Oral lesions of herpes zoster in COVID-19 patients or truly associated to the disease?

In response to the report of Martín Carreras‐Presas, Amaro Sánchez, López ‐Sánchez, Jané ‐Salas, and Somacarrera Pérez (2020) in which they present 3 cases with vesicobullous oral lesions associated with SARS‐Cov‐2 infection and with very interesting findings, however, we cannot consider the possibility that findings be intrinsically related to COVID‐19 disease. The first two cases presented did not have laboratory confirmation of COVID‐19 infection, but the authors reported that these patients had compatible signs and symptoms. The presented oral lesions with the diagnostic hypothesis of recurrent herpetic stomatitis are more consistent with the oral manifestations of herpes zoster, due to the unilateral lesions on the palate in keratinized mucosa and complaint of pain. In addition, these patients never had these lesions before and are in the sixth decade of life.

Varicella‐like skin lesions are also reported by Tang et al. (2020), as may indicate a correlation between the findings by Martín Carreras‐Presas et al. (2020), contributes with hypothesis of herpes zoster (herpes varicella‐zoster‐HVZ3) is implied in both infections (Cohen, 2013). As the clinical manifestations of COVID‐19 are very variable and can occur from asymptomatic cases (most of the cases), to cases with rapid and severe evolution with important disorders, mainly in the respiratory system, we believe that most patients were not fully evaluated in terms of oral mucosa. Due to the severity of the disease, we agree that such an assessment becomes a difficulty for clinicians, and often without painful symptoms, patients end up not reporting lesions in the mouth.

Given the above, there are some questions: Is the clinical manifestation of lesions compatible with herpes zoster an initial manifestation or herpes zoster is a disease strongly associated with COVID‐19? Another very interesting point is if the lesion is a manifestation related to the stress of the pandemic situation itself, also commented by Martín Carreras‐Presas et al. (2020). Latest, it could be a truly clinical manifestation of COVID‐19 itself, being a herpes zoster‐like lesion. Although we do not consider that the symptoms of chickenpox and herpes zoster are caused only by COVID‐19, the development of symptoms can promote by the expression of VZV in COVID‐19.

In this pandemic moment, there is a search for an increasing understanding of the disease, mainly in the matter of signs and symptoms. Most often, the absence of taste and smell has been strongly associated as one of the symptoms that may be associated with the disease (Vaira, Salzano, & De Riu, 2020). Finally, we need to be very precise regarding new signs and symptoms that may appear, including from the oral region, we as clinicians are always attentive to the reports of patients with COVID‐19.

CONFLICT OF INTEREST

The authors declare no conflicts of interest.

AUTHOR CONTRIBUTION

Luis Felipe das Chagas e Silva Carvalho: Conceptualization; Data curation; Formal analysis; Resources; Supervision; Validation; Visualization; Writing‐original draft; Writing‐review & editing. Dárcio Kitakawa: Conceptualization; Formal analysis; Investigation; Resources; Supervision; Validation; Writing‐review & editing. Luiz Antonio Guimarães Cabral: Supervision; Writing‐original draft.