Atypical presentation of varicella-zoster virus reactivation in a lung transplant patient: a case report
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Background. Varicella-zoster virus (VZV) is a human neurotropic virus which commonly causes infection during childhood, presenting as chickenpox. Later in life it may reactivate as herpes zoster. We report a rare manifestation of reactivation of VZV infection presenting as cutaneous vasculitis and varicella pneumonia in a lung transplant recipient.
Case presentation. A 65-year-old man was lung transplanted bilaterally for emphysema and had repeated posttransplant chest infections and colonization with Pseudomonas aeruginosa . Nine months post-transplant he presented with dyspnoea and a cutaneous vasculitis-like eruption with a predilection over face, thorax and distal extremities. Initially, VZV reactivation was not suspected due to absence of the typical vesicular eruptions. The diagnosis was confirmed by VZV PCR from the swabs of the ulcer after skin punch biopsy of a lesion and from bronchoalveolar lavage (BAL). The histology of skin biopsy demonstrated epithelial damage and vascular damage but no typical epithelial virus associated changes. The patient responded to antiviral therapy with total remission of rash and VZV DNA was finally not detectable from repeated BAL after 29 days of therapy. However, the pulmonary radiological features and dyspnoea persisted due to reasons possibly unrelated to the VZV infection.
Conclusion. Had it not been for the patient to mention the resemblance of the vasculitic rash with his primary VZV infection, the diagnosis would easily have been overlooked. In this case, the biopsy did not show typical histopathologic findings of VZV-vasculitis. What led the diagnosis was a PCR from the wound swab taken after the punch biopsy. This case serves as a reminder for atypical presentation of common conditions in immunosuppressed patients and that extensive diagnostic sampling may be warranted in this group.
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The work presented is clear and the arguments well formed.
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The reviewers have highlighted minor concerns with the work presented. Please ensure that you address their comments.
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Comments to Author
Many thanks for your very interesting Case Report. It was quite an enjoyable read and definitely something that clinicians should be made aware of. The case was well presented with relevant clinical and diagnostic information. Therapeutics were well described and the Discussion recognised the clinical dilemma in an environment with atypical findings.
Please rate the quality of the presentation and structure of the manuscript
Very good
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
I…
Comments to Author
Many thanks for your very interesting Case Report. It was quite an enjoyable read and definitely something that clinicians should be made aware of. The case was well presented with relevant clinical and diagnostic information. Therapeutics were well described and the Discussion recognised the clinical dilemma in an environment with atypical findings.
Please rate the quality of the presentation and structure of the manuscript
Very good
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
-
Comments to Author
The authors report an interesting and educative case of an uncommon VZV presentation in a highly immunosuppressed patient. The article is globally well written. Some minor typos or formatting should be fixed: - Line 107, sulfamethoxazole should be written entirely at least at the first time. SXT can be used as an abbreviation for trimethoprim-sulfametoxazole - Line 110, typing error on "immunomodulation" - All taxa names should be italicized, and first letter capitalized, like "Pseudomonas" line 113. - Avoid the use of trade names for drugs, or at least, also provide the International nonproprietary name (line 119 for example) - Arrows and circles in Fig. 3 are hard to see and could be improved. Minor comments: More information on the immunosuppressive regiment during the whole course of the case …
Comments to Author
The authors report an interesting and educative case of an uncommon VZV presentation in a highly immunosuppressed patient. The article is globally well written. Some minor typos or formatting should be fixed: - Line 107, sulfamethoxazole should be written entirely at least at the first time. SXT can be used as an abbreviation for trimethoprim-sulfametoxazole - Line 110, typing error on "immunomodulation" - All taxa names should be italicized, and first letter capitalized, like "Pseudomonas" line 113. - Avoid the use of trade names for drugs, or at least, also provide the International nonproprietary name (line 119 for example) - Arrows and circles in Fig. 3 are hard to see and could be improved. Minor comments: More information on the immunosuppressive regiment during the whole course of the case would be of interest. Line 137 is confusing on the administration of antiviral drugs, as it is stated it was withheld, whereas at line 111, valganciclovir was stopped. This needs to be clarify. Importantly, if valganciclovir was truly administered during the clinical presentation, this should be discussed later as it could have led to symptoms attenuation, or resistance induction. Species identification should be systematically provided if available, line 113 for example, only the Pseudomonas genus is indicated. Were any other serological tests carried out? It could be of interest for the interpretation of VZV IgM. Could you provide manufacturer of the assay used for the main diagnostic? Interpretation of IgG and IgM titers are difficult without knowing thresholds and the name of the assay performed. Can you also provide a Ct value to confirm "the strong positive VZV DNA"? Although this does not call the diagnosis into question, it would have been interesting to detect VZV on the skin biopsy, since no immunohistochemical analysis was done. Several kits exist to purify DNA from formalin and paraffin. There are several PCR assays available on whole blood to detect VZV (usually associated with HSV-1 and 2), that could be discussed for VZV-reactivation monitoring. Authors could also present in more details the changes - if any - induced by the present case in their practice of the follow-up of organ solid transplantation. Chronological rework of the case, focusing on treatments, examinations and retained diagnosis would improve and clarify the understanding of the clinical case.
Please rate the quality of the presentation and structure of the manuscript
Good
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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