Herpes Zoster Ophthalmicus Could Be Rare Manifestation of COVID-19, Possibly Caused by Stress

The physical and emotional stress of a COVID-19 diagnosis might be the triggering factor for the development of herpes zoster ophthalmicus.

Although several skin manifestations have been noted in patients with coronavirus disease 2019 (COVID-19), a new editorial published in the International Journal of Dermatology suggests that a rare form of herpes zoster could be a concern for some patients.

Herpes zoster ophthalmicus (HZO) is a rare variant of herpes zoster affecting the ophthalmic nerve. Symptoms include small cysts, red skin, and dermatomal pain distribution. It can also have serious ocular manifestations, including conjunctivitis and ocular inflammation, according to the editorial. Risk factors include old age, immunocompromising conditions such as autoimmune diseases, and chronic illnesses, such as diabetes.

Although HZO had not be previously reported in COVID-19 patients, the authors outlined 4 patients who contracted both conditions simultaneously. There were 2 pediatric patients and 2 young adults, with ages ranging from 7 to 42 years and a mean of 21.5 years.

All of the patients reported having chickenpox when they were younger, were immunocompetent, and had mild to moderate COVID-19. All of the patients received supportive and symptomatic treatments for COVID-19 and were not hospitalized. The mean time between the onset of COVID-19 and the HZO diagnosis was 4.5 days.

The most serious complications of HZO are ocular complications that can result in visual loss. Although all of the patients had variable degrees of eye impact, no impairment of vision was observed.

According to the authors, timely diagnosis and antiviral treatment are essential in reducing visual morbidity. Systemic steroids have been used in some cases to reduce the long-term incidence of postherpetic neuralgia or ocular complications and can decrease the host inflammatory responses in patients with severe manifestations of COVID-19.

The authors noted that HZO is rare in childhood, especially in immunocompetent children. Most reported cases in this population are related to varicella infection acquired during their first year of life or immunosuppression. Because of this, the authors said it was very interesting to diagnose HZO in such young patients.

Based on the patients’ lack of typical predisposing factors, the authors said the physical and emotional stress of a COVID-19 diagnosis might be the triggering factor for the development of HZO. A second potential explanation could be related to the decrease in the total lymphocytic count in patients with COVID-19.

Lymphopenia occurs as a result of direct infection of lymphocytes with severe acute respiratory syndrome coronavirus 2, the activation-induced cell death, and antiviral response impairment. According to the authors, the 4 patients showed mild to moderate lymphopenia.


Nofal A, Fawzy MM, Sharaf El Deen SM, El-Hawary EE. Herpes zoster ophthalmicus in COVID-19 patients. International Journal of Dermatology; October 11, 2020. https://onlinelibrary.wiley.com/doi/full/10.1111/ijd.15240. Accessed October 14, 2020.

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