Severe Varicella-Zoster Virus Pneumonia in an Unvaccinated Patient With Rheumatoid Arthritis: A Case Report and Literature Review

The global prevalence of rheumatoid arthritis (RA) is increasing, resulting in an increased use of Janus kinase (JAK) inhibitors. Several cases of varicella-zoster virus (VZV) pneumonia in patients with RA have been reported. However, to our knowledge, no reports have demonstrated conclusive evidence of VZV reinfection in this patient population. This case report describes a 52-year-old female with RA who developed severe VZV pneumonia. The patient was treated with a combination of methotrexate, baricitinib, and iguratimod. She had a history of chickenpox during childhood and had not been vaccinated against VZV. Two weeks after her family member was infected by shingles, the patient developed multiple vesicles throughout her body. The patient was diagnosed with VZV reinfection based on the history and serological testing. She was admitted and treated with intravenous acyclovir for the disseminated VZV infection. Despite treatment, her condition rapidly deteriorated, progressing to acute respiratory distress syndrome. Chest computed tomography revealed diffuse bilateral ground-glass opacities, nodules, and consolidations, consistent with VZV pneumonia. The patient required high-flow nasal cannula oxygen and steroid therapy. Following the administration of acyclovir and steroids, the patient gradually improved and was discharged on the 15th day of admission. This case highlights the risk of severe VZV infection in patients with RA, particularly in those treated with JAK inhibitors. This underscores the importance of the VZV vaccination in this population. Despite the current guidelines recommending VZV vaccination, vaccination rates among immunosuppressed patients remain inadequate. Given the potential for VZV reinfection, vaccination is recommended, regardless of previous VZV infection status.