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Three Part Question

In [patients with chickenpox pneumonitis] does [the administration of corticosteroids] affect [mortality]?

Clinical Scenario

A female patient presents to the emergency department via ambulance with severe respiratory failure. Her husband reports that she has just had chickenpox but she has become increasingly breathless over the past few days and today she is much worse. A plain chest xray is hot reported as suggesting varicella pneumonitis. In addition to intravenous aciclovir you wonder whether to administer corticosteroid to the patient.

Search Strategy

{(exp chickenpox) OR (varicella.mp)} AND {(exp pneumonia) OR (pneumonitis.mp) OR (pulmonitis.mp)} LIMIT to human and English language.

Search Outcome

Five hundred and thirty-two papers were reduced to 322 after the limits were imposed. Only 2 of these were relevant to the question asked.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Adhami et al. 2006 Saudi Arabia	Nineteen patients diagnosed with varicella pneumonia. Ten received corticosteroid as well as antiviral treatment.	Retrospective cohort study.			Retrospective study with the more severe patients receiving steroids as well as antivirals. The authors report a more "dramatic" recovery with steroid.
Mer 2001 South Africa	Patients admitted to ICU between 1980 and 1996 with a diagnosis of varicella pneumonia.	Retrospective cohort study.	Length of stay in hospital.	Median difference 10 days (p<0.006) in favour of steroid.
			Length of stay in ICU.	Median difference 8 days (p<0.008) in favour of steroid.

Comment(s)

The two papers found are cohort studies. Both papers suffered from selecting out the patients with severe disease and as part of the care of this group administered corticosteroid.

Clinical Bottom Line

Although there is little robust evidence, corticosteroids appear to be of value in the treatment of previously well patients with severe, life-threatening varicella pneumonia.

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.

References

1. Adhami N., Arabi Y., Raees A. et al. Effect of corticosteroids on adult varicella pneumonia: cohort study and literature review. Respirology 2006; 11(4):437-41.
2. Mer M, Richards GA. Corticosteroids in life-threatening varicella pneumonia. Chest 1998;114(2):355-60.