Beth Longware Duff

Reports of cases of coronavirus disease 2019 (

 (shingles) co-infections are beginning to emerge in medical literature. Given the nature of shingles—a latent infection caused by the varicella zoster virus (

) whose reemergence is most commonly linked to stress—more co-infection cases are likely to follow.

 in May 2020, reports on a previously healthy 39‐year‐old man admitted to a Brazilian emergency room in late March. He presented with left orofacial herpes zoster (HZ) involving the left 3 trigeminal divisions, with intraoral mucosal lesions. The patient had chickenpox as a child. He reported having been fatigued and experiencing bouts of diarrhea during the preceding 10 days.

The patient’s medical history included 2 possible exposures to COVID-19 during the month of March: a cruise and the arrival of a friend from the United States. A subsequent COVID-19 test was positive.

Intravenous acyclovir was initiated to treat his shingles, and clinical improvement was seen within 24 hours. The progression of HZ lesions ceased by the fifth day, and the patient was also free of fever and respiratory symptoms.

“COVID‐19 might have fostered retrograde reactivation of VZV from the nasal cavity, where ophthalmic and maxillary branches of the trigeminal nerve are harboured,” the researchers concluded. “Hence, COVID‐19 might also entail this rare presentation of HZ.”

) in 4 COVID-19 patients in Egypt. The patients ranged in age from 7 to 42, and all reported a previous episode of chickenpox.

The patients were all immunocompetent and had mild-to-moderate COVID-19 at the onset of HZO, but did not require hospitalization. The mean time between the onset of COVID-19 and the HZO diagnosis was 4.5 days.

The treating physicians noted that the usual 

 for reactivation of VZV—advanced age, immunocompromised conditions like autoimmune diseases, and chronic diseases like diabetes—were not present in any of the patients.

“It seems that COVID‐19 infection, as an acute illness with its associated physical and emotional stress, might represent the triggering factor for the development of HZO in our patients,” they wrote.

All 4 patients were treated with systemic and topical acyclovir and topical prednisolone acetate eye drops. No ocular complications or postherpetic neuralgia (

“In conclusion, cutaneous manifestations of COVID‐19 disease are continuously emerging,” the physicians wrote. “HZO might be a complication to or an indicator of COVID‐19 infection, particularly in young, immunocompetent patients.”

Given the ongoing COVID-19 pandemic, individuals at highest risk should consider vaccination against shingles. “Ensuring that routine vaccination is maintained or reinitiated during the COVID-19 pandemic is essential for protecting individuals and communities from vaccine-preventable diseases and outbreaks,” states the 

 expands on that advice, telling health care providers, “If you have an opportunity to vaccinate a patient age 50 years or older who is due for dose 1 or dose 2 of Shingrix, proceed with vaccination as usual.”

 has been approved by the FDA since 2017 for use in the United States. Its efficacy rate has been established at over 90% across all age groups tested.

1. Ferreira ACA de F. Romão TT. Macedo YS. Pupe C, Nascimento OJM. COVID-19 and herpes zoster co-infection presenting with trigeminal neuropathy. 

2. Nofal A, Fawzy MM, Sharaf EL Deen SM, El-Hawary EE. Herpes zoster ophthalmicus in COVID-19 patients. 2020. 

3. CDC. Interim Guidance for Routine and Influenza Immunization Services During the COVID-19 Pandemic. Last updated October 20, 2020. Accessed December 1, 2020. 

https://www.cdc.gov/vaccines/pandemic-guidance/index.html

4. Immunization Action Coalition. COVID-19 and Routine Vaccination. Last updated October 22, 2020. Accessed December 1, 2020. 

https://www.immunize.org/askexperts/experts_covid19.asp

Articles

Reports of cases of coronavirus disease 2019 (COVID-19) and herpes zoster co-infections are beginning to emerge in medical literature. 

