AUCTORES
Globalize your Research
case report | DOI: https://doi.org/10.31579/2690-4861/425
1Department of Anesthesia and Intensive Care Medicine, Rikshospitalet, Oslo University Hospital, Norway.
2Department of Transplantation Medicine, Rikshospitalet, Oslo University Hospital, Norway.
3Section of Clinical Immunology and Infectious Diseases, Rikshospitalet, Oslo University Hospital, Norway.
4Department of Respiratory Medicine, Faculty of Medicine, University of Oslo, Norway.
*Corresponding Author: L. Fjellbirkeland, Department of Respiratory Medicine, Faculty of Medicine, University of Oslo, Norway.
Citation: LE. Kvarstein, A. Barratt-Due, DO. Dahle, I. Nordøy, L. Fjellbirkeland, (2024), Generalized Varicella Zoster Virus Infection with Pseudomembranous Tracheobronchitis following a high-Risk Kidney Transplant Protocol, International Journal of Clinical Case Reports and Reviews, 18(2); DOI:10.31579/2690-4861/425
Copyright: © 2024, L. Fjellbirkeland. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 15 March 2024 | Accepted: 08 April 2024 | Published: 27 June 2024
Keywords: kidney transplant; immunosuppression; varicella zoster virus; pseudomembranous trachebronchitis; pseudomonas aeruginosa
Kidney transplant recipients are susceptible to infections. We present a middle-aged woman who underwent a high-risk immunosuppressive treatment protocol due to a pre-transplant immunization. Six weeks after transplantation she developed severe respiratory failure and endotracheal intubation was required. Bronchoscopy revealed extensive endobronchial membranes, and the lavage fluid tested positive for Pseudomonas aeruginosa. After repeated bronchoscopic removal of membranes, she developed a generalized vesicular rash, positive for Varicella zoster virus, later also identified in the bronchial fluid. After 34 days on mechanical ventilation, she was successfully decannulated and could be discharged from hospital three months later, although still in need of a nasogastric tube for feeding, with a functioning kidney graft. This report underscores the significance of herpes viruses as potential contributors to severe respiratory infections in organ transplant recipients, alongside highlighting the atypical manifestations of bacterial infections.
Potent immunosuppressive treatment may lead to reactivation of latent Varicella zoster virus (VZV) resulting in systemic infections and viral pneumonitis [1-3]. Pseudomembranous tracheobronchitis (PMTB) is a rare condition, but is reported in immunocompromised individuals [4]. PMTB is usually caused by Aspergillus spp., but other microbial agents have been reported [4, 5]. Stridor and serious central airway obstruction have been described, but clinical signs vary related to the extent of pseudomembranes. Bronchoscopy is essential to obtain a precise diagnosis. Treatment includes both anti-microbial agents and repeated toilet bronchoscopies [4, 6, 7]. In this case report, we describe a strongly immunosuppressed patient who developed generalized VZV infection, and P. aeruginosa superinfection, leading to the rarely described condition PTMB. Due to late emergence of the classical vesicular rash, the diagnosis of VZV and adequate treatment were delayed. In this report, we highlight the clinical presentation of a VZV infection and the uncommon diagnosis of PMTB.
A 47-year-old female with IgA nephropathy developed a severe respiratory failure six weeks after kidney transplant. The patient had high levels of human leukocyte antigen antibodies, and according to the Norwegian transplantation program, a high-risk immunosuppression regimen was required. This includes tacrolimus, mycophenolate mofetil (MMF), basiliximab, rituximab, intravenous immunoglobulins (IVIG), and high-dose methylprednisolone (500mg) [8, 9]. Additionally, the patient received prophylactic P. jirovecii treatment with trimethoprim sulfamethoxazole [10]. Postoperatively, the kidney transplantation was considered successful with a well-functioning graft. Four weeks after the transplantation, she was re-scheduled for surgical fenestration of a kidney-close lymphocele (defined as Day 0). During anaesthetic induction, intubation was disrupted due to aspiration. During the following week the patient became increasingly dyspnoeic with stridor and was transferred to the ICU for closer surveillance and non-invasive ventilation support. Her chest x-ray on Day 13 showed bilateral patchy infiltrates as in bronchopneumonia (Figure 1).
Figure 1: Chest X-ray taken on Day 13 showing bilateral patchy infiltrates. (V = left).
Despite antibiotic treatment with cefotaxime and corticosteroids for what was assumed to be an aspiration pneumonitis, her respiratory distress worsened markedly with a concomitant increase in inflammatory parameters. On Day 15, the patient was endotracheally intubated and
mechanical ventilation started, using lung-protective settings. She was highly oxygen dependent with a PaO2/FiO2 ratio of 7,6 kPa (57mmHg) but responded positively to prone positioning and removal of large amounts of pleural effusion.
Figure 2: Chest X-ray taken on Day 17, two days after intubation and on mechanical ventilation. Right upper lobe shows signs of atelectasis and consolidation (asterisk). In the left lung there are extensive patchy infiltrates with partial atelectasis (arrow).
A follow up chest x-ray on Day 17 showed increasing atelectasis (Figure 2) and repeated bronchoscopies the next days turned out to be of utmost importance. Her airways were completely covered with a continuous membranous pale layer, starting along the tracheal tube, reaching down into the bronchial segments (3rd generation bronchi) narrowing the inner lumen significantly. The membranes completely covered the entrance to the left upper lobe, while the right upper lobe bronchus was left with a small remaining lumen (Figure 3).
