key: cord-0689690-ffdzg3km
authors: de Freitas Ferreira, Ana Carolina Andorinho; Romão, Tayla Taynan; SIlva Macedo, Yuri; Pupe, Camila; Nascimento, Osvaldo JM
title: COVID‐19 and herpes zoster co‐infection presenting with trigeminal neuropathy
date: 2020-05-24
journal: Eur J Neurol
DOI: 10.1111/ene.14361
sha: b809c3f7576ffec58296ece56991ed3153f065d0
doc_id: 689690
cord_uid: ffdzg3km

BACKGROUND: Varicella‐zoster virus (VZV) is a human neurotropic virus that remains in a latent state within ganglionic neurons throughout the entire neuroaxis after the primary infection. Whenever herpes zoster leads to trigeminal involvement, the ophthalmic division is the most implicated. COVID‐19 emerged as a viral cause of severe acute respiratory syndrome that spread all over the world in the last months. Co‐infection with COVID and other viruses has been registered, but sparsely and embracing the respiratory ones. METHODS: report a case of a co‐infection of COVID‐19 with VZV, and review the literature. RESULTS: 39‐year‐old immunocompetent man with oligosymptomatic infection by COVID‐19 evolved to left facial herpes zoster affecting the three divisions of trigeminal nerve. The co‐infection was remotely registered with other respiratory virus, being influenza the most mentioned. However, the present case is associated to the emergence of a latent virus infection, which might be related to the viral inflammatory response, especially ascending from the nasal cavity, where trigeminal branches are also placed. CONCLUSIONS: The emergence of the latent infection by VZV under a rare presentation might illustrate the impact at least locally of COVID‐19, once retrograde reactivation of VZV was possibly induced in a young immunocompetent patient.

Varicella-zoster virus (VZV) is a human neurotropic virus that migrates to a latent state within ganglionic neurons throughout the entire neuroaxis after the primary infection ("chickenpox"). 1 Coronavirus, one of the major pathogens targeting the human respiratory system, had featured outbreaks of public health threat. After severe acute respiratory syndrome (SARS)-CoV and the Middle East respiratory syndrome (MERS)-CoV, we From the last ten days, he noticed fatigability and presented occasional diarrheic episodes, followed by left trigeminal neuralgia. On March 22 th , three days after the beginning of the neuralgia, he presented low fever episodes, when he sought an ER for the first time. He had still no cutaneous lesion and was discharged with symptomatic drugs; however, at the end of that day, a papulovesicular rash emerged. His assistant physician prescribed oral acyclovir and pregabalin but no improvement was observed. Therefore, he went back to the ER unit two days later, on March 25 th .

At his second visit to ER, blood analysis was normal and showed WBC: 6,0 In his medical history, he could be exposed to COVID-19 on two different occasions: on a cruise coming from United Arab Emirates that arrived in Brazil on March 7 th and in a meeting on March 14 th with a friend recently arrived from the US.

This article is protected by copyright. All rights reserved VZV tend to remain in a latent state, which is probably related to neuronal resistance to VZV-induced apoptosis. 1 For example, the herpesviruses themselves facilitate this escape by downmodulating the expression of surface ligands that are targeted to natural killer cells. However, these ligands are upregulated following various stress conditions, as a viral infection. 6 The stress condition maintenance, in turn, seems necessary to allow virus reactivation progression 7 . In this case, the infection by COVID-19 might be the stress factor.

The reactivation of HZ affects the sensory ganglion and its cutaneous nerve; cranial nerve dermatomes are less affected than truncal ones. For cases involving the trigeminal nerve, the ophthalmic division is the most implicated. 8 The affection of the three divisions is rare and was punctually reported in immunocompetent patients under 50 years old. 9, 10 There is already evidence of COVID-19 role in the development of a cytokine storm in a subgroup of patients with severe infection. 11 Even the current patient remaining oligosymptomatic for COVID-19, the viral presence and its inflammatory potential arising from nasal cavitywhich is also innervated by ophthalmic and maxillary branches of trigeminal nerve 12might have fostered retrograde reactivation of VZV and underlined this rare presentation of HZ.

Varicella-Zoster Virus infected human neurons are resistant to apoptosis

The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak

Co-infection with SARS-CoV-2 and influenza A virus in patient with pneumonia, China. Emerg Infect Dis

The clinical characteristics of pneumonia patients coinfected with 2019 novel coronavirus and influenza virus in Wuhan

Co-infection with SARS-CoV-2 and Human Metapneumovirus

Disarming cellular alarm systems-manipulation of stress-induced NKG2D ligands by human herpesviruses. Front Immunol

Cohrs RJ A comparison of herpes simplex virus type 1 and varicella-zoster virus latency and reactivation

Herpes Zoster Involving the Second Division of the Trigeminal Nerve: Case Report and Literature Review

Herpes zoster affecting all three divisions of trigeminal nerve in an immunocompetent male: a rare presentation

Multidermatomal herpes zoster in an immunocompetent female