Herpes zoster in COPD cases: Does the use of high-dose inhaled corticosteroids associated asymptomatic hyperglycemia during treatment or COPD-related comorbidity predispose reactivation?

Chronic obstructive pulmonary disease (COPD) is more prevalent in India, especially nonsmoker COPD due to heterogeneous exposure to risk factors as compared to smokers COPD described in the western population. Although COPD starts and primarily involves the lungs, it is considered systemic disease due to shared pathophysiological pathways for many systemic illnesses. Systemic inflammatory burden and dysregulated inflammatory response are predominant mechanisms in COPD, especially in uncontrolled type or cases received inadequate or halfheartedly treatment will have cardiovascular, endocrinal, hematological, and neurovascular complications. COPD itself or treatment options used in COPD will predispose to recurrent viral infections. Inhaled and systemic steroids are commonly used for treatment of steroids which will cause immunosuppression resulting in an increased risk of viral and bacterial infections. In this case series, we have reported COPD patients with Herpes zoster infection. Our first case was received high-dose inhaled corticosteroids fluticasone propionate 500 µg two times without oral steroids in the recent past. She was having hyperglycemia with raised glycated hemoglobin, glycohemoglobin, hemoglobin A1C or A1c (HBA1C) levels. Hyperglycemia secondary to the use of high-dose fluticasone propionate would be the cause of herpes zoster in this patient. In the second case, the patient was getting adequate and rational inhaled medicines such as salmeterol plus fluticasone propionate 250 µg two times with tiotropium. His COPD illness has been stable over many years due to routine flu vaccinations. He has developed cardiovascular complications of COPD such as pulmonary hypertension and cardiac dysfunction. He never received oral steroids in the recent past. Ongoing systemic effects of COPD due to inflammatory surge may be the reason for Herpes zoster in this patient. This patient also responded to oral and topical acyclovir. We recommend Herpes zoster vaccination in all COPD patients irrespective of disease severity and symptom status for prevention of reactivation of herpes zoster.