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CASE REPORT
Year : 2022  |  Volume : 20  |  Issue : 2  |  Page : 109-111

Herpes zoster after inactivated COVID-19 vaccination


1 Ngemplak I Community Health Center, Yogyakarta; Bhayangkara Police Hospital, Sleman, Indonesia
2 Ngemplak I Community Health Center, Yogyakarta, Indonesia

Date of Submission27-Dec-2021
Date of Decision04-Feb-2022
Date of Acceptance06-Feb-2022
Date of Web Publication07-May-2022

Correspondence Address:
Dr. Vincent Ongko Wijaya
Koroulon Kidul, Bimomartani, Ngemplak, Sleman, Yogyakarta, 55584
Indonesia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_116_21

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  Abstract 


Previous evidence has linked the relationship between newly onset skin disorder and SARS-CoV-2 infection. Cutaneous manifestations have been reported after exposure to COVID-19 vaccines that are linked to body immune responses. There is limited information about skin disorder that occurs after the COVID-19 vaccination. We report a case of varicella-zoster virus reactivation following inactivated COVID-19 vaccination in a young female patient.

Keywords: COVID-19, herpes zoster, vaccine


How to cite this article:
Wijaya VO, Putri WB, Alwafi H, Manalu EP. Herpes zoster after inactivated COVID-19 vaccination. Curr Med Issues 2022;20:109-11

How to cite this URL:
Wijaya VO, Putri WB, Alwafi H, Manalu EP. Herpes zoster after inactivated COVID-19 vaccination. Curr Med Issues [serial online] 2022 [cited 2022 May 21];20:109-11. Available from: https://www.cmijournal.org/text.asp?2022/20/2/109/344927




  Introduction Top


Since it was declared as a pandemic in March 2020, coronavirus disease (COVID-19) has spread across the globe and affected hundreds of millions of people, making the urgency for developing a safe and effective vaccine to control severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection.[1] The CoronaVac vaccine, an inactivated SARS-CoV-2 vaccine, has been approved and used in many countries. It has been found effective in reducing symptomatic COVID-19 infection, hospital admissions, and deaths in older adults. Although it requires the booster dose to maintain immunity.[2],[3]

The most commonly reported adverse events are local pain at the injection site, fever, nausea, myalgia, and fatigue.[4] Less frequently reported adverse effects include dermatological complications, such as maculopapular eruptions, morbilliform rashes, urticaria, chickenpox-like lesions, and the more recently reported reactivation of varicella-zoster virus (VZV).[5],[6] Herpes zoster (HZ) is a reactivation of latent infection with VZV, which is most commonly triggered by increased age and immunosuppression.[7] We describe a case report of uncommon adverse effects in the form of HZ eruptions after the second dose of COVID-19 vaccination in the primary care setting.


  Case Report Top


The patient, a 28-year-old female, initially received the first vaccination dose of CoronaVac, with no adverse event was reported. After 28 days, the second dose was administered to the patient. Within 9 days after the vaccine, the patient came to the clinic with local pain complaints at the injection site on the left shoulder. she had no history of previous illness, and the vaccination history was unknown. Physical examination was normal and revealed no discoloration or edema. The patient was treated with analgesic 25 mg twice daily.

Five days later, the patient came to the clinic with no resolve on her symptoms, still felt pain at the injection site, multiple small pink papular rashes with crusted vesicles started to develop on the area corresponding to C6-C7 dermatomes in the left upper arm [Figure 1]. Physical examination revealed increased sensation (allodynia) around the lesion. The diagnosis of cutaneous HZ was made based on the history taking and physical examination. Diagnostic tests for this case are not available in primary care practice. The patient was treated oral acyclovir at a dose of 800 mg five times daily for 7 days. After 6 days, the lesion had resolved, and the pain was reduced.
Figure 1: Multiple small pink papular rashes with crusted vesicles started to develop on the area corresponding to C6-C7 dermatomes in the left upper arm

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  Discussion and Conclusions Top


COVID-19 has been associated with various skin manifestations, varying from immediate or delayed local reactions, which are extremely common to urticaria, morbilliform exanthema, papulovesicular exanthemas, and purpura lesions.[8] A previous report from Brazil observed an increased number of reactivation of VZV cases and assumed an association with the COVID-19 infection.[9] Apart from the local side effects, the most cutaneous reactions secondary to SARS-CoV-2 vaccination link those associated with COVID-19. To explain these reactions, it was hypothesized that the COVID-19 spike protein induces a proinflammatory response through the blockade of a cutaneous angiotensin-converting enzyme 2 (ACE-2 inhibitor) pathway. Hence, the common immunopathological mechanisms may be involved, including host immune activation against viral particles rather than direct viral injury.[10],[11],[12]

HZ is described by multiple, painful, and itching unilateral vesicles, typically occurring in a single dermatome.[13] The mean duration of the rash ranges from 7 to 10 days and is a self-limiting disease.[14] HZ is caused by the reactivation of VZV, which tends to remain in a latent state in the dorsal root ganglia of cutaneous nerve endings following a primary episode of chickenpox.[15] Reactivation happens when the immunological mechanisms that suppress VZV replication fail to contain the virus.[15],[16] Typical risk factors include older age, immunosuppressant medication, immunocompromised conditions (e.g. HIV), and psychological stress.[16] The vaccination may induce immunomodulation that allows VZV to emerge from its latent phase and elicit HZ rash.

