Severe pulmonary co-infection with varicella-zoster virus, Pneumocystis jirovecii and Cytomegalovirus: a case report
水痘-带状疱疹病毒、肺孢子虫和巨细胞病毒的严重肺部合并感染：一份病例报告

Abstract 摘要

Introduction 导言

Pneumocystis jirovecii (PJ), Cytomegalovirus (CMV) and varicella-zoster virus (VZV) are all common opportunistically infective pathogens of the respiratory tract and a serious health threat for immunocompromised individuals.^1–3 To the best of our knowledge, pulmonary co-infection with PJ, CMV and VZV has not been previously reported. This current case report describes pulmonary co-infection with these three pathogens in a patient with autoimmune haemolytic anaemia, including details on the imaging manifestations, diagnosis and successful therapy.
肺孢子虫（PJ）、巨细胞病毒（CMV）和水痘-带状疱疹病毒（VZV）都是呼吸道常见的机会性感染病原体，对免疫力低下的人来说是一种严重的健康威胁。^1-3据我们所知，肺部同时感染 PJ、CMV 和 VZV 的病例以前从未报道过。本病例报告描述了一名自身免疫性溶血性贫血患者肺部同时感染这三种病原体的情况，包括影像学表现、诊断和成功治疗的细节。

Case report 案例报告

In February 2019, a 30-year-old female was brought to the Department of Haematology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, Shandong Province, China after experiencing nausea and abdominal pain with a skin rash spread over the body for 7 days. The patient had grain-sized blisters on the arms and the blisters gradually enlarged and spread to the trunk, legs and face with a slight itch (Figure 1a). She had no other complaints, including fever, cough or dyspnoea. She had a history of autoimmune haemolytic anaemia (AHA) for more than 2 years and she was receiving long-term treatment with methylprednisolone and intermittent use of rituximab and cyclosporine for recurrent exacerbation of AHA. She had no personal history of smoking or family hereditary disease.
2019年2月，一名30岁女性因恶心、腹痛伴皮疹遍布全身7天，被送到中国山东省青岛市山东大学齐鲁医学院附属齐鲁医院（青岛）血液科就诊。患者手臂上出现谷粒大小的水疱，水疱逐渐扩大并蔓延至躯干、腿部和面部，伴有轻微瘙痒（图 1a）。她没有其他不适，包括发烧、咳嗽或呼吸困难。她有两年多的自身免疫性溶血性贫血（AHA）病史，因AHA反复加重而长期接受甲基强的松龙治疗，并间断使用利妥昔单抗和环孢素。她没有个人吸烟史或家族遗传病史。

Open in a separate window

Figure 1. 图 1.

Characteristics of the skin lesions in a 30-year-old female that presented with nausea, abdominal pain and a skin rash that had spread over the body for 7 days: (a) varicella rash on the face, chest and upper limbs; (b) pathology of the skin biopsy showed bullosa formation in the epidermis, dilatation and congestion of intradermal blood vessels, vitreous degeneration of fibrous tissue (scale bar 100 µm) and herpesvirus inclusion body (arrow, scale bar 100 µm). The colour version of this figure is available at: http://imr.sagepub.com.
一名 30 岁女性的皮损特征：(a) 面部、胸部和上肢出现水痘皮疹；(b) 皮肤活检病理显示表皮有牛皮癣形成，皮内血管扩张和充血，纤维组织玻璃样变性（标尺 100 微米）和疱疹病毒包涵体（箭头，标尺 100 微米）。本图的彩色版可在以下网址获取：http://imr.sagepub.com。

