Farshid Etaee1, Tarek Naguib2, Steven Daveluy3. 1. Department of Medicine, Yale University, New Haven, Connecticut. 2. Department of Medicine, Texas Tech University Health Sciences Center, Amarillo, Texas. 3. Department of Dermatology, Wayne State University, Detroit, Michigan.
To the Editor: We read with great interest the report by Lladó et al, “Varicella zoster virus reactivation and mRNA vaccines as a trigger.” Vaccination can result in herpes zoster (HZ) reactivation as previously described for the vaccines for hepatitis A, rabies, and influenza. A wide variety of cutaneous adverse events after COVID-19 vaccination are being described. To our knowledge, more than 60 cases of HZ reactivation after the COVID-19 vaccination have been reported to date, including messenger RNA, inactivated, and adenovirus-based vaccines. Only 2 of the cases were secondary to an inactivated vaccine, and 2 cases were after the adenovirus-based vaccine. In a case-control study of 186 patients with HZ, one-fifth of the patients developed HZ after vaccination against COVID-19 within the study period, and vaccination with COVID-19 vaccines had a significant statistical association with HZ activation.Our patient is a 35-year–old healthy man who presented with severe stinging pain from the right side of the abdomen to his back. He had received the first dose of the live attenuated varicella vaccine (VARIVAX) 3 weeks earlier because he was a health care worker with no antivaricella IgG antibodies. He had also received his second dose of the BioNTech-Pfizer COVID-19 vaccine 6 weeks earlier. At the time of presentation, the patient denied any recent trauma, medical or cosmetic procedures, or foreign travel. Methocarbamol and topical diclofenac gel were prescribed. Three days later, he developed multiple mildly tender plaques on an erythematous base corresponding to a T5 to T11 dermatomal distribution. He had no history of immunodeficiency, malignancy, or immunosuppressive therapy. He was initiated on valacyclovir at 1 g thrice daily. In 3 days, the erythema began to resolve. Both pain and rash completely resolved after 2 weeks.We report a case of HZ dermatitis after BioNTech-Pfizer and varicella vaccinations in an immunocompetent person who was previously seronegative and who had no history of chickenpox. In this case, the COVID-19 vaccination may have influenced the development of HZ after the varicella vaccination. Arguments that support a link among COVID-19 vaccination, varicella vaccination, and HZ include the following: (1) rapid onset of rash after vaccination, (2) eruption on the same side as the vaccinated arm for both vaccines, (3) several previous cases of HZ after COVID-19 vaccination, and (4) cases of HZ reported after various vaccinations. In 3 immunocompetent children presenting with HZ after varicella vaccination, the varicella virus DNA from the vaccine strain was detected in the skin vesicles by polymerase chain reaction. These children developed HZ 7 to 19 months after vaccination. The presentation only 3 weeks after varicella vaccination in our case raises the concern about the potential effects of previous COVID-19 vaccination. The pathogenesis of this reaction is currently unclear, but it is possible that the immune dysregulation caused by the COVID-19 vaccine may have contributed to HZ after the varicella vaccine in our case. Clinicians should be aware of potential HZ after COVID-19 vaccination in individuals with recent varicella vaccination.