Atypical Presentation of Varicella-zoster Virus in an Immunocompetent Adult

A 36-year-old male patient presented to the intensive care unit (ICU) of a tertiary care center with severe dyspnea.He had no known comorbidities.Before this admission, he had been admitted to another hospital with a history of fever with rash for 10 days and acute onset dyspnea for 2 days.The rashes were vesicular and maculopapular in nature (Fig. 1).He was diagnosed with varicellazoster virus (VZV) pneumonia clinically based on his vesicular rashes and was started empirically on intravenous acyclovir.Despite this, he developed pancytopenia with hemoglobin (Hb) 5.0 gm/dL, platelet count (PC) 11,000/mm³, and total leukocyte counts 2,200 cells/mm³ along with acute liver failure with serum glutamic oxaloacetic transaminase at 320 U/L, serum glutamic pyruvic transaminase at 288 U/L, and coagulopathy.He had worsening respiratory distress, for which he was started on noninvasive ventilation (NIV).On presentation to the ICU, he had tachycardia with a heart rate of 106/minute, tachypnea of 30 breaths/minute, peripheral oxygen saturation was 91% on high flow nasal oxygen (40 L/minute, fraction of inspired oxygen-0.4).On examination, he had extensive dried scab skin lesions all over the body, bilateral conjunctival bleeding, and basal crepitations in both lung fields (Figs 2 and 3).A two-dimensional echocardiogram was normal.He was initiated on empirical antibiotic coverage with meropenem 1 gm thrice daily and vancomycin 1 gm twice daily, pending culture reports.Initially managed with NIV, he required endotracheal intubation, mechanical ventilation, and a prone position due to increasing respiratory distress and hypoxia (Fig. 4).An infusion of noradrenaline at 2 µg/minute, hydrocortisone 200 mg over 24 hours, and aviptadil 150 mg infusion over 12 hours was also instituted.High-resolution computed tomography (HRCT) of the thorax showed consolidation in both lungs suggestive of acute respiratory distress syndrome (ARDS) (Fig. 4).Skin biopsy showed necrotic acantholytic cells (Fig. 5).Bone marrow biopsy showed hypoplastic marrow.The tropical core polymerase chain reaction (PCR) panel returned positive for VZV immunoglobulin M (IgM) with an immune status ratio (ISR) of 1.55 (ISR >1.1 is positive).Blood culture after 48 hours came back positive for multidrug-resistant 1-