Figure 3: The right main bronchus with the carina (asterisk) to the left as seen through the bronchoscope. The membrane (open arrow) was easily detachable by forceps and revealed a raw, inflamed bronchial wall underneath (star). The bronchial orifice to the upper right lobe was significantly narrowed (arrow).
With a combination of flushing with saline and use of forceps, the membranous layers were successively removed down to the segmental level. The membranes were easily detached in large pieces from the wall. Due to their large size, the individual pieces had to be removed mechanically by retracting the bronchoscope with the forceps in place. Bronchoscopy had to be repeated over three consecutive days before the bronchial lumens were found to be satisfactorily open. The removal exposed a large wound surface, however, there were hardly any signs of reappearance of the membranes. Microbial tests of bronchial fluid demonstrated growth of P. aeruginosa despite antibiotic coverage with meropenem from the time of intubation. No Aspergillus spp. or other common respiratory pathogens were found in our patient. Due to deteriorating renal function, continuous renal replacement therapy (CRRT) was started on Day 18. On Day 20, the patient developed a generalized vesicular rash. Qualitative PCR test of fluid from vesicles and peripheral blood was positive for VZV DNA (Altona Realstar GmbH, Hamburg, Germany). New testing on blood samples taken before her transplantation came up positive for VZV IgG, indicating that the current VZV infection was caused by reactivation. Retrospective blood analyses also demonstrated VZV DNA one day ahead of the surgical fenestration of her lymphocele, and repeated chest x-rays showed progressive, scattered nodular and reticular consolidations in both lungs compatible with VZV pneumonia (Figure 1). Upon reassessment, the bronchial lavage samples collected at the time of intubation also revealed the presence of VZV DNA in the patient's airways. Intravenous acyclovir was started on Day 20, and considering her critical state, immunosuppression and prolonged hospitalization, linezolid and anidulafungin were empirically added. Regarding her immunosuppression, the dosages of tacrolimus and MMF were held stable during her intensive care course, and additional corticosteroids were initially added, based on the suspected aspiration pneumonitis. However, after the findings of VZV, the methylprednisolone dosage was lowered to baseline level of 15 mg. After a distinct increase in plasma levels of tacrolimus on Day 21, the dosages of tacrolimus and MMF were both reduced. From Day 22 her respiratory failure gradually improved, sedatives could be reduced, and linezolid and CRRT were terminated on Day 25. Due to an unsuccessful extubation on Day 27, she was tracheostomized to ease further weaning from the ventilator. Her vesicular rash had developed into crusty lesions, but blood tests showed persisting VZV viremia. Antiviral treatment was therefore continued, while antibiotics and antifungal treatment were discontinued. The further weaning of the ventilator was complicated by new infections and recurring need of broad-spectrum antibiotics. On Day 49, after 34 days of mechanical ventilation, she could finally be decannulated and transferred to a hospital ward for rehabilitation with a well-functioning kidney graft. VZV DNA was detected in her blood until Day 60. She was discharged from the hospital on Day 118, still in need of a nasogastric tube feeding and further rehabilitation.
It is evident that transplant patients are especially susceptible to infections due to use of a broad spectre of immunosuppressive medication. Drugs associated with T-cell depletion predispose to viral infections, candidemia and Pneumocystis pneumonia. B-cell depletion make patients vulnerable to certain capsulated bacterial airway infections, and corticosterioids to a broad range of bacterial, viral, and fungal infections (1, 11). VZV infections are typically characterized by a vesicular rash. A recent literature review emphasizes the late presence, up to three weeks, or even complete absence of skin eruption in kidney transplant patients subjected to systemic VZV infection (12). As the herpes viruses are usually not part of a standard airway multiplex PCR, conscious diagnostics are needed. Both P. aeruginosa and VZV were identified in our patient. VZV can indeed lead to severe pneumonitis (13), but bronchial pseudomembranes are not described. PMTB, however, has been reported in intubated, immunocompromised patients suffering a P. aeruginosa infection (4).
We conclude that our patient most likely developed a VZV pneumonia following an ongoing viremia with a subsequent P. aeruginosa driven PMTB. The current case is a reminder of atypical presentations of viral and bacterial infections in immunocompromised patients. Balancing infectious control and immunosuppression is challenging and requires a vigilant practice to prevent serious complications. In our case an initial aspiration and the late presence of the vesicular rash delayed the correct diagnosis and effective treatment.
PCR: Polymerase chain reaction.
VZV: Varicella zoster virus.
BAL: Bronchoalveolar lavage.
PMTB: Pseudomembranous tracheobronchitis.
CRRT: continuous renal replacement therapy.
MMF: Mycophenolate mofetil.
IVIG: Intravenous immunoglobulins.
Ethics approval and consent to participate
Written informed consent was obtained from the patient for publication of this case report.
Written consent for publication was obtained from the patient prior to submission of this manuscript in line with Oslo University Hospital consent form.
The authors declare that they have no competing interests.
Not applicable.
All authors participated in the treatment of the patient. LEK has written the initial draft of the manuscript. All authors have reviewed and approved the final version of the manuscript. LF is the last and corresponding author of the case report.
Not applicable
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
