Clinical Characteristics and Determinants of Complications in Pediatric Herpes Zoster Requiring Hospitalization

Background: Herpes zoster (HZ) is uncommon in children and is typically considered a mild disease. However, hospitalized cases may be associated with complications. Data on herpes zoster in children in Eastern Europe are limited. This study aimed to describe the clinical features, complications, and factors associated with severity in hospitalized pediatric HZ. Methods: We conducted a retrospective cohort study including children (<18 years) hospitalized with HZ between January 2015 and December 2025, at a tertiary infectious diseases center in Bucharest, Romania. Demographic, clinical, laboratory, and outcome data were extracted from medical records. Univariable and multivariable analyses were performed to identify factors associated with complications and prolonged hospital stay. Results: Among 612 pediatric HZ cases, 92 (15.0%) required hospitalization. The median age was 8.8 years (IQR 4.8–13.2), and 52.2% were male. Overall, 43.5% developed complications, most commonly bacterial superinfection (30.4%), followed by neurological and ophthalmological involvement. Herpes zoster sine herpete was identified in 4.3% of cases and was associated with central nervous system involvement. Headache (OR = 4.34, p = 0.025) and lymphopenia (OR = 3.01, p = 0.020) were independently associated with complications. Patients with complications had longer hospital stays (median of 6 vs. 4 days, p = 0.002). In multivariable analysis, complications, immunocompromised status, and chronic conditions were associated with prolonged hospitalization. Conclusions: Herpes zoster in children is generally mild and has a favorable prognosis; however, hospitalized cases are often associated with complications, especially bacterial superinfections and neurological involvement. These findings derive from a selected population and highlight the role of clinical and host-related factors in shaping outcomes in hospitalized pediatric herpes zoster.