Teaching Case

A 56-year-old female patient complaining of cough and dyspnoea for many weeks. No complaints of weight loss. She was a heavy smoker and had chickenpox at 33 years.
Chest radiograph (Fig. 1) was performed followed by thoracic CT examination (Fig. 2).

Chest radiograph (Fig. 1) revealed diffuse, multiple small nodular opacities, with random distribution. Some of them were dense suggesting calcification. In the right perihilar region a spiculated nodule was observed and CT was suggested.

Computed tomography (Fig. 2a, Fig.2b and Fig.2c) showed multiple pulmonary nodules with random distribution, and well-defined edges. They varied from 2 to 5 mm in diameter and they were not cavitated.
In the inferior right lobe there was a subpleural spiculated nodule with 30 x 18 x 29 mm, with some calcifications (Fig.2d). It was considered a suspicious lesion and biopsy was suggested.

Varicella zoster virus pneumonia (VZVP) is a serious complication of an infection with varicella zoster virus, which sometimes proves fatal.[3] Risk factors for developing VZVP are contact with chickenpox, smoking and pregnancy (third trimester). Smoking has been recognised as the most important risk factor. [3] VZVP is more prevalent among young men and usually presents 1–6 days after onset of the skin rash. Symptoms are nonspecific and include tachypnoea, chest tightness, cough, dyspnoea, fever, pleuretic chest pain and occasionally haemoptysis. [4] The initial chest radiograph typically shows ill-defined nodular (2–5 mm in diameter) or reticular densities that represent interstitial pneumonitis, more evident in the periphery of the lung. Radiological abnormalities usually resolve, but may persist for weeks or months and in a few cases nodules can calcify and remain indefinitely. [2] In this case, we present a typical pattern of diffuse calcified pulmonary nodules, with random distribution, seen years after acute VZVP. This is a nonspecific finding; however, when the physician is confronted with disseminated small (< 1cm) calcified pulmonary nodules, a history of prior VZVP should be sought, since it can greatly facilitate the differential diagnosis between tuberculosis, coccidioidomycosis, histoplasmosis and pneumonoconiosis, rendering extensive diagnostic workup unnecessary. [3, 5] Definitive diagnosis in the acute phase can be provided by isolation of varicella zoster virus on vesicular fluid cultures. [2] Treatment of VZVP as well as other complications of varicella zoster virus infection in adults and children is effective by intravenous acyclovir. Recurrence of VZVP has been reported in immunocompromised patients. [3] Another clinically important finding in this patient was a spiculated lesion found in the apical segment of the right lower lobe, whose biopsy revealed an undifferentiated adenocarcinoma. The patient initiated chemotherapy, but developed multiple metastatic pulmonary lesions and died a few months later.