On admission, there was no obvious rale in the bilateral lungs. The laboratory tests results revealed that CMV immunoglobulin (Ig) M antibody was negative, CMV IgG antibody was positive and 1,3-β-D-glucan and galactomannan levels were slightly increased (Table 1). Computed tomography (CT) of the chest revealed multifocal mixed ground-glass opacities (GGO) from the apex to the bottom of the lung, and from the proximal hilar to the visceral pleura, with a small amount of bilateral pleural effusion (Figure 2, day 2 panel). After admission, 40 mg/day methylprednisolone intravenous and 125 mg/12 h cyclosporine oral were administered to treat the AHA. In view of her immunocompromised situation and the levels of 1,3-β-D-glucan and galactomannan, 400 mg/day moxifloxacin and 200 mg/12 h voriconazole were administered intravenously for the empirical treatment of pneumonia.
入院时，双侧肺部无明显啰音。实验室检查结果显示，CMV 免疫球蛋白（Ig）M 抗体阴性，CMV IgG 抗体阳性，1,3-β-D-葡聚糖和半乳甘露聚糖水平略有升高（表 1）。胸部计算机断层扫描（CT）显示，从肺顶到肺底，从近肺门到内脏胸膜均有多灶性混合性磨玻璃不透明（GGO），双侧胸腔有少量积液（图 2，第 2 天面板）。入院后，为了治疗 AHA，她静脉注射了 40 毫克/天的甲基强的松龙，口服了 125 毫克/12 小时的环孢素。考虑到她的免疫功能低下情况以及 1,3-β-D 葡聚糖和半乳甘露聚糖的水平，我们静脉注射了 400 毫克/天的莫西沙星和 200 毫克/12 小时的伏立康唑，用于肺炎的经验性治疗。

Open in a separate window

Figure 2. 图 2.

Dynamic evolution of chest computed tomography in a 30-year-old female that presented with nausea, abdominal pain and a skin rash that had spread over the body for 7 days. Lung window (rows A–D): initial imaging demonstrated multifocal nodular opacity with the slightly ground-glass opacity halo sign (yellow arrows) and bilateral pleural effusion (panel day 2). Lesions enlarged and developed to be ill-defined patchy areas (red arrows) and partly merged and formed consolidation (green arrows) (panel day 8, day 11). After effective treatment, ground-glass opacity and consolidation gradually dissolved (panel day 16, day 24) and a few nodular opacities similar to the initial lesions remained (panel day 36). Mediastinal window (rows a–d) showed some non-specific changes such as pleural effusion and compression atelectasis. The colour version of this figure is available at: http://imr.sagepub.com.
一名 30 岁女性的胸部计算机断层扫描动态变化图，该患者因恶心、腹痛和全身皮疹扩散就诊 7 天。肺窗（A-D 行）：初始成像显示多灶结节性不透明，伴有轻微磨玻璃不透明晕征（黄色箭头）和双侧胸腔积液（第 2 天面板）。病变扩大并发展为界限不清的斑片状区域（红色箭头），部分合并并形成合并症（绿色箭头）（第 8 天，第 11 天）。经过有效治疗后，磨玻璃状不透明和合并症逐渐消退（第 16 天和第 24 天），但仍有一些与最初病变相似的结节状不透明（第 36 天）。纵隔窗（a-d 行）显示出一些非特异性变化，如胸腔积液和压缩性肺不张。该图的彩色版可在以下网址获取：http://imr.sagepub.com。

The patient gradually developed dyspnoea and her body temperature reached a maximum of 37.5°C. On day 7, the partial pressure of the arterial oxygen/fraction of inspired oxygen ratio (PaO₂/FiO₂) was 138. Electronic bronchoscopy revealed oedema of the tracheal wall with local protruding lesions; rough and erosive mucosa was evident after removal of secretions (Figure 3). Bacterial and fungal cultivation tests of bronchoalveolar lavage fluid (BALF) were negative.
患者逐渐出现呼吸困难，体温最高达到 37.5°C。第 7 天，动脉血氧分压/吸入氧分压比值（PaO2/_FiO2）为 138。电子支气管镜检查显示气管壁水肿，局部病变突出；清除分泌物后，可见气管黏膜粗糙糜烂（图 3）。支气管肺泡灌洗液（BALF）的细菌和真菌培养试验均为阴性。

Open in a separate window

Figure 3. 图 3.

