Atypical Presentation of Herpes Simplex 1 Virus in a COVID-19 Patient

Abstract

A 74-year-old man with past medical history of obesity and type 2 diabetes mellitus was admitted for COVID-19 pneumonia. Due to unfavorable disease progression, ten days later, the patient was admitted to the intensive care unit and intubated, requiring periods of prone position and systemic corticosteroid treatment. During the following weeks, the patient developed several infectious complications successfully managed with systemic antibiotics and herpes simplex infection of the left upper lip, treated with acyclovir 400 mg twice daily for 10 days. Dermatology observation was requested 2 days after acyclovir cessation due to an infiltrative hyperkeratotic erythematous plaque with pustules on the right zygomatic region (see picture 1) that had been noticed 2 days before. Polymerase chain reaction (PCR)-testing of swab samples from the pustules was positive for herpes simplex virus (HSV) 1, with negativity for HSV 2 and for varicella-zoster virus (VZV). Blood and CSF fluid PCR were negative for HSV 1, HSV 2 and VZV. The patient restarted acyclovir (400 mg, thrice daily for 12 days) with significant improvement of the lesion (less infiltration and hyperkeratotic crusts) and negative PCR-testing for HSV1 DNA after treatment cessation (see picture 2). About 2 weeks later the lesion was completely healed leaving a minor atrophic scar.