Chickenpox pneumonia: experience with antiviral treatment

Structural and Synthetic Aspects of Small Ring Oxa- and Aza-Heterocyclic Ring Systems as Antiviral Activities

Antiviral properties of different oxa- and aza-heterocycles are identified and properly correlated with their structural features and discussed in this review article. The primary objective is to explore the activity of such ring systems as antiviral agents, as well as their synthetic routes and biological significance. Eventually, the structure-activity relationship (SAR) of the heterocyclic compounds, along with their salient characteristics are exhibited to build a suitable platform for medicinal chemists and biotechnologists. The synergistic conclusions are extremely important for the introduction of a newer tool for the future drug discovery program.

Acute respiratory failure on varicella pneumonia in Indonesian adult with chronic hepatitis B: A case report and review article

Background

Varicella pneumonia is a rare clinical manifestations and potentially lethal complications of varicella in a previously healthy adult.

Case presentation

An Indonesian male, 44 years old, Javanese ethnic, complained of progressive dyspnea two days. He had previously been contacting varicella from his daughter 3–4 days before dyspnea onset. He showed typical symptoms of varicella, such as fever and vesicles all over the body. He had been in good health despite having a chronic hepatitis B infection. Chest X-ray on admission revealed bilateral diffuse consolidation with air-bronchogram. Diagnosis of varicella pneumonia was based on typical varicella cutaneous, clinical and chest X-ray findings. We installed mechanical ventilatory support in the isolation ward and he received acyclovir and symptomatic treatment. Ventilatory support was removed on the 3rd day. He successfully recovered on the third day and uninstalled an endotracheal tube.

Discussion

The early and accurate diagnosis of varicella pneumonia was based on disease course and chest X-ray. Managing varicella pneumonia with acute respiratory failure was mechanical ventilator support (when needed), an antiviral, and other symptomatic treatment.

Conclusion

Varicella pneumonia is a rare and severe complication with a good prognosis if diagnosed and treated promptly.

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Chronic hepatitis B increases the risk of varicella developing into acute respiratory failure.

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Early diagnosis and prompt treatment give excellent outcome.

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Ventilation mechanical support is a crucial intervention in acute respiratory failure.

[Update on respiratory infections in the emergency department]

Las infecciones respiratorias agudas (IRA) constituyen uno de los motivos de consulta más frecuentes en los Servicios de Urgencias (SU) y se encuentran entre las primeras causas de morbimortalidad en los países en vías de desarrollo, según la Organización Mundial de la Salud (OMS). De manera general, se pueden definir como un deterioro clínico agudo caracterizado por la presencia de tos, expectoración, disnea, fiebre, cambios en las características del esputo y alteraciones radiológicas; todas estas mani- festaciones pueden comprometer de manera significativa la salud de los pacientes. Realizar un buen diagnóstico y tratamiento de las IRA es primordial en la práctica diaria, tanto en Atención Primaria como a nivel hospitalario, para evitar complicaciones y mortalidad relacionadas con estas enfermedades. En esta actualización, hablaremos de las infecciones respiratorias más frecuentes en el SU, la bronquitis aguda, las agudizaciones de la EPOC o bronquiectasias y las neumonías.

[Varicella pneumonia in adult population: review of 21 cases]

BACKGROUND

Retrospective study of the varicella pneumonia in adults, in order to know incidence, environmental and clinical characteristics and treatments of patients with this diagnosis during the last 9 years in Toledo.

MATERIAL AND METHODS

Twenty-one adult patients with the diagnosis of varicella pneumonia were studied, using the information of clinical histories and codified data. The backgrounds of pregnancy, smoking habit, concomitant diseases, previous contacts with another patients and the season of the year, were evaluated. Diagnosis was established by clinical and radiologic criteria in the course of varicella infection.