Performance of fibreoptic bronchoscopy in a 30-year-old female that presented with nausea, abdominal pain and a skin rash that had spread over the body for 7 days: (a) epiglottic oedema; (b) trachea wall oedema and local lesions (yellow arrow); (c) phlegm attached to left principal bronchus (blue arrow); (d) mucosal bleeding after clearance of phlegm (green arrow); (e) congestion and oedema of segmental bronchial mucosa; (f) trophozoite in bronchoalveolar lavage by hexamine silver staining. The colour version of this figure is available at: http://imr.sagepub.com.
为一名 30 岁女性进行纤维支气管镜检查，该患者出现恶心、腹痛和全身皮疹，已持续 7 天：(a) 会厌水肿；(b) 气管壁水肿和局部病变（黄色箭头）；(c) 左主支气管附着痰液（蓝色箭头）；(d) 痰液清除后粘膜出血（绿色箭头）；(e) 支气管节段粘膜充血和水肿；(f) 支气管肺泡灌洗液中的滋养体（六胺银染色）。本图的彩色版可在以下网址获取：http://imr.sagepub.com。

On day 8, CT revealed small multifocal ill-defined areas of nodular opacity with the GGO halo sign in both lungs (Figure 2, day 8 panel). The saturation of arterial blood oxygen (SaO₂) decreased to 70% when a non-invasive ventilator was used with an oxygen flow of 6 l/min and positive end expiratory pressure (PEEP) of 6 cmH₂O. Therefore, she was intubated with an oral tracheal cannula and transferred to the intensive care unit. Biphasic positive airway pressure ventilation, continuous sedative analgesia and muscular relaxation therapy were applied. Treatment with moxifloxacin and voriconazole was ceased. Then, 50 mg/day caspofungin, 1000 mg/8 h meropenem, 1000 mg/8 h vancomycin, 500 mg/8 h acyclovir and 500 mg/8 h ganciclovir were administered intravenously to cover as many potential pathogens as possible. Meanwhile, pathogen detection in the blood and sputum was performed using next-generation sequencing (NGS). When the PEEP was adjusted between 10 and 15 cmH₂O and the FiO₂ was adjusted between 70% and 100%, the SaO₂ was difficult to keep at 90%. The lowest PaO₂/FiO₂ ratio was 62.5. Prone positioning did not effectively improve oxygenation. Intravenous methylprednisolone was increased to 80 mg/day. Some tests were rechecked: CMV nucleic acid level: 1.70 × E3 (reference: <5×E3), CD4⁺ lymphocytes: 26/µl, CD4⁺/CD8⁺: 0.18.
第 8 天，CT 显示双肺有小的多灶不清晰结节性不透明区域，并伴有 GGO 光晕征（图 2，第 8 天面板）。使用无创呼吸机，氧流量为 6 升/分钟，呼气末正压（PEEP）为 6_cmH2O，动脉血氧饱和度（_SaO2）降至 70%。因此，医生用口腔气管插管为她插管，并将她转入重症监护室。重症监护室采用了双相气道正压通气、持续镇静镇痛和肌肉松弛疗法。停止了莫西沙星和伏立康唑的治疗。然后，静脉注射 50 毫克/天的卡泊芬净、1000 毫克/8 小时的美罗培南、1000 毫克/8 小时的万古霉素、500 毫克/8 小时的阿昔洛韦和 500 毫克/8 小时的更昔洛韦，以覆盖尽可能多的潜在病原体。同时，使用新一代测序技术（NGS）检测血液和痰中的病原体。当 PEEP 调节在 10 至 15_cmH2O之间，_FiO2调节在 70% 至 100% 之间时，_SaO2很难保持在 90%。最低的_PaO2/FiO2比值为 62.5。俯卧位并不能有效改善氧合状况。静脉注射甲基强的松龙增至每天 80 毫克。重新进行了一些检查：CMV 核酸水平：1.70 × E3（参考值）：<5 data-dl-uid="72">+ 淋巴细胞：26/µl，^CD4+/CD8+：0.18。

