INTRODUCTION:
In the first nine months of 2020, it is becoming increasingly clear that being infected with the severe acute respiratory syndrome Coronavirus 2 (SARSCoV-2), now commonly referred to as COVID-19, may lead to the reactivation of varicella-zoster virus (VZV), causing herpes zoster (HZ). Many clinical laboratories have been reporting this observation. In this report, we will discuss clinical presentations of HZ in COVID-19 patients.
DISCUSSION:
Marzano et al.1Marzano, A.V., Genovese, G., Fabbrocini, G., Pigatto, P., Monfrecola, G., Piracinni, B. M., Veraldi, S., Rubegni, P., Cusini, M., Caputo, V., Rongioletti, F., Berti, E, & Piergiacomo Calzavara-Pinton. (2020). Varicella-like exanthem as a specific COVID-19-associated skin manifestation: Multicenter case series of 22 patients. Journal of American Academy of Dermatology, 83(1), 280-285. https://doi.org/10.1016/j.jaad.2020.04.044 observed varicella-like papulovesicular exanthem as a rare but specific COVID-19-associated skin manifestation. They collected data from patients with COVID-19 in eight Italian dermatology units, as determined by a nasopharyngeal swab. The median age of the 22 patients was 60 years, and 72.7% of the patients were male. The median duration of skin manifestations was eight days. Lesions were scattered in most patients and were diffuse in six days. This observation is one of the earliest reports of varicella-like exanthem as a specific COVID-19-associated cutaneous presentation.
Llamas-Velasco et al.2Llama-Velasco, M., Rodríguez-Jiménez, P., Chicharro, P., De Argila, D., Muñoz-Hernández, P., & Daudén, E. (2020). Reply to “Varicella-like exanthem as a specific COVID-19-associated skin manifestation: multicenter case series of 22 patients”: To consider varicella-like exanthem associated with COVID-19, virus varicella zoster and virus herpes simplex must be rule out. Journal of American Academy of Dermatology, 83(3), e253-e254. https://doi.org/10.1016/j.jaad.2020.04.180 reported from Spain three patients with COVID-19 who presented with HZ. They performed a Herpesvirus family microarray polymerase chain reaction of vesicle fluids. They demonstrated a combination of herpes simplex-1 virus, herpes simplex-6 virus, and Epstein-Barr virus in one patient; herpes simplex-1 and herpes simplex-7 in another patient; and varicella-zoster virus in a third patient.
Tartari et al.3Wei, L., Zhao, J., Wu, W., Zhang, Y., Fu, X., Chen, L., & Wang, X. (2017). Decreased absolute numbers of CD3+ T cells and CD8+ T cells during aging in herpes zoster patients. Scientific Reports. 7(1), 1-8. https://doi.org/10.1038/s41598-017-15390-w, also from Italy, reported on four COVID-19 patients who had HZ. They speculated that a decrease in absolute lymphocyte numbers, especially CD3+ CD8+ lymphocytes, due to COVID-19 infection, is a possible explanation for VZV reactivation.
Wei et al.4Wei, L., Zhao, J., Wu, W., Zhang, Y., Fu, X., Chen, L., & Wang, X. (2017). Decreased absolute numbers of CD3+ T cells and CD8+ T cells during aging in herpes zoster patients. Scientific Reports. 7(1), 1-8. https://doi.org/10.1038/s41598-017-15390-w notes previous observations of a decrease in the absolute numbers of CD3+ T-cells and CD8+ T-cells during aging and postherpetic neuralgia in HZ patients. As suggested by Marzano et al.5Marzano, A.V., Genovese, G., Fabbrocini, G., Pigatto, P., Monfrecola, G., Piracinni, B. M., Veraldi, S., Rubegni, P., Cusini, M., Caputo, V., Rongioletti, F., Berti, E, & Piergiacomo Calzavara-Pinton. (2020). Varicella-like exanthem as a specific COVID-19-associated skin manifestation: Multicenter case series of 22 patients. Journal of American Academy of Dermatology, 83(1), 280-285. https://doi.org/10.1016/j.jaad.2020.04.044, this does raise questions on whether the dysfunctional immune system of COVID-19 patients initiates the reactivation of latent herpes viruses in general.
Finally, another study from Spain by Fernandez-Nieto et al.6Fernandez-Nieto, D., Ortega-Quijano, D., Suarez-Valle, A., Burgos- Blasco, P., Jimenez-Cauhe, J., & Fernandez-Guarino, M. (2020). Comment on: “To consider varicella-like exanthem associated with COVID-19, virus varicella zoster and virus herpes simplex must be ruled out. Characterization of herpetic lesions in hospitalized COVID-19 patients”. Journal of American Academy of Dermatology, 83(3), e257-e259. https://doi.org/10.1016/j.jaad.2020.06.063 showed that in a total of 96 COVID-19 dermatologic consultations, eight patients had herpes simplex, while seven had HZ.
CONCLUSION:
All of the clinicians cited above agree that while further studies are needed, it is becoming clear that the weakened immune systems from COVID-19 patients may result in herpes viruses’ reactivation in general, and HZ in particular. During the current COVID-19 pandemic, Clinicians should test patients presenting with HZ for an underlying COVID-19 infection. Complementary diagnostic tests for herpes viruses should be encouraged along with COVID-19 testing.
By David Kilpatrick, PhD and Abbas Vafai, PhD
MKTG 1050 Rev A
