Case profile
The patient, a 68-year-old male, retired, was admitted to the hospital for "intermittent chest pain with fever for 2 months".
Features of the medical history: the patient had chest pain and discomfort before 2 months without obvious triggers, the left side was dominant, mild cough, no sputum, no fever, poor appetite, accompanied by mental malaise, ct of the outer hospital chest suggesting lung inflammation, cephalosporin treatment, symptoms could not be relieved, fever occurred during the period, body temperature was as high as 38.5 ° C, review of chest CT inflammation significant progression, admitted to the hospital on 2021-12-26.
Past history: history of hypertension, fatty liver disease, and smoking.
Physical examination: clear, superficial lymph nodes are not enlarged, both lungs breath sounds are clear, dry and wet rales are not met, heart rhythm, abdominal softness, both lower limbs are not swollen.
Auxiliary tests: normal liver and kidney function electrolytes, normal blood tumor indicators, negative T-SPOT, negative autoantibodies, inflammatory indicators are shown in the figure. There were no obvious abnormalities on tracheoscopy, and alveolar lavage fluid was sent for second-generation sequencing (NGS).
Treatment: After admission, meropenem + moxifloxacin was given anti-infective therapy, and post-sputum culture showed fungal spores and hyphae, GM experiment 8.857. Consider fungal infections, add anti-infective therapy with voriconazole and give methylprednisolone 40 mg anti-inflammatory.
Treatment progression
2021-12-30
CHEST CT: multiple lesions in both lungs (upper lobe of the left lung), mediastinal lymphadenopathy, left pleural effusion, progression compared with the previous 2021-12-23 tablets. Lavage solution NGS shows: pox seedling virus, sequence number 439, relative abundance of 6.02%.
2022-01-06
Chest CT: multiple lesions in both lungs (upper lobe of the left lung), swollen mediastinal lymph nodes, left pleural effusion, slightly better than the previous 2021-12-30 tablets.
2022-01-12
Re-examination of tracheoscopy in parallel with alveolar lavage.
2022-01-13
Lavage solution NGS shows: pox seedling virus, sequence number 114, relative abundance of 12.51%. The patient with the medical history has been engaged in rabbit skin processing in the past, and the possibility of viral infection is not ruled out, and acyclovir antiviral therapy is added.
2022-01-17
CT chest: multiple lesions in both lungs (upper lobe of the left lung), mediastinal lymphadenopathy, and absorption of fluid in the left pleural cavity compared with the 2021-1-5 pre-1-5 tablets.
Figure 1 (Image source: Author team)
2022-01-20
Symptoms improved and given discharge.
2022-02-18
Outpatient follow-up, there is still left chest discomfort. Chest CT: multiple lesions of both lungs (upper lobe of the left lung), the infection may be larger, compared with 2022-01-17 The range of lesions in the upper lobe of the left lung is increased, and the lower lobe of the right lung is new.
2022-02-22
Re-admission, post-admission re-examination of inflammatory indicators as shown in the figure, cefoperazone sulbactam sodium anti-infective therapy.
Figure 2 (Image source: Author team)
2022-02-24
Under local anesthesia bronchoscopy, bronchoalveolar lavage is performed on the left tongue segment, and ultrasound probing is performed on the subsection of the upper tongue segment of the left lung and the subsection of the anterior right lung, and ultrasonography is performed for transscathial bronchial lung biopsy (EBUS-GS-TBLB). The subsection of the anterior segment of the right upper lung is brushed for examination, and the specimen is sent for pathology.
2022-02-25
Lavage solution NGS shows: pox seedling virus, sequence number 57, relative abundance of 15.79%.
Figure 3 (Image source: Author team)
2022-02-25
Discharge: moxifloxacin tablets 1 tablet per day, prednisone tablets 30 mg per day.
2022-03-07
Outpatient follow-up, symptoms improved significantly, chest CT lesions were further absorbed and improved, prednisone was changed to 25mg/day, moxifloxacin was discontinued, and outpatient follow-up was continued.
