A 50-year-old female was brought to the emergency room with complaints of cough and breathlessness for 1 month. History of on and off low-grade fever was present. The patient had no underlying co-morbidities. On examination, she was tachypneic with a respiratory rate of 34 breaths/minute and saturation was 84% while breathing ambient air. Her pulse rate was 110/min and her blood pressure was 124/80 mm Hg. Respiratory examination revealed bilateral inspiratory crepitations in the lung bases. She was admitted to the high dependency unit because of pneumonia and type 1 respiratory failure. Her blood investigations revealed leukocytosis. Blood cultures were drawn and tests for renal function showed urea of 34 mg/dL, creatinine of 0.8 mg/dL, sodium of 134 mEq/L, and potassium of 3.4 mmol/L. Liver function tests showed total bilirubin of 1.8 mg/dL, aspartate transaminase (AST) (SGOT) of 34 U/L, alanine transaminase (ALT) (SGPT) of 40 U/L, prothrombin time of 11 s, and albumin level of 3.5 g/dL. The C-reactive peptide was elevated. X-ray done during admission revealed bilateral reticulonodular opacities in all lung zones as shown in Figure 1(a). Hence, a diagnosis of interstitial pneumonitis was made. She was started on intravenous (IV) antibiotics for community-acquired pneumonia and cotrimoxazole given empirically for Pneumocystis jirovecii (PCP). Oral glucocorticoids were also added for suspected PCP pneumonia.
The patient, however, did not show improvement as would be expected with the above treatment. Her oxygen requirement increased every day from 4 L nasal cannula to 60% venturi. Arterial blood gas analysis persistently showed type 1 respiratory failure. Hence, the authors decided to proceed with high-resolution computerized tomography (HRCT) of the chest which showed bilateral symmetrical diffuse ground-glass opacities with superimposed fibrotic changes noted in the form of irregular inter/intralobular septal thickening with associated mild tractional bronchiectasis as shown in Figure 1(b). These findings were consistent with fibrotic non-specific interstitial pneumonitis (NSIP). Hence, a decision to add azathioprine was made along with steroids for the NSIP. To find the etiology of NSIP, an auto-immune workup was done consisting of anti-nuclear antibody, antineutrophil cytoplasmic antibody titers, and rheumatoid factor which were negative.
At this stage, the authors took a Pulmonologist opinion, and bronchoscopy was done. Bronchial washings were collected for bacterial culture, acid-fast bacilli, and nucleic acid amplification test for tuberculosis, fungal culture, nocardiosis, and molecular tests for PCP. To our dismay, all of which were reported to be negative. As a further course of action, we had planned for a lung biopsy. However, we decided to take a complete medical history and redo examination for any missing clues aiding the diagnosis.
A review of medical history and repeat general physical examination was carried out again. Careful examination revealed herpetic lesions with vesicles at the C3 dermatomal level. She was not vaccinated for varicella previously or during her childhood. She also did not suffer from chickenpox illness before this admission. She was not taking any immunosuppressants or steroids. She also had no history of household contact with a similar case or any exposure elsewhere she could remember. She was living with her husband and four children and none of them had any recent chickenpox or herpes zoster. Hence, a possibility of disseminated varicella infection with varicella pneumonia was considered. She was started on IV acyclovir with adequate hydration and monitoring of renal function daily. The patient showed dramatic improvement clinically. IV acyclovir was given for a total duration of 10 days. Post-treatment completion her X-ray showed improvement in the form of disappearing infiltrates as shown in Figure 2. She was gradually tapered off oxygen and discharged without need for supplemental oxygen after 37 days of hospital stay. She is still under follow-up of the Internal Medicine unit chief as a token of gratitude.