Case report links prolonged VZV DNA detection to herpes zoster ophthalmicus in a 77-year-old woman after COVID-19

A case report of a 77-year-old woman with herpes zoster ophthalmicus found that varicella-zoster virus (VZV) DNA remained detectable by PCR for at least two months after symptom onset despite marked clinical improvement and antiviral treatment. The patient had recently recovered from a mild COVID-19 infection and experienced substantial stress before her shingles symptoms began, but the single-patient report cannot establish that either factor caused the prolonged viral detection.

The patient initially developed intense scalp itching after bathing, followed by pain, a fever of 39 °C and a vesiculopustular rash. She waited several days before seeking medical attention. Between the second and third weeks after symptom onset, primary care treatment included a vitamin B complex, topical fusidic acid and oral acyclovir at 800 mg per day for eight days. Codeine, tramadol hydrochloride and paracetamol did not provide substantial relief for the severe neuropathic pain.

At a medical virologist consultation in the fourth week, the patient still had active vesicles and difficulty speaking. The rash was predominantly right-sided, involving the forehead, upper eyelid and nose in the distribution of the ophthalmic division of the right trigeminal nerve. A few aberrant papules crossed the midline. Hutchinson’s sign was negative, and ophthalmologic assessment found no ocular involvement. The case was diagnosed as herpes zoster ophthalmicus.

Investigators collected swabs from the facial skin, right upper eyelid, conjunctiva, nose and scalp for viral testing. Qualitative real-time PCR detected VZV DNA but did not detect HSV-1 or HSV-2 genomes. Serology showed elevated VZV IgM and very high VZV IgG levels, while cultures of nasal, conjunctival and skin samples were negative for pathogenic bacteria and the complete blood count was unremarkable. The patient was not receiving immunosuppressive therapy, and no additional immunological screening was performed because she had no other clinical features of immunosuppression.

With active vesicles and positive VZV PCR results, clinicians started valacyclovir at 1,000 mg three times daily for 10 days. One week later, her pain had decreased and the vesicular rash had resolved with crusting. PCR nevertheless remained positive at week 4 and at week 8, when no active vesicular lesions were present. The later positive result represented detection of viral DNA at least five weeks after virological confirmation and at least two months after symptom onset.

By six months after onset, the rash and pain had completely resolved, the PCR result was negative and only minimal right-eyelid swelling remained. Small atrophic scars remained where the rash had been present. At this follow-up, the patient reported increased tearing from the right eye during exertion, although the viral PCR result was negative. The report notes that the diagnosis of herpes zoster ophthalmicus does not itself establish ocular involvement.

The principal limitation was the use of qualitative PCR assays, which did not permit precise quantification of viral load or viral particles. Cycle-threshold values were recorded and increased gradually over time, a pattern consistent with declining levels of VZV DNA, but exact viral quantities were not available. As a single-patient case report, the findings also cannot establish the frequency of prolonged shedding, distinguish the effects of age, COVID-19 infection, vaccination history and stress, or show that repeated PCR testing or extended antiviral treatment affected the outcome.

Prior research cited in the report detected VZV DNA by PCR in 72% of patients at one month, 47% at 45 days and 11% at 90 days after disease onset. The authors also cited cohort studies associating COVID-19 infection with increased herpes zoster risk, particularly among people older than 50, and noted that SARS-CoV-2 infection may produce a transient immunosuppressive state that favors VZV reactivation. These findings provide context for the case but do not demonstrate why this patient’s viral DNA remained detectable for so long.

The case documents discordance between clinical resolution and continued molecular detection of VZV: the rash and severe pain improved, yet PCR remained positive after antiviral treatment. Management of uncomplicated herpes zoster is generally based on clinical findings, and serial PCR is not routinely used to guide treatment duration. The authors conclude that further studies are needed to determine the clinical significance of prolonged VZV shedding and assess whether repeated PCR testing could have a role in treatment decisions.

Subject of Research: Prolonged VZV DNA detection in a 77-year-old woman with herpes zoster ophthalmicus after recent COVID-19 infection

Article Title: Herpes zoster ophthalmicus with prolonged viral shedding following COVID-19 infection

Article References: Kalvatchev, N., Tsekov, I., Keogh, H. A., & Manuelyan, K. (2026). Herpes zoster ophthalmicus with prolonged viral shedding following COVID-19 infection. Pharmacia, 73, Article e206847. https://doi.org/10.3897/pharmacia.73.e206847

Image Credits: AI Generated

DOI: 10.3897/pharmacia.73.e206847

Keywords: herpes zoster ophthalmicus, varicella-zoster virus, prolonged viral shedding, PCR monitoring, COVID-19, case report, antiviral treatment, older adults, Herpes, zoster, ophthalmicus, prolonged