COVID-19 and Herpes Zoster Co-infections Identified	

) is most commonly associated with a painful, blistering rash in a band across the skin on 1 side of the body that lasts 2 to 4 weeks. However, depending on where it erupts and other variables, HZ can also cause hearing, vision, and balance problems; secondary skin infections; post-shingles 

When shingles occurs on the face, for example, early symptoms may include headache, general malaise, or fever. “When shingles involves branches of the trigeminal nerve, which innervates the region around the eye, eyelid swelling, conjunctivitis, ocular pain, light sensitivity, or visual changes may result,” explained Sarina B. Elmariah, MD, PhD, a board certified dermatologist at Massachusetts General Hospital.

Some forms of shingles are identified by their location on the body and have their own symptoms and complications. In cases of 

, which affects the eye, ocular pain, redness, and permanent visual changes or vision loss are all possible outcomes. 

 (HZO), also known as Ramsay Hunt syndrome, is a shingles outbreak that affects facial nerves near the ear. In addition to blisters inside or around the outer ear, HZO can cause ear pain, altered hearing, facial paralysis on the affected side, tinnitus, vertigo, and hearing loss. 

 occur internally along the digestive track and can affect the esophagus, stomach, and large and small intestines. It causes unexplained and chronic abdominal pain, and has been found in patients with 

Dr Elmariah said that early warning signs that a case of shingles may be more complicated than usual include taste or hearing changes, severe headaches, sensory loss, muscle weakness, and bladder or bowel dysfunction, which may signify encephalitis, meningitis, or myelitis. She advises her patients who experience shingles symptoms to seek care immediately from their health care provider and to start anti-viral therapy as soon as possible. She also encourages them to cover any blisters, erosions, or open skin to limit the spread of the virus.

“It is also important for individuals with shingles to distance themselves from immunocompromised individuals, pregnant women, or those who have not been vaccinated against chickenpox, as these populations can face serious complications if they were to become infected,” she said.

Finally, Dr Elmariah highly recommends the shingles vaccine Shingrix to her eligible patients, including immunocompetent individuals who are 50 and older and immunocompromised individuals under 50 years old. “Shingrix not only reduces the risk of experiencing the shingles rash, but it also limits the severity of disease and reduces the risk of postherpetic neuralgia even in those who do develop the rash,” she noted.

 recommends 2 doses of Shingrix separated by 2 to 6 months for immunocompetent adults age 50 years and older. For individuals who previously received Zostavax, it advises a wait of at least 8 weeks before administering Shingrix. Individuals who are getting other routinely recommended adult vaccines in the same physician’s visit, including 

 vaccines, can receive Shingrix at the same time.

1. Shingrix Recommendations. CDC. Last reviewed January 25, 2018. Accessed October 30, 2020. 

https://www.cdc.gov/vaccines/vpd/shingles/hcp/shingrix/recommendations.html

Herpes zoster can take a toll on the entire body.

Shingles: More Than Just a Rash	

The herpes zoster (HZ) incidence rate in the United States has been steadily 

 over recent decades despite FDA approval of shingles vaccines in 2006 and 2017. A study published in 

earlier this year reviewed rates for HZ between 1994 and 2018. It concluded that incidence rates have continued to rise in age groups for which HZ vaccines are not recommended at this time, warranting a review of existing vaccination guidelines.

Statistics show that 1 out of 3 adults will experience 

 during their lifetime. The risk increases with age, with individuals over the age of 60 accounting for approximately half of all cases. Up to 20% of patients with shingles will develop the complication called postherpetic neuralgia (

), a pain syndrome that lasts for 30 days or more after the rash subsides.

A team of investigators based at the Francis I. Proctor Foundation, University of California, San Francisco, noted that few studies of the incidence rates of HZ and PHN have been conducted since the introduction of 2 shingles vaccines—Zostavax in 2006 and Shingrix in 2017. When they conducted their study, both were available. Zostavax was subsequently removed from the US market by manufacturer Merck 

 remains and is recommended by the CDC for use in healthy adults age 50 and older.

Using the OptumLabs® Data Warehouse database, investigators focused on whether HZ and PHN rates had continued to increase. Incidence rates among more than 610,000 individuals with HZ were assessed. Unstandardized and standardized incidence rates were calculated by year, 10-year age groups, sex, and race/ethnicity. The median age of the subjects of the study was 56 years.

