Bronchoscopic recognition of tracheobronchial lesions in severe varicella pneumonia after resolution of the characteristic rash: A case report.

Varicella pneumonia is a serious complication of primary varicella-zoster virus (VZV) infection in adults and may be associated with substantial morbidity and mortality, despite being vaccine-preventable. Poor outcomes are often related to rapid disease progression and delayed initiation of antiviral therapy. Here, we report a case of severe varicella pneumonia with tracheobronchial involvement in a 35-year-old man with diabetes mellitus. The patient developed progressive dyspnea five days after rash onset, by which time most cutaneous lesions had already crusted. Bronchoscopy revealed scattered pustular lesions involving the distal trachea, carina, and main bronchi, providing direct visual evidence of airway involvement. Targeted next-generation sequencing (tNGS) of bronchoalveolar lavage fluid (BALF) detected VZV without evidence of other pathogens. The patient improved rapidly after intravenous acyclovir and respiratory support, and follow-up chest computed tomography five days later showed marked resolution of pulmonary infiltrates. This case demonstrates that bronchoscopic recognition of characteristic airway lesions may aid diagnosis when cutaneous manifestations have crusted or are absent and may provide information about the extent of respiratory tract involvement. BALF molecular testing can provide complementary etiological confirmation and assist in evaluating possible co-pathogens.