New research suggests that pregnant women appear to be at an increased risk for complications of coronavirus disease 2019 (COVID-19), including herpes zoster (HZ) infection. For this reason, experts say the clinical presentation of HZ in pregnant women should be carefully monitored and reported for further assessment, especially if it is associated with other signs of COVID-19.

According to a case report presented in Cutis, COVID-19 has been associated with an array of skin manifestations, including maculopapular eruptions, morbilliform rashes, urticaria, chickenpox-like lesions, livedo reticularis, so-called “COVID toes,” erythema multiforme, and pityriasis rosea. In the case study, the authors presented a case of HZ complication in a woman who was 27 weeks pregnant and tested positive for COVID-19.

The 36-year-old woman was referred by her obstetrician to the dermatology clinic, where she presented with a low-grade fever and a vesicular painful rash. The dermatologist also found painful, itchy, dysesthetic papules and vesicles on the left side of her forehead, as well as mild edema of the left upper eyelid, but no watering of the eye or photophobia. She reported episodes of fever, fatigue, and myalgia over the previous week, although no dry cough, gastrointestinal, or urinary tract symptoms were noted.

The physician diagnosed HZ and she was prescribed 1g valacyclovir 3 times per day for 7 days, acetaminophen for the fever, and calamine lotion. After recommending COVID-19 testing based on her symptoms, a chest radiograph and nasopharyngeal smear confirmed COVID-19 infection.

During a telephone follow-up 1 week after presentation, the woman reported that her skin condition had improved and the vesicles had dried. With regards to her COVID-19 infection, her oxygen saturation was 95% at presentation, she self-quarantined at home, and she was treated with oseltamivir 75 mg orally every 12 hours for 5 days, azithromycin 500 mg orally daily, acetaminophen, and vitamin C. Electronic fetal heart rate monitoring and ultrasound examinations found that the fetus was normal.

The investigators noted multiple reasons for pregnant women to be especially cautious during the COVID-19 pandemic. Physiologic changes in the immune and cardiopulmonary systems during pregnancy make pregnant women intolerant to hypoxia. The authors noted that the mortality rate during the 1918 influenza pandemic was 2.6% among the overall population but 37% among pregnant women. In 2003, they said approximately 50% of pregnant women who tested positive for severe acute respiratory syndrome coronavirus were admitted to the intensive care unit, approximately 33% required mechanical ventilation, and the mortality rate was as high as 25%.

Based on these historical statistics and the known link between pregnancy and a higher risk of COVID-19 complications, the authors urged clinicians to monitor and educate pregnant patients about the potential for HZ to be a symptom of COVID-19.

REFERENCE
Elsaie M, Youssef E, Nada H. Herpes Zoster May Be a Marker for COVID-19 Infection During Pregnancy. Cutis; December 2020. https://www.mdedge.com/dermatology/article/233024/infectious-diseases/herpes-zoster-may-be-marker-covid-19-infection-during?sso=true. Accessed February 4, 2021.