RESULTS

21 patients (10 males and 11 females, between 25 and 73 years) were studied. 17 (81%) were smokers, in 15 (71.4%) there was documented contact with varicella infection and 4 (19%) were immunocompromised. In the first 3-7 days after the development of skin lesions (100%), there was fever in 20 cases (95.2%) and dyspnea in 14 (66.7%). There were 4 patients (33,3%) without respiratory symptoms and in 5 (23,8%) there was important hypoxemia. Evolution was satisfactory in 20 cases (95.2%); three others requiring admission to Intensive Care Unit. Chest X-ray revealed an interstitial pattern in 11 cases (52.4%), nodular in 4 (19%) and a mixed pattern in 5 (23.8%). 20 patients were treated with acyclovir and in one case with foscarnet. In 28.57% cases, corticosteroids were needed.

CONCLUSIONS

We believe smoking habit could be a risk factor related to an increase of varicella pneumonia. A chest X-ray should be made in every patient, despite the symptoms. Adults with pneumonia have a better prognosis if acyclovir is started early in time. Concomitant treatment with corticosteroids should be used in those cases with respiratory insufficiency.

Medical treatment of viral pneumonia including SARS in immunocompetent adult

Since no randomized controlled trials have been conducted on the treatment of viral pneumonia by antivirals or immunomodulators in immunocompetent adults, a review of such anecdotal experience are needed for the more rational use of such agents. Case reports (single or case series) with details on their treatment and outcome in the English literature can be reviewed for pneumonia caused by human or avian influenza A virus (50 patients), varicella zoster virus (120), adenovirus (29), hantavirus (100) and SARS coronavirus (SARS-CoV) (841). Even with steroid therapy alone, the mortality rate appeared to be lower when compared with conservative treatment for pneumonia caused by human influenza virus (12.5% vs. 42.1%) and hantavirus (13.3% vs. 63.4%). Combination of an effective antiviral, acyclovir, with steroid in the treatment of varicella zoster virus may be associated with a lower mortality than acyclovir alone (0% vs. 10.3%). Combination of interferon alfacon-1 plus steroid, or lopinavir/ritonavir, ribavirin plus steroid were associated with a better outcome than ribavirin plus steroid (0% vs. 2.3% vs. 7.7%, respectively). Combination of lopinavir/ritonavir plus ribavirin significantly reduced the virus load of SARS-CoV in nasopharyngeal, serum, stool and urine specimens taken between day 10 and 15 after symptom onset when compared with the historical control group treated with ribavirin. It appears that the combination of an effective antiviral and steroid was associated with a better outcome. Randomized therapeutic trial should be conducted to ascertain the relative usefulness of antiviral alone or in combination with steroid.

Varicella-zoster virus pneumonia in adults: report of 14 cases and review of the literature

BACKGROUND: The aim of this retrospective study was to determine the clinical, laboratory, and radiological features of all adult patients with varicella-zoster virus pneumonia (VZVP) treated in our departments during the last 5 years. Important therapeutic and evolutionary features are also reported. METHODS: Fourteen patients (11 males and 3 females, mean age OF 36.4 and 34.3 years, respectively), diagnosed as suffering from VZVP, were included in this study. The antecedents of previous contact with patients with varicella, smoking, pregnancy, and underlying diseases were evaluated. In all cases, the diagnosis of pneumonia was established by clinical and radiological criteria in the course of varicella infection. RESULTS: All but one patient had had previous contact with a varicella patient. Eleven of them (78.57%) were smokers. None of the patients was immunocompromised. All patients had the characteristic rash of the disease, fever, and cough. Only six (43%) had bilateral sparse rales on auscultation. Arterial blood gas analysis at the onset of VZVP revealed hypoxemia in seven patients (50%) and hypocapnia in six (43%). Mean PaO(2) was 55 mmHg (range of 42-68 mmHg) and mean PaCO(2) was 34 mmHg (range of 27-36 mmHg). Chest radiographs showed ill-defined nodular or reticular densities of various sizes scattered throughout both lung fields. A CT scan of the chest, performed in seven patients (50%), confirmed the radiological findings and marked out patchy ground-glass attenuation in three patients and coalescence of lesions in two others. After diagnosis, all patients were immediately started on acyclovir 5-10 mg/kg every 8 h. Five patients (36%) were admitted to the ICU due to acute hypoxemic respiratory failure. Two patients received noninvasive positive pressure ventilation via a facemask and the other three patients with a clinical diagnosis of ARDS were intubated and ventilated mechanically. The duration of patient hospitalization was 16+/-10 days. One patient (8%) died in the ICU on the third day after admission due to multiple organ dysfunction (MOF). All of the other patients recovered completely without any sequelae. CONCLUSIONS: Adult patients with severe VZVP must be admitted and treated in the ICU. The use of intravenous acyclovir may be lifesaving, preventing progressive respiratory failure and reducing the high mortality rate of the disease.

