Can COVID-19 Increase the Risk of Herpes Zoster? A Narrative Review

Abstract

Herpes zoster (HZ) is associated with substantial morbidity. It is caused by reactivation of the latent varicella zoster virus (VZV) following decline in cell-mediated immunity, which is commonly age-related, but also occurs in individuals with immunosuppressive diseases and/ or treatment. Since coronavirus disease (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, has been associated with T cell immune dysfunction and there have been reports of HZ in COVID-19 patients, we have performed a review of available literature on whether COVID-19 could trigger HZ. We identified 27 cases of HZ following COVID-19, which most frequently occurred within 1-2 weeks of COVID-19, and the majority of cases had typical presentation. Atypical presentations of HZ were noted especially in patients with lymphopenia. It has been hypothesized that VZV reactivation occurs as a consequence of T cell dysfunction (including lymphopenia and lymphocyte exhaustion) in COVID-19 patients. Based on current evidence, which is limited to case reports and case series, it is not possible to determine whether COVID-19 increases the risk of HZ. Practitioners should be aware of the possible increased risk of HZ during the pandemic period and consider timely therapeutic and preventive measures against it.

A Rare Case of Herpes Zoster in an Adult Patient Recovered From Symptomatic Reinfection of COVID-19

“…The reactivation of the VZV is considered to be a result of a decline in VZV-specific cell-mediated immunity most commonly due to aging or other causes of immunosuppression. In immunocompetent adults, HZ is usually seen in the age group above 50 years [9]. Similarly, the majority of the cases of HZ developed in patients with COVID-19 were reported in patients aged above 50 years [9].…”

“…Although most of the cutaneous manifestations of COVID-19 have been attributed to microthromboses, lymphocytic vasculitis, or Langerhans cell activation by the SARS-CoV-2 [8]. A few studies described an increase in HZ co-infection causing skin lesions during the COVID-19 pandemic [9]. HZ is caused by the reactivation of latent varicella virus in dorsal root ganglia years after primary varicella infection.…”

“…In immunocompetent adults, HZ is usually seen in the age group above 50 years [9]. Similarly, the majority of the cases of HZ developed in patients with COVID-19 were reported in patients aged above 50 years [9]. However, Nofal et al described four immunocompetent patients developing HZ ophthalmicus in the age group of 7-42 years during active COVID-19 infection [10].…”

“…Reactivation of HZ in COVID-19 patients can be explained by the immune alteration apparent in such patients. A decrease in total lymphocytes, a cluster of differentiation (CD4+) T cells, CD8+ T cells, B cells, and natural killer (NK) cells are observed in COVID-19 patients [9]. Functional exhaustion of CD8+ T cells and NK cells with increased expression of natural killer cell receptor (NKG2A) causing decreased antiviral immunity is also evident in the early stages of SARS-CoV-2 infection [15].…”

Varicella zoster virus-induced neurological disease after COVID-19 vaccination: a retrospective monocentric study

“…Among triggers for VZV reactivation, vaccines are rarely reported, but a vaccine-induced immunomodulatory mechanism might be potentially involved [ 9 , 10 ]. To date, there are cases of VZV reactivation concomitant with severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) infection [ 11 ] but no description of VZV-ND after COVID-19 vaccination.…”