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RSV and Varicella: Viral Pneumonia in COPD

This patient case explores a 67-year-old male with COPD who develops viral pneumonia caused by respiratory syncytial virus (RSV) and varicella. The case discusses the treatment options, including the use of ribavirin for RSV, and highlights the risk factors for developing shingles.

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RSV and Varicella: Viral Pneumonia in COPD

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  1. SpR 2 Matt Dickson 25/01/2017

  2. Patient case • 67 year old male • PMH: COPD, cigarette smoker (20/day), GCA, hypertension, diverticulosis, left sided rib fractures post-fall 2015, alcohol excess • Two admissions with exacerbation of COPD in 12 months • Admitted 28.12.16 with increased breathlessness, dry cough and wheeze. Hypoxic on arrival, type 1 RF. • Lives alone, no significant occupational history, no pets • On weaning dose of prednisolone, 50mg OD on presentation

  3. 29/12/16 • WCC 20 • CRP 207

  4. Patient case (2) • Chest radiograph • Commenced on IV Co-amoxiclav and oral clarithromycin • Treatment dose Oseltamivir • Deteriorated significantly on 31.12.16, more hypoxic and wheezy • Escalated to ITU for respiratory support, initially on high flow nasal cannulae • Commenced on co-trimoxazole • Slipped into type 2 respiratory failure – intubated

  5. 31/12/16

  6. Patient case (3) • RSV positive from swab 28/12/16 • Pneumococcal/Legionella antigen negative on 29/12/16 • PCP negative on BAL 7/1/17 • Erythematous rash noticed on right thigh 9/1/17 • VZV positive from swab 11/1/17 • 14/7 IV aciclovir • Now improving, still on ITU, on HFNC

  7. Respiratory syncytial virus • Bronchiolitis/pneumonia in infants and young children (2-3%) • Upper respiratory tract infections in older children and adults • Increased asthma risk in adults • Accounts for up to a quarter of exacerbations of COPD (1,2) • Annual incidence is nearly twice that of Influenza A • Higher rates of intensive care use and mortality in hospitalised patients (3) • Increased vulnerability to LRTI: • Asthma, COPD • Residence at altitude >2500m • Immunocompromised patients • Institutionalised

  8. RSV LRTI (adults) • Pneumonia • Pneumonitis • Acute lung injury/ARDS Treatment – • Supportive • Ribavirin (nebulised/oral/IV)

  9. Varicella Zoster/Herpes Zoster • Few reported cases of Herpes Zoster (shingles) leading to pneumonitis/pneumonia • Varicella pneumonia common in adult population (1 in 400 chickenpox cases) • Presents after rash usually • Smokers, immunocompromised, pregnancy (3rd Trimester), chronic lung diseases at increased risk • Treatment – aciclovir • Mortality of 6% (4)

  10. Risk factors for Shingles • Having chickenpox! • Being older than 50. • Having a weakened immune system due to another disease, such as diabetes or HIV infection. • Experiencing stress or trauma. • Having cancer or receiving treatment for cancer. • Immunosuppressants

  11. This case… • Viral pneumonia – RSV or Herpes Zoster • Ribavirin – should it have been used?

  12. Thank you

  13. References • 1. Borg I, Rohde G, Loseke S, Bittscheidt J, Schultze-Werninghaus G, Stephan V, Bufe A. Evaluation of quantitative real-time PCR for the detection of respiratory syncytial virus in pulmonary diseases. EurRespir J 2003;21:944–951. • 2. Seemungal T, Harper-Owen R, Bhowmik A, Moric I, Sanderson G, Message S, MacCallum P, Meade TW, Jeffries DJ, Johnston SL, Wedzichia JA. Respiratory viruses, symptoms, and inflammatory markers in acute exacerbations and stable chronic obstructive pulmonary disease. Am J RespirCrit Care Med 2001;164:1618–1623. • 3. Respiratory syncytial virus infection in elderly and high-risk adults. Falsey AR, Hennessey PA, Formica MA, Cox C, Walsh EE. N Engl J Med. 2005;352(17):1749.  • 4. Mohsen, A.H., and M. McKendrick. "Varicella pneumonia in adults." European Respiratory Journal 21.5 (2003): 886-891.

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