On day 11, the PaO₂/FiO₂ gradually increased to 108. CT revealed consolidation (Figure 2, day 11 panel). NGS performed on both blood and sputum detected PJ, CMZ and VZV nucleotide sequences. Skin biopsy revealed viral inclusion bodies (Figure 1B), which confirmed varicella caused by the herpes virus. Caspofungin and vancomycin treatment was ceased. Then, 240 mg/1200 mg/6 h trimethoprim-sulfamethoxazole (TMP-SMX) oral combined with 500 mg/8 h acyclovir and 500 mg/8 h ganciclovir administered intravenously were used to treat the mixed infection. According to the NGS results, hexamine silver staining of BALF was undertaken and the staining of trophozoites further confirmed PJ infection. The PaO₂/FiO₂ gradually increased. Intravenous methylprednisolone was decreased to 40 mg/day after 5 days of 80 mg/day.
第 11 天，PaO2/_FiO2逐渐升至 108。CT 显示患者有合并症（图 2，第 11 天面板）。对血液和痰液进行的 NGS 检测发现了 PJ、CMZ 和 VZV 核苷酸序列。皮肤活检发现病毒包涵体（图 1B），证实水痘由疱疹病毒引起。停止了卡泊芬净和万古霉素的治疗。随后，口服 240 毫克/1200 毫克/6 小时的三甲双胍-磺胺甲噁唑（TMP-SMX），同时静脉注射 500 毫克/8 小时的阿昔洛韦和 500 毫克/8 小时的更昔洛韦，用于治疗混合感染。根据 NGS 结果，对 BALF 进行了六胺银染色，滋养体染色进一步证实了 PJ 感染。_PaO2/FiO2逐渐升高。静脉甲基强的松龙在使用 5 天 80 毫克/天后，降至 40 毫克/天。

On day 16, CT revealed improvement of the lung lesions. The oral tracheal cannula was removed and the patient was transferred back to the Department of Haematology. On day 36, CT revealed that the inflammatory exudation was mostly absorbed, but scattered mixed GGO was still present. TMP-SMX was adjusted to 160 mg/800 mg/day oral for preventive therapy. The ganciclovir was continued until day 42 and the acyclovir was continued until day 69.
第 16 天，CT 显示肺部病变有所好转。拔除了口腔气管插管，患者被转回血液科。第 36 天，CT 显示炎性渗出物大部分被吸收，但仍存在散在的混合 GGO。TMP-SMX调整为160毫克/800毫克/天口服，用于预防治疗。更昔洛韦继续服用至第42天，阿昔洛韦继续服用至第69天。

Discussion 讨论

This current case report presents a patient that had severe pneumonia caused by PJ, VZV and CMV. To the best of our knowledge, this is the first report on this co-infection in the literature. Diffuse mixed GGO nodules, which rapidly enlarged and fused, were important imaging changes, accompanied by lung consolidation and pleural effusion. Routine pathogen tests were not sufficiently sensitive and NGS was important for early aetiological diagnosis. Timely targeted therapy and corticosteroid pulse treatment were beneficial for the patient’s outcome.
本病例报告介绍了一名由 PJ、VZV 和 CMV 引起的重症肺炎患者。据我们所知，这是文献中首次报道这种合并感染。弥漫性混合型 GGO 结节迅速增大并融合，是重要的影像学改变，同时伴有肺部合并症和胸腔积液。常规病原体检测不够敏感，NGS 对早期病原学诊断非常重要。及时的靶向治疗和皮质类固醇脉冲治疗有利于患者的预后。

Opportunistic infections, including PJ, are found increasingly in non-human immunodeficiency virus (non-HIV) patients. ¹ PJ is usually concomitant with CMZ infection. ¹ Combined therapy using corticosteroids and other immunosuppressants may be a risk factor for CMV co-infection among patients with PJ pneumonia. ¹ This AHA patient had a long history of recurrent methylprednisolone and cyclosporine therapy, which increased the probability of this co-infection. VZV pneumonia is also prone to occur in immunosuppressed patients. ⁴ Therefore, for patients that have a history of immunosuppressive therapy or immunosuppressive diseases, a mixed infection should be considered when severe atypical pneumonia occurs.
包括 PJ 在内的机会性感染越来越多地出现在非人类免疫缺陷病毒（Non-HIV）患者身上。 ^1PJ 通常与 CMZ 感染同时发生。 ¹ 使用皮质类固醇和其他免疫抑制剂进行 ^联合 治疗可能是 PJ 肺炎患者合并 CMV 感染的一个危险因素。 ^1这位 AHA 患者有长期反复使用甲基强的松龙和环孢素治疗的病史，这增加了合并感染的可能性。免疫抑制患者也容易发生 VZV 肺炎。 ^4因此 ，对于有免疫抑制治疗史或免疫抑制疾病史的患者，当发生严重的非典型肺炎时应考虑混合感染。

