Severe pulmonary co-infection with varicella-zoster virus, Pneumocystis jirovecii and Cytomegalovirus: a case report

Abstract

Pneumocystis jirovecii, Cytomegalovirus and varicella-zoster virus are all opportunistically infective pathogens, but pulmonary co-infection with these pathogens is rare. Herein, this case report describes a patient with autoimmune haemolytic anaemia treated with methylprednisolone and cyclosporine that presented with rapidly progressive severe respiratory failure. Analysis of microbial nucleic acid sequences in both blood and sputum using next-generation sequencing revealed pulmonary co-infection with Pneumocystis jirovecii, varicella-zoster virus, and possibly Cytomegalovirus. After timely targeted and supportive treatments, the patient recovered. This case report highlights the imaging features of co-infection with these pathogens, the importance of next-generation sequencing for early diagnosis in immunosuppressed patients, and the effects of corticosteroid therapy.

A case of varicella due to primary varicella zoster virus infection followed by respiratory disease on the background of an immunocompromised condition

“…showed that CMV was reactivated after an inoculation with VZV in an experiment on monkeys 10 . If pneumonia was involved with CMV reactivation in the present case, it follows that VZV infection preceded CMV pneumonia in accordance with the previous reports 6–8 …”

“…In the past 10 years, three cases of VZV-infectious disease combined with CMV reactivation in immunocompromised adults have been reported in the English literature. [6][7][8] In all the cases, varicella preceded CMV reactivation. The reactivation or reinfection of VZV was suggested as the developmental mechanism of varicella in the cases reported by Kasuya et al 6 and Hioki et al, 7 although Qi et al did not definitively indicate the developmental mechanism of varicella.…”

“…The reactivation or reinfection of VZV was suggested as the developmental mechanism of varicella in the cases reported by Kasuya et al 6 and Hioki et al, 7 although Qi et al did not definitively indicate the developmental mechanism of varicella. 8 Based on these findings, a hypothesis arises that VZV-infectious diseases might relate to CMV reactivation in immunocompromised patients.…”

“…In the past 10 years, three cases of VZV‐infectious disease combined with CMV reactivation in immunocompromised adults have been reported in the English literature 6–8 . In all the cases, varicella preceded CMV reactivation.…”

“…10 If pneumonia was involved with CMV reactivation in the present case, it follows that VZV infection preceded CMV pneumonia in accordance with the previous reports. [6][7][8] Three mechanisms have been proposed for the development of adult-onset varicella: (i) the reactivation of latent VZV, (ii) reinfection by VZV of a different genotype from that of latent VZV, and (iii) primary VZV infection. In the case of varicella caused by the reactivation of latent VZV, VZV-specific IgG potentially increases commonly from a certain level, whereas VZV-specific IgM does not.…”