Varicella pneumonia: another 'steroid responsive' pneumonia?

Varicella-zoster virus (VZV) pneumonitis remains an often-fatal complication of VZV infection. Antiviral agents and supportive care are widely accepted therapies. Cautious use of corticosteroids in life-threatening VZV pneumonitis may be justified. Appropriate patient selection factors are as yet unidentified and the decision to commence corticosteroid therapy in this setting is clinical.

Outcome of varicella pneumonitis in immunocompetent adults requiring treatment in a high dependency unit

OBJECTIVES

The incidence of varicella infection is increasing in adults, where primary pneumonitis is the main complication. Little information exists concerning treatment of those patients who require admission to a high dependency unit (HDU) facility. A study was performed to examine the risk factors for developing varicella pneumonitis (VP), to document disease progression and assess prognosis for patients with VP requiring HDU admission.

METHODS

A 10-year retrospective casenote review of patients admitted to the Regional Infectious Diseases Unit HDU. Varicella pneumonitis (VP) was defined as diffuse nodular shadowing on a chest X-ray (CXR) of a patient with a classical chickenpox rash. Severe pneumonitis was defined as an hypoxaemia index (pO2 in mmHG/FiO2) of less than 150 at any time during hospital stay. All patients were treated with intravenous acyclovir at a dose of 10 mg/kg.

RESULTS

A total of 33 patients were admitted to the HDU with VP over the study period, 30 were included in the study. Annual admission rates remained constant. Most patients (76.7%) had at least one recognised risk factor for severe VP: smoking 18/30, pregnancy 9/30, chronic lung disease 7/30. Twelve (40%) patients had severe VP, eight (26.7%) required assisted ventilation. The presence of greater than one risk factor (p < 0.02) was associated with progression to severe VP. There was one death: a 63-year-old man with a long history of chronic airflow limitation whose treatment had included domicillary long-term oxygen therapy. Nine (30%) patients developed secondary bacterial pneumonia; all recovered with appropriate antibiotic treatment. The period of stay in HDU for the majority of patients was short (mean 4.5 days).

CONCLUSIONS

The prognosis for severe adult VP with current available treatment is good. The only predictor on admission for severe VP is the presence of more than one recognised risk factor for developing VP.

Chickenpox pneumonia: case report and literature review

The incidence of primary chickenpox infection in young adults appears to be rising in the UK and other developed countries. The infection is more severe in adults than in children and complications, including pneumonia, are more frequent. An illustrative case of severe chickenpox pneumonia in an immunocompetent, non-pregnant adult smoker is presented. The epidemiology and pathology of the disease is discussed and a review of current management in the emergency department and the intensive care unit is presented. Strategies for the prevention of chickenpox pneumonia are also discussed.

Corticosteroids in life-threatening varicella pneumonia

BACKGROUND

Varicella pneumonia that results in respiratory failure or progresses to the institution of mechanical ventilation carries a significant morbidity and mortality despite intensive respiratory support and antiviral therapy. There has been no reported study of the role of corticosteroids in life-threatening varicella pneumonia.