Pneumonia has different imaging characteristics for different pathogens. For PJ, the most frequent finding is symmetrical, apically perihilar distributed GGO with peripheral sparing. ⁵ Centrilobular nodules, a crazy-paving appearance and nodules are the most common manifestations of CMV infection. ⁶ Nodules distributed in multilobar segments are a typical image feature of varicella pneumonia. ⁴ PJ and CMV infections can show similarities in GGO, while CMV and VZV infections share similarities in centrilobular nodules. This case was characterized by diffusely distributed centrilobular nodules, GGO with rapid progress and fusion, so it was difficult to analyse for a specific pathogen. In addition, bronchoscopy revealed local protruded lesions in the trachea and main bronchus. Rare cases in the literature have reported white-coated protruded lesions in the trachea and bilateral bronchi in VZV pneumonia; patients with limited or shallow bronchial ulcers had favourable prognoses. ² The current patient was initially treated with empirical antibacterial, antifungal, anti-CMV and anti-VZV therapies. However, the therapeutic response was not good, which indicated that the empirical therapy was wrong or did not adequately cover the aetiological pathogens. The patient presented a severe and progressive respiratory failure. Oxygenation was hard to maintain despite bundle therapy that included positive-pressure ventilation, prone positioning, continuous sedation and analgesia, and muscle relaxation.
不同病原体引起的肺炎具有不同的影像学特征。就 PJ 而言，最常见的表现是对称性、心尖周缘分布的 GGO，周围无病变。 ⁵ CMV 感染最常见的表现是 ^中心叶 结节、疯狂铺路外观和结节。 ⁶ 分布在多叶区段的 ^结节 是水痘肺炎的典型影像特征。 ^4PJ 和 CMV 感染在 GGO 上有相似之处，而 CMV 和 VZV 感染在中心叶结节上也有相似之处。该病例的特点是弥漫分布的中心叶结节、进展迅速的 GGO 和融合，因此很难分析出特定的病原体。此外，支气管镜检查发现气管和主支气管局部病变突出。文献中有罕见病例报道 VZV 肺炎患者气管和双侧支气管有白色涂层的突出病变；支气管局限性溃疡或溃疡较浅的患者预后良好。 ² 本例患者最初接受了经验性抗菌、抗真菌、抗CMV 和抗 VZV 治疗。然而，治疗效果并不理想，这表明经验疗法是错误的，或者没有充分覆盖致病病原体。患者出现了严重的进行性呼吸衰竭。尽管捆绑疗法包括正压通气、俯卧位、持续镇静和镇痛以及肌肉松弛，但仍难以维持氧合。

Routine pathogen tests were undertaken, including sputum culturing, blood culturing and detection of pathogenic antibodies. However, no positive results were found. NGS on the sputum and blood was performed and aetiological results were obtained within 48 h. Compared with traditional tests, NGS is not limited by specific mediums or culture methods, can perform ‘pan-viral’ and ‘pan-microbial’ screening, and shows a good diagnostic value for various pathogens, including PJ, CMV, and VZV.^7–9 It is especially superior for detecting specific pathogens in a mixed infection. ¹⁰ In theory, NGS specificity is increased by using combined blood and lower-respiratory-tract samples, such as BALF and sputum. The clinical manifestations, imaging characteristics, high nucleic acid levels detected in both blood and sputum and the therapy responses all supported VZV and PJ infection in the current case. Detection of trophozoites in BALF using hexamine silver staining further confirmed PJ infection. A diagnosis of CMV infection cannot be confirmed by clinical manifestations and CT imaging. However, PJ infection is often accompanied by CMV infection. ¹ Since CMV nucleotide sequences were detected in both the blood and sputum, it was necessary for us to be alert to CMV infection. According to these results, targeted therapies were performed and the pneumonia was relieved rapidly and effectively.
进行了常规病原体检测，包括痰培养、血液培养和病原体抗体检测。但未发现阳性结果。与传统检测方法相比，NGS 不受特定培养基或培养方法的限制，可进行 "泛病毒 "和 "泛微生物 "筛查，对包括 PJ、CMV 和 VZV 在内的多种病原体都有很好的诊断价值。^7-9尤其是在混合感染中检测特定病原体方面更具优势。 ¹⁰ 理论 ^上 ，使用血液和下呼吸道样本（如 BALF 和痰）联合检测可提高 NGS 的特异性。本病例的临床表现、影像学特征、血液和痰中检测到的高核酸水平以及治疗反应都支持 VZV 和 PJ 感染。使用六胺银染色法在 BALF 中检测到滋养体，进一步证实了 PJ 感染。CMV感染的诊断无法通过临床表现和CT成像确认。然而，PJ 感染往往伴有 CMV 感染。 ^1由于 在血液和痰中都检测到了 CMV 核苷酸序列，我们有必要对 CMV 感染保持警惕。根据这些结果，我们采取了有针对性的治疗，并迅速有效地缓解了肺炎。

