A previously healthy 37-year-old man presented with fever, nonproductive cough, and 2 days of diffuse rash that started on his chest. He denied dyspnea. He had never received the chickenpox vaccine. Physical examination revealed vesicular lesions of various stages on the trunk, neck (Image 1), head, and extremities. Chest radiograph revealed bilateral patchy opacities, and a CT scan of the chest (Image 2) showed diffuse ground-glass opacities. The patient was treated with intravenous acyclovir for severe chickenpox (varicella-zoster virus), which was subsequently confirmed on vesicular fluid PCR. Human immunodeficiency virus testing was negative. On hospital day two, he developed respiratory failure requiring mechanical ventilation for 5 days. He had a full recovery and was discharged with a 10-day course of oral acyclovir.

Image 1
figure 1

Vesicular lesions in various stages.

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Image 2
figure 2

CT scan of chest showing diffuse ground-glass opacities.

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Varicella pneumonia is the most common complication of adult chickenpox, with an incidence of one-in-400 cases.1 Risk factors include immunosuppression, smoking, and underlying lung disease. Mortality ranges from 10 to 30% overall and up to 50% in those on mechanical ventilation.1 Common imaging findings include ill-defined confluent nodules and ground-glass opacities that may surround the nodules (halo sign) or be diffuse.2 Treatment consists of early intravenous acyclovir, and steroid use remains controversial.3 This case highlights the importance of early diagnosis of varicella-zoster infections to minimize complication-related mortality.