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Year : 2021  |  Volume : 9  |  Issue : 1  |  Page : 54-57

Herpes zoster-An indicator of a hidden COVID-19 infection-A case series

Department of Anesthesiology, Pain and Critical Care Medicine, All India Institute of Medical Sciences, New Delhi, India

Date of Submission05-Oct-2020
Date of Acceptance08-Dec-2020
Date of Web Publication20-May-2021

Correspondence Address:
Dr. Irfan Altaf
Department of Anesthesiology, Pain and Critical Care Medicine, All India Institute of Medical Sciences, Malviya Nagar 238-A First Floor, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njecp.njecp_41_20

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Clinical presentation of COVID-19 infection can be variable in current pandemic even in patients presenting to the clinic with mild history of upper respiratory complaints. Various cutaneous manifestations have been noticed in COVID-19 patients with herpes zoster (HZ) being one among them. HZ is an infection that results that results when varicella-zoster virus reactivates from its latent state in a posterior dorsal root ganglion. Here, we aim to expand our knowledge by reporting three cases of associated zoster infection in COVID-19 patients admitted to our intensive care unit in view of respiratory complaints. All the three patients admitted had revealed lymphocytopenia at the time of HZ diagnosis and were managed conservatively throughout the course. In all the cases, acyclovir/valaciclovir led to the resolution of lesions in 10 days. No postherpetic sequelae were observed. We hereby suggest that the clinical presentation of HZ at the time of the current pandemic should be considered as an alarming sign for a latent subclinical SARS CoV2 infection and thorough follow-up of such patients be adopted.

Keywords: Acyclovir, COVID-19, herpes zoster, immune suppression, lymphocytopenia, SARS CoV-2

How to cite this article:
Altaf I. Herpes zoster-An indicator of a hidden COVID-19 infection-A case series. Niger J Exp Clin Biosci 2021;9:54-7

How to cite this URL:
Altaf I. Herpes zoster-An indicator of a hidden COVID-19 infection-A case series. Niger J Exp Clin Biosci [serial online] 2021 [cited 2022 Aug 14];9:54-7. Available from: https://www.njecbonline.org/text.asp?2021/9/1/54/316530

  Introduction Top

The most recently identified member of the zoonotic pathogens of coronaviruses, SARS CoV-2, started with an outbreak of pneumonia in Wuhan City of China in December 2019.[1] Although closely related to SARS-CoV and Middle East Respiratory Syndrome Corona Virus, with bat as reservoir, SARS-CoV-2 is markedly more infectious with a high potential for human to human transmission. The novel virus was officially named SARS-CoV-2, and the disease was termed COVID-19.[2],[3],[4] Although most patients with COVID-19 exhibit mild-to-moderate symptoms, approximately 10%–15% of them progress to severe pneumonia, and roughly 5% of the patients develop complications such as acute respiratory distress syndrome, septic shock, and/or multiple organ failure.[5],[6] A relevant history and clinical examination for the recognition of asymptomatic carriers can be very helpful in the management of this outbreak.[1] A wide range of skin manifestations in COVID 19 infection have been reported ranging from erythematous rash, erythema multiforme, to urticarial/chickenpox-like lesions.[7] We encountered three cases of clinically diagnosed herpes zoster (HZ) infection admitted to our hospital. All patients showed mild respiratory symptoms related to COVID-19 infection and denied any history of travel or contact with patients with known COVID-19 infection.

  Case Series Top

Case 1

A 52-year-old male presented with painful blisters on the right side of his neck and upper chest. The pain was continuous, severe, and burning in nature. He gave a history of pain followed by the development of blister-like lesions. The lesions were initially small and few in number and now with serous discharge. The area surrounding the vesicular eruption was flared and tender to touch [Figure 1]. The patient denied any such history in the past except the history of hypertension which is controlled with medication. The patient was prescribed oral acyclovir 500 mg 5 times daily for 1 week, oral prednisolone 20 mg thrice a day for 1 week, and calamine lotion for topical application. Two days following the presentation, the patient started with fever, dry cough, sore throat, and dyspnea required intensive care unit (ICU) admission. Computed tomography (CT) of the thorax was done which revealed basal and peripheral patchy ground-glass infiltration in both lungs consistent with findings of COVID-19 infection. A nasopharyngeal swab was also taken and revealed a positive for COVID-19.
Figure 1: Zosteriform rash on the right side of the neck and upper chest with dermatomal pattern

