The outcome of severe varicella pneumonia with respiratory failure admitted to the intensive care unit for mechanical ventilation

Abstract

The outcome of severe varicella pneumonia with respiratory failure admitted to the intensive care unit for mechanical ventilation To the Editor: Varicella pneumonia carries a mortality of 10-30%; mortality rate increases to 50% in patients that warrant mechanical ventilation secondary to respiratory failure despite appropriate antiviral and supportive treatment. Risk factors for the development of severe disease include cigarette smoking, pregnancy, immunocompromised states and more extensive skin involvement [1]. Treatment options for life-threatening varicella consist mainly of cardiorespiratory support, antiviral therapy and steroid use. The benefit of antiviral therapy, however, is still controversial [2]. Due to the paucity of data pertaining to varicella zoster pneumonia, attributed to its rarity, we aimed to describe all cases of varicella pneumonia admitted to an intensive care unit (ICU) that provides tertiary care to a population with a high HIV and tuberculosis burden. Moreover, we aimed to identify possible predictors of nonsurvival. All cases of varicella pneumonia presenting to Tygerberg Academic Hospital adult respiratory intensive care unit between January 2004 and December 2016 were identified from an existing registry. Tygerberg Academic Hospital is a 1380-bed public hospital in South Africa serving ∼3 million people in and around the Cape Town metropole. The population served has a HIV prevalence of 5.2% (95% CI 3.4-7.8%) [3, 4] and the incidence of tuberculosis was 100 cases per 100 000 persons in 2016 [5]. Only patients aged >18 years with complete medical and radiological records were included in the final analysis. Ethical approval for the study was provided by the Stellenbosch University Research Ethics Committee (S16/04/082). Apart from the general epidemiological characteristics, we specifically documented the presence or absence of comorbid diseases and other potential risk factors, including current or recent pregnancy, HIV infection, active or previous pulmonary tuberculosis, chronic obstructive pulmonary disease, obesity (body mass index >30 kg•m −2), known malignancies and the use of immunosuppressive drugs. The severity of illness was assessed by means of the Acute Physiology and Chronic Health Evaluation (APACHE) II score [6], which was calculated 24 h after admission to the ICU, as well as the arterial oxygen tension/inspiratory oxygen fraction ratio. We adapted a scoring system described by OPRAVIL et al. [7] to grade the severity and extent of pulmonary infiltrates: each lung was divided into four equal quadrants and each quadrant was scored on a scale of 0-3 (0: normal; 1: subtle increased interstitial markings; 2: prominent interstitial opacities; 3: confluent interstitial and acinar opacities), giving a maximum score of 24 for both lungs. Peripheral blood white cell counts and C-reactive protein (CRP) levels were performed on admission We specifically noted the following complications defined according to accepted criteria: acute respiratory distress syndrome (ARDS) [8], sep...

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