DESIGN AND METHODS

This was an uncontrolled retrospective and prospective study of all adult patients with a diagnosis of varicella pneumonia who were admitted to the ICUs of the Johannesburg group of academic hospitals in South Africa between 1980 and 1996. Patient demographics, clinical and laboratory features, necessity for mechanical ventilation, and complications were reviewed. The outcome and therapy of varicella pneumonia was evaluated with particular reference to the use of corticosteroids. Patients with comorbid disease and those already taking immunosuppressive agents were excluded. Key endpoints included length of ICU and hospital stay and mortality.

MEASUREMENTS AND RESULTS

Fifteen adult patients were evaluated, six of whom received corticosteroids in addition to antiviral and supportive therapy. These six patients demonstrated a clinically significant therapeutic response. They had significantly shorter hospital (median difference, 10 days; p<0.006) and ICU (median difference, 8 days; p=0.008) stays and there was no mortality, despite the fact that they were admitted to the ICU with significantly lower median ratios between PaO2 and fraction of inspired oxygen than those patients (n=9) who did not receive corticosteroid therapy (86.5 vs 129.5; p=0.045).

CONCLUSION

When used in addition to appropriate supportive care and early institution of antiviral therapy, corticosteroids appear to be of value in the treatment of previously well patients with life-threatening varicella pneumonia. The observations presented in this study are important and should form the basis for a randomized controlled trial, as no other relevant studies or guidelines are available.

Prolonged extracorporeal life support (ECLS) for varicella pneumonia

OBJECTIVE

To review the institutional experience of a national tertiary referral center for extracorporeal life support (ECLS) in severe varicella pneumonia.

DATA SOURCES

Hospital records and ECLS flow sheets.

STUDY SELECTION

All pediatric (nonneonatal) and adult patients who were treated for varicella pneumonia with ECLS at the University of Michigan Medical Center between 1986 and 1995.

DATA EXTRACTION

Diagnosis of varicella pneumonia was made by history of recent exposure to chickenpox, progressive dyspnea, fever, a characteristic diffuse, vesicular rash, and a supporting chest roentgenogram. Indications for ECLS included a shunt fraction of > 30% or PaO2/FlO2 ratio of < 80 despite maximal conventional therapy, which included aggressive diuresis, blood transfusions to optimize oxygen-carrying capacity, pressure-controlled/inverse-ratio ventilation, and intermittent prone positioning.

DATA SYNTHESIS

Between 1986 and 1995, 191 patients were referred for ECLS. Among these patients, there were 51 (27%) cases of viral pneumonia, of which nine cases were due to acute varicella-zoster infection. Intravenous acyclovir was administered to eight of the nine patients. Of the nine patients, two patients improved using conventional ventilator management, and seven patients underwent ECLS. Overall survival on ECLS was 71% (5/7). The mean (+/-SD) alveolar-arterial oxygen gradient and PaO2/FlO2 ratio were 533 +/- 101 torr (71.3 +/- 13.5 kPa) and 67 +/- 24, respectively. The median duration of mechanical ventilation before ECLS and the subsequent duration of ECLS were 4 and 12.8 days, respectively. One of the deaths was from progressive right heart failure secondary to pulmonary hypertension and the other death was from overwhelming Pseudomonas sepsis.

CONCLUSIONS

Early recognition of imminent pulmonary failure and rapid institution of ECLS are critical in the successful management of severe, life-threatening varicella pneumonia.