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Case 2

A 45-year-old male got admitted with 3 days history of low-grade fever, myalgias, and a painful vesicular rash on the right side of his neck. On examination, a tender vesicular rash with serous discharge was noted on the right side of the neck. He was prescribed valaciclovir 1 g twice daily for 1 week, prednisolone 5 mg twice daily for 5 days besides calamine lotion for local application. Oral mucosa was free from such findings [Figure 2] and [Figure 3]. No similar history in the past was revealed. During the course, he became dyspneic and got admitted in ICU. Pulmonologist consultation was sought for his respiratory symptoms. Meanwhile, the chest X-ray was done and nasopharyngeal smear was sent for Reverse transcription polymerase chain reaction (RT-PCR) and was later on found to be positive for COVID-19 infection.
Figure 2: Vesicular rash with serous discharge on the right side of the neck

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Figure 3: Fluid-filled vesicular rash with surrounding erythema

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Case 3

A 37-year-old male presented with 5 days history of dry-cough, loss of smell, and headache. The patient came to the hospital for COVID screening and the patient was kept in the isolation ward. On the same day, the patient reported a sudden onset of itching with painful rash on the right lateral wall of the chest [Figure 4]. The rash appeared as small fluid-filled vesicles that had rupture upon scratching, with clear discharges. The spread of the rash was consistent with T8 dermatome and did not extend beyond the midline, therefore supporting the diagnosis of HZ. Vital signs and rest of the physical examination were normal except the skin manifestations. Next day the nasopharyngeal swab turned positive for SARS CoV-2.
Figure 4: Grouped vesicular rash on lateral thoracic wall associated with scarring

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Diagnosis of COVID-19 disease is made on the grounds of clinical signs such as fever, dry cough, malaise, ageusia, anosmia, and radiological findings such as chest CT scan for the presence of ground-glass opacity.[3] The clinical scenario differs with most patients receiving only the supportive care, while others require admission to an ICU for mechanical ventilation or hemodynamic monitoring.[6],[7] Incubation period of COVID-19 can range from 10 to 14 days. Besides the history of travel and close contact, diagnosis can be confirmed by detection of viral RNA through real-time RT-PCR for nasopharyngeal smear or bronchoalveolar fluid.[3] Elderly patients >60 years of age, especially male gender, cardiovascular disease, and other patients with debilitating chronic conditions with immunocompromised status are at an increased risk of severe disease and poor outcome.[6] However, little is known regarding the cutaneous manifestations of COVID-19 patients. Recently, different groups have reported patients with features of skin rash after COVID-19, ranging from erythematous rash to chickenpox like/urticarial eruption.[7] We encountered the HZ activations in three COVID-19 patients admitted in our ICU revealing characteristic features. In all the cases, acyclovir led to the resolution of lesions in around 10 days time with no postherpetic neuritic sequelae.

HZ is the infection that results when varicella-zoster reactivates from its latent state in dorsal root ganglia following an early episode of chickenpox. The condition manifests in the form of painful, unilateral vesicles, usually multiple, and get ulcerated and follow a typical dermatomal pattern innervated by single dorsal root ganglion. Involvement of three or more dermatomes is known as disseminated zoster and seen in immunocompromised individuals.[7],[8],[9] One possible explanation of the HZ re-activation could be the reduction in absolute lymphocyte count, especially the CD3+ CD8+ lymphocytes due to SARS CoV-2 infection.[10] Lower percentages of T-cell functional markers have also been observed within the T-cell population as COVID-19 patients showed decreased percentages of CD-107a+, CD8+, IFN-γ+, CD8+, and IL-2+ CD8+ T cells and mean fluorescence intensity of granzyme B+ CD8+ T cells when compared to normal controls.[11] It is reasonable to hypothesize that, in addition to the activation-induced cell death, SARS CoV-2 directly infects lymphocytes, particularly the T cells and promotes their cell death of causing lymphopenia and eventually leading to impaired antiviral response.[11] Moreover, functional damage of CD4 + T-cells has been postulated, thereby predisposing to higher grades of severity of the disease COVID-19.[11],[12],[13]

