key: cord-294262-yvbufnf4
authors: Fernandez-Nieto, D.; Ortega-Quijano, D.; Suarez-Valle, A.; Burgos-Blasco, P.; Jimenez-Cauhe, J.; Fernandez-Guarino, M.
title: Comment on: “To consider varicella-like exanthem associated with COVID-19, virus varicella zoster and virus herpes simplex must be ruled out. Characterization of herpetic lesions in hospitalized COVID-19 patients.”
date: 2020-06-22
journal: J Am Acad Dermatol
DOI: 10.1016/j.jaad.2020.06.063
sha: 
doc_id: 294262
cord_uid: yvbufnf4

nan

be performed in order to rule out other viral infections. Marzano and Genovese 2 were 32 not able to perform PCR tests in their previous study of varicella-like exanthem 3 due to 33 logistic reasons, but also due to clinical presentation not being suggestive of varicella. 34

We previously conducted a prospective study of vesicular COVID-19 rashes (all with 35 positive nasopharyngeal swab for SARS-CoV-2) in our hospital from March 1st to 36

April 20th, 2020 4 . Out of a total of 53 patients, 15 were excluded because of an 37 alternative herpes simplex/zoster clinical diagnosis (clinical data are summarized in 38 Table 1 ). All 15 patients presented typical clinical lesions and symptoms of herpes 39 simplex/zoster. Only one patient (6.7%) had a previous history of immunosuppression. 40

Latency time between COVID-19 symptoms and herpetic lesions was variable (median 41 time 16 days, range 6-32). In spite of performing PCR tests for SARS-CoV-2 from the 42 content of the vesicles in only three patients, the results were all negative. 43

Regarding vesicular rashes or varicella-like COVID-19 exanthems 3 , we previously 44 reported four cases in which we performed both PCR multiplex for herpesvirus and rt-45 PCR for SARS-CoV-2, directly from the content of the vesicles. Interestingly, both 46 techniques were negative in all four cases 4 . This reasonably rules out a role of herpes 47 viruses 3 , and a potential infective ability of SARS-CoV-2 through the vesicles. 48

We agree with the authors that there is a potential role for herpetic viral infections and 49 super-infections in COVID-19 patients. In fact, some presumed COVID-19 vesicular 50 lesions have been later proven to be caused by herpetic infections 1,5 . In our prospective 51 study, 4 from a total of 96 COVID-19 dermatological consultations in the reported 52 period, 15.6% corresponded to herpes simplex/zoster diagnoses. However, we cannot 53 categorically affirm that there is an incidence increase of these diagnoses in COVID-19 54 patients, due to the lack of a control group. In our current experience, the diagnosis of 55 herpesvirus infection in COVID-19 patients does not usually involve diagnostic doubts, 56 due to the clinical presentation and reported symptoms being typical of the disease, 57 even when lesions are extensive (Figure 1) . 58

In conclusion, complementary diagnostic tests for herpesvirus and even SARS-CoV-2 59 may prove useful for clinical research, and should be encouraged if the necessary 60 resources are available. However, we believe that, regarding clinical practice, we should 61 reserve these techniques for atypical clinical presentations or cases where therapeutic 62 management would change significantly. 

Figure 1: A) A 69-year-old male with COVID-19 pneumonia and extensive orolabial HSV-1 reactivation. B) A 56-year-old female with COVID-101 19 pneumonia and herpes zoster on the trunk