Intensive care management of varicella pneumonia

To determine the clinical features, treatment and outcome of severe varicella pneumonia with hypoxic respiratory failure requiring intensive care management, a prospective survey of consecutive cases was undertaken. Fifteen consecutive adult cases of varicella pneumonia with respiratory failure admitted to a 10-bed respiratory intensive care unit over a period of 10 y from 1984-1993 were studied. All patients were given acyclovir immediately on admission. The level of ventilatory support needed was determined by the severity of gas exchange abnormality, and varied from face mask oxygen (three patients), through continuous positive airway pressure (CPAP) by face mask (eight patients), to continuous positive pressure ventilation (CPPV) (four patients). The majority of patients were young females, only one of whom was pregnant. All patients had been in close contact with a known case of chickenpox. All patients responded well to acyclovir and ventilatory support with improved oxygenation. Monitoring with pulse oximetry was important to detect episodes of desaturation on inadvertent discontinuation of positive and expiratory pressure (PEEP). Two patients were admitted with bacterial superinfection, and one patient, who had required intubation and CPPV, developed nosocomial respiratory tract infection. There were no deaths. This experience suggests that intensive care admission, with the early administration of intravenous acyclovir and recognition of the severity of the hypoxaemia resulting from varicella pneumonia (which can be reversed with PEEP), should reduce the mortality of severe varicella pneumonia in adults.

Fatal chickenpox pneumonia in an asthmatic patient on oral steroids and methotrexate

A 49 year old man with a long history of severe chronic asthma, treated with oral corticosteroids and weekly doses of methotrexate, contracted chickenpox from his son whose chickenpox rash had developed three weeks before presentation. Five days before admission the patient developed a vesicular skin rash which became extensive, with general malaise, bilateral pneumonia, and acute deterioration of his asthma. He died two weeks after admission despite treatment with acyclovir.

Antiviral agents

In recent years, the antiviral armamentarium has expanded considerably. Currently available agents are virustatic, inhibiting specific steps in the process of viral replication. No agent is active against nonreplicating or latent viruses. Acyclovir is useful in the treatment of genital herpes, herpes simplex encephalitis, mucocutaneous herpetic infection, varicella infection in the immunosuppressed host, and herpes zoster infection in the normal and the immunosuppressed host. It can also be used for prevention of herpesvirus infection in immunocompromised patients. Ganciclovir is indicated for the treatment of cytomegalovirus retinitis in patients with acquired immunodeficiency syndrome (AIDS) and is effective in the management of organ-specific cytomegalovirus infection in other immunocompromised patients. Chronic hepatitis C and condyloma acuminatum due to human papillomavirus respond to therapy with interferon alfa-2b. Patients with human immunodeficiency virus infection and CD4 lymphocyte counts of less than 500 cells/mm3 should be treated with zidovudine. Amantadine is useful in a therapeutic and prophylactic role in the management of influenza A virus infection. With the expanded use of and indications for antiviral therapy, clinically significant resistance to these agents has been encountered with increasing frequency.

Chickenpox pneumonia, its complications and management. A report of three cases, including the use of extracorporeal membrane oxygenation

We report three cases of chickenpox pneumonia in adults, all of whom required intermittent positive pressure ventilation. One patient developed a variety of complications, and another, a pregnant woman, required extracorporeal membrane oxygenation.

Viral pneumonias. A diagnostic and therapeutic challenge

Viral pneumonias are both a diagnostic and a therapeutic challenge for primary care physicians. The illness should be suspected when an upper respiratory tract infection progresses to include dyspnea and cyanosis. Rapid diagnostic tests are now available to detect most of the viruses that cause pneumonias. Fortunately, viral pneumonias usually resolve without specific antiviral therapy; however, ribavirin is indicated for respiratory syncytial virus pneumonia in children and ganciclovir sodium (Cytovene) for cytomegalovirus pneumonia in immunocompromised patients. Acyclovir (Zovirax) is indicated for pneumonias due to herpes simplex virus and varicella-zoster virus infections. A high index of suspicion for bacterial superinfections is essential to reduce the risk of death from this complication.

Chickenpox pneumonia: an association with pregnancy

Three pregnant patients with chickenpox pneumonia are described. A review of reports published since 1965 together with these cases shows that 28 of the 46 women (61%) were pregnant, and 21 were in the last trimester. Although the disease is more common and more severe in pregnancy, the proportion of deaths was no greater than usual. In this retrospective analysis there was no evidence that treatment with acyclovir conferred benefit but this may have reflected its use only in very ill patients.