Figure 4 (Image source: Author team)
Expert reviews
Zhao Zhangyan attending physician, Department of Respiratory and Critical Care Medicine, Shanghai Public Health Clinical Center
Poxvirus (VACV) is a class of DNA viruses that can infect vertebrate and non-vertebrate animals. Serologically and immunologically closely related to smallpox virus and vaccinia virus, since the WHO announced the elimination of smallpox in 1980, the smallpox vaccine has basically stopped vaccination, which may have restored the susceptibility of the population to pox virus. Pox virus is weakly pathogenic, according to literature reports, even if humans are infected with pox vaccine symptoms are generally mild, and can recover on their own, while pox vaccine virus causes pneumonia is rare.
The patient has insidious onset, chest pain onset, poor concomitant tolerance, mental malaise, no clear underlying disease or immunodeficiency, combined with chest CT imaging and community-acquired pneumonia (CAP) is difficult to distinguish, white blood cells, C-reactive protein (CRP) and other inflammatory indicators are also elevated, but the conventional anti-infection treatment effect is not obvious, and the lesion is repeated, the conventional sputum bacteriological examination has no obvious abnormalities, the alveolar lavage liquid NGS examination is clearly identified as pox vaccine virus, and after repeated questioning of the medical history, the patient has rabbit skin processing plant work exposure before the disease.
At present, there are few reports of pox vaccine virus infection, treatment methods are mainly symptomatic supportive treatment, it has been reported that small doses of hormones can promote the absorption of lesions, the patient is given acyclovir antiviral therapy after diagnosis, combined with small dose glucocorticoid therapy, re-examination of chest CT lesions is absorbed, but after discharge, hormones are stopped, outpatient follow-up visits to re-examine chest CT lesions have progressed, re-examination of tracheoscopy after re-admission, alveolar lavage fluid NGS still has acne seedling virus, Trans-bronchoscopic lung biopsy (TBLB) examination excludes tumors and tuberculosis, glucocorticoid therapy is continued, the duration of treatment is extended, and chest CT shows further absorption of lesions.
Director Tang Haicheng, Department of Respiratory and Critical Care Medicine, Shanghai Public Health Clinical Center
At present, pox vaccine virus (VACV) is mainly used in biological research, as an inflammatory substance for biopharmaceuticals, but also a common carrier in the laboratory, for the treatment and prevention of a variety of diseases, acne seedling virus inflamed rabbit skin extract (AGC) is a biologically active preparation extracted from the rabbit skin tissue of the Japanese big-eared white rabbit inflamed by the acne seedling virus, containing a variety of polypeptides, amino acids, nucleotides and other substances. Clinically, it is mainly used to relieve and treat a variety of pains.
Humans are susceptible to pox vaccine, often through contact with infected animals or virus-contaminated environmental infection, clinical manifestations vary in severity, in the case of inhalation of a large number of viral particles, can lead to lung infection, imaging manifestations of extensive exudation of two lungs and nodular lesions, lesions change rapidly, nodules are accompanied by cavities, slow absorption of lesions, some patients eventually leave small nodules, which is different from other viral pneumonia manifestations, the patient's chest CT manifestations are two lung lesions, the left lung is dominated by patch consolidation, and the surrounding exudation is obvious, With a small amount of pleural effusion, the right side is dominated by nodules with cavitation, which makes differential diagnosis difficult.
At present, there are few reports of lung disease infection caused by pox vaccine virus, the infectivity is unknown, and no case of disease in close contact with the patient has been found, and the pox vaccine virus remains in the lung of the patient for a long time, the specific cause and mechanism are not clear, and further clinical studies need to be confirmed. It is hoped that through the reporting of this case, it will provide assistance for clinical diagnosis and treatment, strengthen safety protection, and the investigation of epidemiological history is crucial for the diagnosis and treatment of pneumonia of unknown cause.
Image source: 123RF
bibliography:
Gao Fei,Liu Jie. Five cases of long-term follow-up of pneumonia-onset pox virus infection and literature review. Chinese Journal of Respiratory and Critical Care[J].2021.20(09):618-624.
This article is reproduced from the "Respiratory Channel of the Medical Profession"
The author: Shanghai Public Health Clinical Center Respiratory and Critical Care Medicine Team
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