Herpes zoster and severe acute herpetic neuralgia as a complication of COVID-19 infection

Introduction

An increasing number of dermatologic manifestations are attributed to coronavirus disease 2019 (COVID-19). I present a telemedicine case in which a patient developed varicella zoster virus reactivation of the V2 dermatome during the course of COVID-19 infection. In addition, she developed severe acute herpetic neuralgia despite the early initiation of antiviral therapy.

Case report

A 49-year-old otherwise healthy woman was treated by telemedicine consultation for a new facial rash. She reported that during the past week she had felt unwell, with 1 episode of fever to 38.8°C (101.8°F), which quickly defervesced. She also experienced aches and chills, headache, and profound fatigue. She denied sore throat, cough, shortness of breath, anosmia, or ageusia, and had no history of diabetes, hypertension, or cardiac disease. On the seventh day of symptoms, she developed a mildly itchy rash on the trunk. The following day, several dysesthetic papules and vesicles appeared on the cutaneous portion of her left upper lip, and during the next 24 hours edema and similar lesions appeared throughout the V2 dermatome. Based on the patient's self-photograph (Fig 1), a presumptive diagnosis of herpes zoster was made, and she began receiving valacyclovir 1 g 3 times daily within 12 hours of the initial eruption. The patient was also advised to present for consideration of COVID-19 testing based on her other symptoms. On follow-up telephone visit 48 hours later, she noted that her COVID-19 reverse transcription–polymerase chain reaction test result was positive. The eruption was slow to respond to therapy and persisted after 7 days of treatment (Fig 2). During this time, the patient developed sensations of skin burning and allodynia, as well as sinus and tooth pain. On follow-up 4 weeks after the first appearance of her eruption, she continued to experience severe neuralgia of her left cheek that was only partially controlled by 900 mg daily of gabapentin and use of topical lidocaine preparations.

Fig 1.

V2 herpes zoster occurring on day 8 of coronavirus 2019 symptoms.

Fig 2.

The eruption at 1 week despite prompt intervention with valacyclovir.

Discussion

Recalcati¹ described the Italian experience with dermatologic manifestations in COVID-19, noting that 18 of 88 patients developed skin findings that included erythematous rash (14/88), widespread urticaria (3/88), and chicken pox vesicles (1/88). Additionally, another Italian study reported on a truncal varicella-like eruption in 22 patients.² Chilblainlike manifestations have also been described in 63 patients.³ Last, a single patient was reported to have a petechial eruption.⁴ The original descriptive study from Wuhan, China, noted leukopenia and lymphopenia in 25% and 63% of patients, respectively.⁵ In this patient, lymphopenia or other stresses related to her underlying illness may have served as a mechanism for reactivation of varicella zoster. The patient's severe herpetic neuralgia is unusual, given that she started appropriate antiviral therapy within 12 hours of initial presentation. It may be that her underlying COVID-19 infection contributed to an exaggerated inflammatory response at the dorsal root ganglion, given that severe acute respiratory syndrome coronavirus 2 is known to elicit strong host responses.