Recurrent Herpes Zoster Ophthalmicus Preceded by Anabolic Steroids and High-Dose L-Arginine

Abstract

Purpose. To report a case of a 34-year-old male with recurrent herpes zoster ophthalmicus (HZO) preceded by a 6-week cycle of anabolic steroids and high-dose amino acid supplementation. Case Presentation. A 34-year-old man presented to our institution for left eye pain for one week associated with a vesicular rash in the V1 dermatome, respecting the midline. The patient had no significant past medical or past ocular history, including systemic immunosuppressive agents or HIV. However, prior to the onset of his symptoms the patient had completed a 6-week course of anabolic steroids including trenbolone, deca-durabolin, and testosterone as well as high-dose arginine supplementation averaging more than 40 grams a day. The best-corrected vision was 20/25 OS with slit-lamp examination remarkable for punctate staining and pseudodendrites at 6 o’clock, outside the visual axis. The patient was treated with oral acyclovir 800 mg five times a day for seven days along with prednisolone QID and moxifloxacin QID which was tapered over a month. Four months after resolution, the patient developed a recurrent HZO keratitis preceded by another cycle of anabolic steroids and amino acid supplementation. Conclusion. In vitro L-arginine supplementation has been associated with the proliferation and virulence of a variety of herpes viruses. Anabolic steroids have also been demonstrated by various studies to negatively affect cell-mediated immunity necessary to prevent viral infection. Thus, it is possible that anabolic steroids in conjunction with increased L-arginine intake may have precipitated a recurrent HZO in a previously healthy, immunocompetent individual.

Varicella-Zoster Virus Encephalitis in an Immunocompetent Adult with Disseminated Cutaneous Herpes Zoster after Testosterone Booster Supplements: Case Report

“…Few cases attributed the use of daily testosterone supplements or using AAS with reactivation of varicella-zoster. A study by LoBue et al [ 1 ] described a case of recurrent herpes zoster ophthalmicus preceded by anabolic steroids and the use of testosterone 500 mg a week. In relation to our case, this patient did not develop complete dissemination of the virus, and he had an additional use of AAS.…”

“…Athletes and bodybuilders use different types of performance-enhancing drugs, mainly to boost their strength and muscle growth. Anabolic-androgenic steroids (AAS) contain a combination of synthetic and natural hormones that are like testosterone in structure [ 1 ]. A variety of side effects have been linked to AAS use, such as organ damage (e.g., liver, heart, and kidneys), alopecia, higher risk of tendinitis and tendon rupture, severe acne, and immune suppression [ 2 , 3 ].…”

L‐lysine: Its antagonism with L‐arginine in controlling viral infection. Narrative literature review

“…17,18 When reactivated, in addition to dermal involvement, it can also compromise the ocular mucosa with corneal sequelae and must be controlled to avoid blindness. 19,20 HHV-6/7 (Roseovirus, Subfamily Beta) has also been drawing attention during the COVID-19 pandemic. Causer of the sixth disease 21 Like all herpesviruses, HHV-6/7 establishes lifelong latency where viral genome expression is limited but is delivered to daughter cells without the production of infectious virus.…”

“…The viral manifestations reported here such as pityriasis rosea, herpes zoster and herpes simplex can be treated and controlled with antivirals such as acyclovir, a polymerase inhibitor. 19,20,53,54 In the case of herpes simplex in addition to acyclovir, other DNA polymerase inhibitors, virus fusion inhibitors or nucleoside analogues can be used, some of which are reserved for immunocompromised patients with severe herpes simplex. 15,31,54…”

“…58 The first antiviral used against HHV-1/2 viruses was idoxuridine, a nucleoside analogue capable of inhibiting viral nucleic acid synthesis, but, due to systemic toxicity, its use was limited. 59 Acyclovir is one of the most prescribed antivirals for the treatment of herpesvirus manifestations 19,20,25,27,60,61 being considered gold standard, 62,63 but this kind of drug, which inhibits viral replication at certain levels, has a narrow spectrum of action, does not act on latent viruses, causes undesirable side effects, and continued use may promote drug resistance. 2 It is known that prolonged use of this agent will promote viral resistance due to the alteration in the viral thymidine kinase, which prevents the action of acyclovir.…”