In addition to routine anti-pathogen drugs, a corticosteroid pulse was administered for this current patient. Corticosteroid therapy for pneumonia is controversial and it may have different effects in pneumonias caused by different pathogens. In a few case reports and a non-strict retrospective case–control study on VZV pneumonia, treatment with corticosteroids showed a much more rapid improvement in oxygenation and a trend towards shortening the duration of mechanical ventilation. ³ However, another study revealed that patients treated with corticosteroids had longer mechanical ventilation durations and similar hospital mortality. ⁴ Thus, the effect of corticosteroids remains uncertain. The routine adjunctive use of corticosteroids in non-HIV patients with PJ pneumonia and respiratory failure is not recommended. ¹¹ Moreover, it remains unclear how to treat these patients (maintaining the dose versus escalation versus tapering). For CMV pneumonia, corticosteroid therapy suppresses the CMV-specific T-cell immune responses. ¹² Therefore, corticosteroid treatment should not be administered to patients with CMV pneumonia.
除了常规的抗病原体药物外，该患者还接受了皮质类固醇脉冲治疗。皮质类固醇治疗肺炎还存在争议，它对不同病原体引起的肺炎可能有不同的效果。在一些病例报告和一项关于 VZV 肺炎的非严格回顾性病例对照研究中，使用皮质类固醇治疗可更快地改善氧合，并有缩短机械通气时间的趋势。 ^3然而 ，另一项研究显示，使用皮质类固醇治疗的患者机械通气时间更长，住院死亡率相似。 ^4因此 ，皮质类固醇的效果仍不确定。不建议对患有 PJ 肺炎和呼吸衰竭的非艾滋病毒患者常规辅助使用皮质类固醇。 ^11此外 ，如何治疗这些患者（维持剂量还是逐渐增加剂量）仍不明确。对于 CMV 肺炎，皮质类固醇治疗会抑制 CMV 特异性 T 细胞免疫反应。 ^12因此 ，CMV 肺炎患者不应使用皮质类固醇治疗。

In this current case, due to progressive AHA, methylprednisolone and cyclosporine were administered. In view of the continuously deteriorating PaO₂/FiO₂ ratio, methylprednisolone was doubled to 80 mg/day as an antivirus and anti-PJ treatment. The PaO₂/FiO₂ improved rapidly. This suggests that VZV pneumonia dominated the severe respiratory failure. Therefore, corticosteroid therapy should be considered for VZV pneumonia patients with severe respiratory failure. In the future, randomized controlled trials will be necessary to determine the efficacy of corticosteroid treatments in non-HIV patients with VZV and PJ pneumonia.
在本病例中，由于渐进性 AHA，使用了甲基强的松龙和环孢素。鉴于_PaO2/FiO2比值持续恶化，甲基强的松龙加倍至 80 毫克/天，作为抗病毒和抗 PJ 治疗。_PaO2/FiO2迅速改善。这表明 VZV 肺炎是导致严重呼吸衰竭的主要原因。因此，对于严重呼吸衰竭的 VZV 肺炎患者，应考虑使用皮质类固醇治疗。今后，有必要进行随机对照试验，以确定皮质类固醇治疗对非艾滋病毒 VZV 和 PJ 肺炎患者的疗效。

Acknowledgement 鸣谢

Footnotes 脚注

References 参考资料