The investigators reported that between 1994 and 2018, the incidence of HZ increased from 286 to 580 cases per 100,000 person-years, for an annual increase of 3%. The results also showed that annual HZ incidence rates since 2007 have decreased in individuals below the age of 20 and those aged 60 and older. 

Additionally, the overall incidence rate for PHN was 57 cases per 100,000 person-years. The proportion of individuals with HZ who developed PHN was higher from 2007 to 2018 than from 1994 to 2006.

“In this same period, HZ incidence rates continued to rise in individuals 31 to 60 years old,” 

 “This led investigators to caution that, ‘it is crucial healthcare providers and policymakers continue to advocate for HZ vaccination and consider revising age recommendations for vaccination to include individuals younger than 50 years of age.”

1. Thompson RR, Kong CL, Porco TC, et al. Herpes zoster and post-herpetic neuralgia: changing incidence rates from 1994 to 2018 in the United States. 

Study suggests review of current recommendations.

Herpes Zoster on the Rise Among Individuals Ineligible for Vaccine	

Shifting hormones, hot flashes, mood swings, sleep deprivation, and short-term memory loss are all normal and natural changes women experience and anticipate during menopause. However, many women may be unaware that they are also at an increased risk for developing shingles (herpes zoster) while transitioning through menopause.

Herpes zoster (HZ) is a reactivation of the 

 that causes chickenpox and subsequently burrows into the host’s dorsal root ganglia, where it lays dormant until 

 back to life decades later. Individuals at greatest risk for shingles are those 50 years of age and older; women account for more cases than men. Peak incidence for women coincides with the average age for menopause (51-54), while men tend to develop shingles later in life.

The menopause/shingles connection generally focuses on three factors: hormones, stress, and immunity.

According to the North American Menopause Society (

), “Changes in our cellular immunity occur with age, stress, certain medications, and hormones, and make us more vulnerable to viruses, especially those in the herpes family (shingles, herpes simplex, cytomegalovirus).” NAMS also explained that “women, particularly during the menopause transition, have higher rates of shingles than men, most likely due to hormonal changes to their immune response.”

In her OBGYN practice in Ithaca, NY, Kathleen Gardner, MD, witnesses first-hand how hormones, stress, and immunity interact in her menopausal patients. “Herpes zoster is a reactivation of a virus that looks for opportunities of physiologic stress, and menopause is a time of both physiologic and emotional stress,” she said.

For example, hormonal disruptions associated with menopause affect sleep patterns. “Poor sleep patterns clearly play a role in overall health, but also play a role in immunologic health,” added Gardner.

NAMS Past President Marla Shapiro, CM, MDCM, points out that while there are gender differences when it comes to shingles, conclusive research data is lacking when it comes to shingles and women per se. “We often jump to the conclusion that these gender differences must be hormonal because it’s happening in 50 and 60 year olds, but we really don’t know if there are pathophysiological causes in gender differences,” she explains. “There are a number of theories that look at the fact that estrogen and progesterone may tamp down the inflammation, so in their absence during the onset of menopause we could lose that protection. But a lot of it is quite theoretical.”

NAMS advocates for the best protection against preventable diseases. The shingles vaccine is among the most valuable vaccinations for midlife women, according to NAMS.

Shapiro offered specific guidance to all women as well as men. “When you hit age 50, you really want to think about getting the shingles vaccine,” she said. “For those who had the attenuated live virus vaccine [Zostavax], we’re still recommending reimmunization with 2 doses of the recombinant vaccine [Shingrix].” She noted that 

 is not only highly effective in preventing shingles, but it also can help lessen the risk of complications like 

 announced that it would no longer sell Zostavax in the United States. The move leaves Shingrix as the lone shingles vaccine in distribution. Administered in 2 doses, it is FDA-approved for immunocompetent adults 50 years and older.

The link between menopause and shingles may be explained by hormones, stress, and immunity.