In conclusion, we suggest that during the current COVID-19 pandemic, the clinical presentation of HZ infection, in patients having an associated history of mild upper respiratory complaints should be considered as an alarming signal for a latent or subclinical SARS CoV-2 infection. A thorough follow-up of such patients should be adopted and it is prudent to adhere to maximum precautions until the diagnosis of COVID-19 is excluded from the study.

Since the decision to pharmacologically immunosuppress a critically unwell patient with COVID-19 remains a challenge. We also suggest that further studies be done before the use of immunosuppression as possible beneficial effects of reducing inflammation by immunosuppressive medication should be carefully weighed against the delay in viral clearance.[13],[14],[15]

Declaration of patient consent

The authors certify that all appropriate patient consent forms have been obtained. The patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patient(s) understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020;323:1061-9.  Back to cited text no. 1
Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early transmission dynamics in Wuhan, China, of novel corona virus-infected pneumonia. N Engl J Med 2020;382:1199-207.  Back to cited text no. 2
Wiersinga WJ, Rhodes A, Cheng AC, Peacock SJ, Prescott HC. Pathophysiology, transmission, diagnosis, and treatment of coronavirus disease 2019 (COVID-19): A Review. JAMA 2020;324:782-93.  Back to cited text no. 3
Zhang YZ, Holmes EC. A genomic perspective on the origin and emergence of SARS-coV-2. Cell 2020;181:223-7.  Back to cited text no. 4
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.  Back to cited text no. 5
Ruan Q, Yang K, Wang W, Jiang L, Song J. Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China. Intensive Care Med 2020;46:846-84.  Back to cited text no. 6
Wollina U, Karadag AS, Rowland-Payne C, Chiriac A, Lotti T. Cutaneous signs in COVID-19 patients: a review. Dermatol Ther 2020;33:e13549.  Back to cited text no. 7
Ahouach B, Harent S, Ullmer A, Martres P, Bégon E, Blum L, et al. Cutaneous lesions in a patient with COVID-19: are they related? Br J Dermatol 2020;183:e31.  Back to cited text no. 8
Dayan RR, Peleg R. Herpes zoster-typical and atypical presentations. Postgrad Med 2017;129:567-71.  Back to cited text no. 9
Wang F, Nie J, Wang H, Zhao Q, Xiong Y, Deng L, et al. Characteristics of peripheral lymphocyte subset alteration in COVID-19 pneumonia. J Infect Dis 2020;221:1762-9.  Back to cited text no. 10
Henry BM, de Oliveira MH, Benoit S, Plebani M, Lippi G. Hematologic, biochemical and immune biomarker abnormalities associated with severe illness and mortality in coronavirus disease 2019 (COVID-19): a meta-analysis. Clin Chem Lab Med 2020;58:1021-8.  Back to cited text no. 11
Wei L, Zhao J, Wu W, Zhang Y, Fu X, Chen L, et al. Decreased absolute number of CD3+ T-cells and CD8+ T-cells during aging in herpes zoster patients. Sci Rep 2017;7:15039.  Back to cited text no. 12
Zheng M, Gao Y, Wang G, Song G, Liu S, Sun D, et al. Functional exhaustion of antiviral lymphocytes in COVID-19 patients. Cell Mol Immunol 2020;17:533-5.  Back to cited text no. 13
Cao X. COVID-19: Immunopathology and its implications for therapy. Nat Rev Immunol 2020;20:269-70.  Back to cited text no. 14
Ritchie AI, Singanayagam A. Immunosuppression for hyperinflammation in COVID-19: A double-edged sword? Lancet 2020;395:1111.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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