AM Report Pearls: Approach to Patients with Rashes & Hypoxemia
Many ways to think about disease processes with rashes & hypoxemia, and it comes down to: what is the morphology of the rash?
- Infectious: Viral – VZV, influenza can have non-specific rash, Fungal pneumonias with infiltrative skin lesions, TB or NTM with infiltrative skin lesions, bacterial superinfection of viral processes
- Autoimmune: Pulmonary predominant vasculitis such as GPA (Wegener’s) and EGPA (Churg-Strauss), many pulmonary manifestations of SLE including effusions, pleuritis
- Embolic disease: Cholesterol atheroembolic disease – look for the characteristic rash of livedo reticularis
- Malignancy: Sweet’s syndrome can have pulmonary manifestations & skin rash (can be bullous or non-specific)
- Allergy: DRESS /DISH can have pulmonary involvement but it is rare, CT can show interstitial pneumonitis or pleural effusions
AM Report Pearls: Disseminated Zoster & VZV Pneumonia
- To review, Varicella-zoster virus (VZV) primary infection = varicella (chickenpox), secondary infection/reactivation = herpes zoster/shingles
- The rash starts as erythematous papules which evolve to grouped vesicles or bullae, crust within 7-10 days
- Usually limited to one dermatome, <20% of pts have systemic symptoms
- Disseminated zoster usually seen in organ transplant patients, patients with heme malignancies undergoing chemo
- VZV pneumonitis has a very high mortality and usually seen in bone marrow transplant patients – rare!
- Usually VZV pneumonia is characterized by nodular opacities with scattered necrotic foci
- IV Acyclovir is treatment of choice for severe VZV pneumonitis/pneumonia