R. M. Nasreddine et al.
logical co mplications (vario us motor neuropathie s, meningitis, encephalitis, and Guillain-Barre syndrome), sec-
ondary bacterial infection of vesicles, and otologic complications (Ramsay Hunt syndrome). Immunocompro-
mised patients are at an increased risk of developing complicated herpes zoster infections including cutaneous
disseminatio n and visceral end organ involvement includi ng pneumonia, hepa titis, and encephalitis.
Cardiac complications however, are extremely rare. An extensive search of the PUBMED, EMBASE, and
The Cochrane Library databases using the search terms “herpes zoster”, “varicella zoster”, “pericarditis”, and
“vzv”; either alone or in combination was performed. Articles published in English were reviewed. Myocardial
and pericardial complications associated with primary VZV infection have been described. A review of these
reports revealed varying complications with morbidity and mortality ranging from full recovery to death
[3]-[11].
However, to the best of our knowledge, this is the first report of pericarditis associated with herpes zoster. As
the virus is di fficult to do cu ment in tissue s in associa tio n wi th VZV -associated complications, the recognition of
the varied spectrum of disease caused by VZV is always a challenge. In such instances, viral PCR detection
proves helpful to confirm the diagnosis. As such, this report should serve to shed light on the potential for car-
diac complications associated with herpes zoster.
There is limited data concerning the use of antiviral agents (acyclovir), intravenous immunoglobulin (IVIG),
and supportive treatments when managing patients with complications of VZV, especially cardiac complications.
Reviewing the literature, there are no clear guidelines for the management of patients with myopericarditis ei-
ther associated with the primary or reactivation forms of VZV. Indeed, according to Cohen, it has been shown
that t he ea rly i niti ation of antiviral therap y for herpes zoster hastens the resolution of lesions, reduces the forma-
tion of new lesions, reduces viral shedding, and decreases the severity of acute pain [1]. In addition, as described
by the review article of Mohsen et al., on the rare occasion in which an immunocompetent adult develops a
complication of varicella, such as pneumonia, the benefit is there for the use of intravenous acyclovir [12]. In
immunocompromised patients however, the risk of cutaneous and visceral dissemination of VZV is well recog-
nized, and these include encephalitis, pneumonia, and hepatitis [1] [13]. In Gnann’s review article, the use of
high dose intra venous acyclo vir therapy res ulted in substanti ally reduced mortality associa ted with disseminated
zoster [13].
In this patient the timely initiation of valacyclovir did not prevent the occurrence of pericarditis. Although
there is no standard therapy for VZV pericarditis, we elected to administer valacyclovir for three weeks, consi-
dering this complication as visceral involvement. Whether the antiviral treatment contributed to the improve-
ment of the patient or not remains to be answered, since no objective markers can be follo wed and no repeated
pericardiocentesis would have been feasible to evaluate the numeric changes in viral concentration of the studied
fluid. Furthermore, the viral PCR was positive for both VZV and Enterovirus, questioning the culprit, knowing
that the latter is a known common cause of viral pericar ditis. However, the isolatio n of VZV argues for its’ ro le
at least as a co-infection.
4. Conclusion
Clinical infection with varicella in both its’ forms is most often but not always benign. However, clinicians
should be aware of potential cardiovascular presentations and sequelae of shingles, and patients should be inves-
tigated further when the suspicion is raised. Finally, the development of clear guidelines with regards to the
mana gement of s uch patients is warranted.
References
[1] Cohen, J.I. (2013) Herpes Zoster. The New England Journal of Medicine, 369, 255-263.
http://dx.doi.org/10.1056/NEJMcp1302674
[2] Fashner, J. and Bell, A.L. (2011) Herpes Zoster and Postherpetic Neuralgia: Prevention and Management. American
Family Physician, 83 , 1432-1437.
[3] Hackel, D.B. (1953) Myocarditis in Association with Varicella. The American Journal of Pathology, 29, 369-379.
[4] Samps on, C.C . ( 19 59) Va ri c e l la Myoc a r di ti s . Journal of the National Medical Association, 51, 138-139.
[5] Winfield, C.R. and Joseph, S.P. (1980) Herpes Zoster Pericarditis. British Heart Journal, 43, 597-599.
http://dx.doi.org/10.1136/hrt.43.5.597