COVID-19 and Herpes Zoster Co-infections Identified

Reports of cases of coronavirus disease 2019 (COVID-19) and herpes zoster (shingles) co-infections are beginning to emerge in medical literature. Given the nature of shingles—a latent infection caused by the varicella zoster virus (VZV) whose reemergence is most commonly linked to stress—more co-infection cases are likely to follow.

The first study, published in the European Journal of Neurology 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.¹

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.”

The October 2020 issue of the International Journal of Dermatology reports on herpes zoster ophthalmicus (HZO) in 4 COVID-19 patients in Egypt. The patients ranged in age from 7 to 42, and all reported a previous episode of chickenpox.²

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 risk factors 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 (PHN) were observed.

“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 CDC.³

The Immunization Action Coalition 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.”⁴

Shingrix 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.

References

1. Ferreira ACA de F. Romão TT. Macedo YS. Pupe C, Nascimento OJM. COVID-19 and herpes zoster co-infection presenting with trigeminal neuropathy. European Journal of Neurology. 2020. https://doi.org/10.1111/ene.14361

2. Nofal A, Fawzy MM, Sharaf EL Deen SM, El-Hawary EE. Herpes zoster ophthalmicus in COVID-19 patients. 2020. https://doi.org/10.1111/ijd.15240

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