The papulovesicular rash described in our case is strongly related to VZV reactivation triggered by the second dose of the CoronaVac vaccine. Consistent with the average incubation period of HZ rash, from 10 to 21 days. The patient started to develop the rash in 14 days after the vaccine injection. Furthermore, the evolution of the rash is typical, starting with an urticarial-like papular rash, becoming vesicular with blisters filled with serous exudates immediately after. Moreover, the lesions developed in the root innervation of the left brachial plexus (from C6 to C7 dermatomes). This is in line with the typical HZ appearance, which follows a dermatomal distribution.

The CoronaVac vaccine is the first approved vaccination by the Indonesian government and is administered massively throughout the country. The most common adverse effects are mild-to-moderate, and mostly local, involving the site of the injection (pain, swelling, and redness) or systemic (chills, malaise, and headache) reactions. However, little is known about the factors associated with COVID-19 vaccine adverse effects.

The incidence of shingles after the COVID-19 vaccine injection is not known. More studies are needed to understand how the reactivation of the VZV and the CoronaVac vaccine are related. It is hypothesized that the vaccination-induced immune response triggered VZV reactivation, which is consistently occurs with the groups of VZV reactivation in COVID-19 patients or immunocompromised individuals.

Consent

Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.  Back to cited text no. 1
    
2.
Yigit M, Ozkaya-Parlakay A, Cosgun Y, Ince YE, Bulut YE, Senel E. Should a third booster dose be scheduled after two doses of CoronaVac? A single-center experience. J Med Virol 2022;94:287-90.  Back to cited text no. 2
    
3.
Pormohammad A, Zarei M, Ghorbani S, Mohammadi M, Razizadeh MH, Turner DL, et al. Efficacy and safety of COVID-19 vaccines: A systematic review and meta-analysis of randomized clinical trials. Vaccines (Basel) 2021;9:467.  Back to cited text no. 3
    
4.
Xia S, Duan K, Zhang Y, Zhao D, Zhang H, Xie Z, et al. Effect of an inactivated vaccine against SARS-CoV-2 on safety and immunogenicity outcomes: Interim analysis of 2 randomized clinical trials. JAMA 2020;324:951-60.  Back to cited text no. 4
    
5.
Recalcati S. Cutaneous manifestations in COVID-19: A first perspective. J Eur Acad Dermatol Venereol 2020;34:e212-3.  Back to cited text no. 5
    
6.
Sachdeva M, Gianotti R, Shah M, Bradanini L, Tosi D, Veraldi S, et al. Cutaneous manifestations of COVID-19: Report of three cases and a review of literature. J Dermatol Sci 2020;98:75-81.  Back to cited text no. 6
    
7.
Tartari F, Spadotto A, Zengarini C, Zanoni R, Guglielmo A, Adorno A, et al. Herpes zoster in COVID-19-positive patients. Int J Dermatol 2020;59:1028-9.  Back to cited text no. 7
    
8.
Bellinato F, Maurelli M, Gisondi P, Girolomoni G. Cutaneous adverse reactions associated with SARS-CoV-2 vaccines. J Clin Med 2021;10:5344.  Back to cited text no. 8
    
9.
Maia CM, Marques NP, de Lucena EH, de Rezende LF, Martelli DR, Martelli-Júnior H. Increased number of Herpes Zoster cases in Brazil related to the COVID-19 pandemic. Int J Infect Dis 2021;104:732-3.  Back to cited text no. 9
    
10.
Català A, Muñoz-Santos C, Galván-Casas C, Roncero Riesco M, Revilla Nebreda D, Solá-Truyols A, et al. Cutaneous reactions after SARS-CoV-2 vaccination: A cross-sectional Spanish nationwide study of 405 cases. Br J Dermatol 2022;186:142-52.  Back to cited text no. 10
    
11.
McMahon DE, Amerson E, Rosenbach M, Lipoff JB, Moustafa D, Tyagi A, et al. Cutaneous reactions reported after Moderna and Pfizer COVID-19 vaccination: A registry-based study of 414 cases. J Am Acad Dermatol 2021;85:46-55.  Back to cited text no. 11
    
12.
van Dam CS, Lede I, Schaar J, Al-Dulaimy M, Rösken R, Smits M. Herpes zoster after COVID vaccination. Int J Infect Dis 2021;111:169-71.  Back to cited text no. 12
    
13.
Dayan RR, Peleg R. Herpes zoster – Typical and atypical presentations. Postgrad Med 2017;129:567-71.  Back to cited text no. 13
    
14.
van Oorschot D, Vroling H, Bunge E, Diaz-Decaro J, Curran D, Yawn B. A systematic literature review of herpes zoster incidence worldwide. Hum Vaccin Immunother 2021;17:1714-32.  Back to cited text no. 14
    
15.
Wei L, Zhao J, Wu W, Zhang Y, Fu X, Chen L, et al. Decreased absolute numbers of CD3+T cells and CD8+T cells during aging in herpes zoster patients. Sci Rep 2017;7:15039.  Back to cited text no. 15
    
16.
Gershon AA, Breuer J, Cohen JI, Cohrs RJ, Gershon MD, Gilden D, et al. Varicella zoster virus infection. Nat Rev Dis Primers 2015;1:15016.  Back to cited text no. 16
    


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