International Journal of Clinical Medicine, 2015, 6, 322-325
Published Online May 2015 in SciRes.
How to cite this paper: Nasreddine, R.M., Mollaei, C.A., Bahous, J.N., Azar, E.E. and Afif, C.M. (2015) Shingles and Pericardi-
tis: A Rare Combination. International Journal of Clinical Medicine, 6, 322-325.
Shingles and Pericarditis: A Rare
Rakan M. Nasreddine1, Chirine A. Mollaei2, Joudy N. Bahous2, Eid E. Azar1, Claude M. Afif1*
1Division of Infectious Disease, St. George Hospital University Medical Center, in association with the University
of Balamand, Beirut, Lebanon
2Division of Pulmonary and Critical Care Medicine, St. George Hospital University Medical Center, in association
with the University of Balamand, Beirut, Lebanon
Email: *
Received 8 April 2015; accepted 17 May 2015; published 20 May 2015
Copyright © 2015 by authors and Scientific Research Publishing Inc.
This work is licensed under the Creative Commons Attribution International License (CC BY).
http://creativ ecommon icenses/by /4.0/
Clinical infection with varicella in both its’ forms, primary and reactivation, can be associated with
a variety of complications. Cardiac complications, though very rare, have been associated with the
primary form of varicella zoster and as such should be recognized in order to initiate early treat-
ment and prevent morbidity and mortality. However, cardiac complications have not been de-
scribed in association with the reactivation form of varicella. We report a case of an adult immu-
nocompetent male who presented with herpes zoster complicated by pericarditis with pericardial
effusion and a positive varicella zoster virus (VZV) polymerase chain reaction (PCR) in pericardial
Herpes Zos ter , Shingles, Pericarditis
1. Introduction
Varicella zoster virus (VZV) is one of eight herpesviruses known to cause human infection and is distributed
worldwide. V ZV infection cause s two clinicall y distinct forms o f disease. Pri mary VZV infection results in the
diffuse vesicular rash of varicella, also known as chic kenpox. Endogenous reactivation of latent VZV typically
results in a localized skin infection known as herpes zoster, or shingles [1]. Infection can sometimes be asso-
ciated with a variety of complications that are more common in adults and in immunocompromised patients [1]
[2]. Complications involving the cardiovascular system are rare however, specifically in the shingles form.
Corresponding author.
R. M. Nasreddine et al.
2. Case Presentation
An 87-year-old man presented for fever, fatigue, cough and dyspnea upon exertion. Five days earlier, he was
diagnosed with shingle s of the r ight neck ( C2 territo ry) for whic h he was prescrib ed valac yclovir. The p atient is
known to have atr ial fibrillati on and a trio -ventricular block for which a pacemaker was inserted seven years ear-
lier. Upon admission, the patient looked tired; however his physical examination did not reveal any abnormali-
ties except for crusti ng lesions over the neck. A chest X-ray on admission revealed an enlarged heart obscuring
the left lung base (Figure 1(a)). CT scan of the chest sho we d interstitial i n filtrate s wit h gro und glass app ear ance
in the left upper lobe, lingula and both bases along with a moderate to large pericardial effusion (Figure 1(b)).
An echocardiogram revealed normal contractility with no cardiomyopathy, with an estimated 1 liter of pericar-
dial effusion without signs of tamponade. CT guided pericardiocentesis drained 500 ml of a non-hemorrhagic
exudative fluid, the analysis of which showed a lactate dehyrdogenase level of 189 U/L wit h an effus ion/ser um
ratio of 0. 99, a to tal prote in level of 4.6 g/dL with an effusion/serum ratio of 0.68, a glucose level of 136 mg/dL,
a white blood cell count of 100/mm3 with a lymphocytic predominance of 98%, and a red blood cell count of
3000/mm3. Microbiological evaluation for tuberculosis and rheumatic work-up was non-revealing. However,
furt her ana l ysi s o f the per icard ial fluid using the DNA microarray technique for the detection of gene expression
in cells revealed both VZV and Enterovirus.
The patient was treated with Colchicine (1 mg daily) and valacyclovir was continued to complete a three
week course. On discharge, patient showed significant improvement in dyspnea and overall well-be ing while
repeat echocardiography and chest X-ray showed almost complete resolution. Follow up at 3 months showed
complete clinical and radio logical resolution o f si gn s and symptoms.
3. Discussion
Herpes zoster, also known as shingles, results from reactivation of endogenous latent VZV infection within the
sensor y ganglia. Cli nically, sh ingles is c haracterized initiall y by pain or discomfort in the involved dermatome,
usual ly without constitutional symptoms. Local edema and erythema the n appear followed by the development
of a mac ulopap ular and ve sicular rash whic h eventua lly evol ves into cr usts. Vesicular lesio ns that follow a der-
matomal pattern should alert the clinician for a diagnosis of shingles. Viral cultures are currently the best me-
thod for establishing the diagnosis. Scraping the base of a vesicle and performing a Tzanck smear on the sample
may demonstrate multin ucleated giant cells which raises the suspicion for the diagnosis; however this test does
not d istin guish H SV fro m V ZV. PCR of the ve sicular lesions i s becoming more a nd more the dia gnostic test of
choice because of sensitivity, specificity, and specimen stability.
The most common complication associated with herpes zoster is post-herpetic neuralgia. Less frequent com-
plications include ocular complications (keratitis, iridocyclitis, secondary glaucoma, and loss of sight), neuro-
(a) (b)
Figure 1. (a) Chest X-ray showing cardiomegaly with silhouetting of left diaphragm; (b) Chest CT (parenchymal view):
interstitial infiltrates with ground glass appearance along with a moderate to large pericardial effusion.
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
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.
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