fig.
1F).
Discussion
Varicella pneumonia is estimated to occur in one of every 400 cases of
adulthood chickenpox infections, being more common in pregnant and
immunosuppressed patients [1,
6]. 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 [1]. The diagnosis of
varicella pneumonia rests on the finding of new pulmonary infiltrates in the
context of active chickenpox infection. Alternative causes for pulmonary
infiltrates should be sought and excluded. The finding of viral inclusion
bodies on histology, as was seen in our patient, provides strong supporting
evidence for the diagnosis of varicella pneumonia
[1].
Chest radiography findings in varicella pneumonia are well described and
include pulmonary nodules, consolidation, hilar adenopathy, and pleural
effusions [2]. The CT findings
of varicella pneumonia are less well described in the literature. Kim et al.
[3] reported the CT findings of
three immunocompetent patients with varicella pneumonia. These included 5- to
10-mm ill-defined nodules, some of which had a surrounding ground-glass halo.
In one patient, areas of consolidation on chest radiography corresponded to
areas of coalesced nodules on CT. None of the three patients in that series
had evidence of adenopathy or pleural effusions. Nakamura et al.
[4] described a woman with
rheumatoid arthritis who presented with reactivation of Varicella
zoster infection. In that case, CT showed diffuse nodular shadowing.
Similarly, Picken et al. [5]
described multiple pulmonary nodules on CT in a case of primary varicella
infection.
The CT changes that we report differ markedly from those described
previously in varicella pneumonia and created considerable diagnostic
difficulty. Interlobular septal thickening and pleural effusions are
recognized to occur in acute allograft rejection, but this diagnosis was
excluded both by transbronchial biopsy and by the patient's subsequent
response to therapy. Similarly, these changes may have occurred as a
consequence of fluid overload, but signs of fluid overload were not observed
clinically.
It is likely, however, that alterations in lymphatic drainage that occurred
after lung transplantation were important in the evolution of both the pleural
effusions and the interlobular septal thickening in response to varicella
infection. In keeping with this hypothesis, the findings in our patient show
considerable overlap with those described in other forms of pneumonia
occurring in lung transplant recipients. Collins et al.
[7] reviewed the CT findings of
45 episodes of pneumonia occurring in 35 lung transplant recipients. Pulmonary
nodules, ground-glass attenuation, septal thickening, and pleural effusions
were common findings in bacterial, fungal, and cytomegalovirus pneumonia.
Mediastinal adenopathy, however, was noted in only a single case of bacterial
pneumonia.
In summary, we present the CT findings of varicella pneumonia that
developed as the consequence of primary varicella infection occurring in a
double lung transplant recipient. The CT findings of marked mediastinal
adenopathy and interlobular septal thickening are previously undescribed in
varicella pneumonia. These differences may be a peculiarity of varicella
pneumonia occurring in transplanted lungs. However, the CT characteristics of
varicella pneumonia have been infrequently described; thus, it is probable
that many of the features seen in this case may also be observed in
nonimmunosuppressed, nonlung transplantation patients. This case reiterates
the previously made observation that the extensive changes associated with
varicella pneumonia resolve rapidly and can be expected to have disappeared by
the time the cutaneous lesions of chickenpox have cleared
[3].
References
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infection in adult renal allograft recipients: four cases and a review of the
literature. Transplantation 2002;73
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- Kim JS, Ryu CW, Lee SI, Sung DW, Park CK. High-resolution CT
findings of varicella-zoster pneumonia. AJR1999; 172:113
–116[Abstract/Free Full Text]
- Nakamura M, Kanazawa M, Yamaguchi K, Akizuki M, Satoh S, Inada S.
Pneumonia caused by varicella-zoster virus in a patient with rheumatoid
arthritis [in Japanese]. Nihon Kyobu Shikkhan Gakkai
Zasshi 1996; 34:610
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- Picken G, Booth AJ, Williams MV. Case report: the pulmonary lesions
of chickenpox pneumonia—revisited. Br J Radiol1994; 67:659
–660[Abstract/Free Full Text]
- Mohsen AH, McKendrick M. Varicella pneumonia in adults.
Eur Respir J 2003;21
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Introduction
Case Report
