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CASE SERIES REPORT
Year : 2022  |  Volume : 66  |  Issue : 1  |  Page : 83-85  

Herpes zoster following vaccination with ChAdOx1 nCoV-19 Coronavirus vaccine (recombinant)


1 Assistant Professor, Department of Dermatology, GMC, Palakkad, Kerala, India
2 Associate Professor and HOD, Department of Dermatology, GMC, Palakkad, Kerala, India
3 Junior Resident, Department of Dermatology, GMC, Palakkad, Kerala, India

Date of Submission02-Nov-2021
Date of Decision28-Nov-2021
Date of Acceptance05-Jan-2022
Date of Web Publication5-Apr-2022

Correspondence Address:
Anupa Mary Job
“Madhootty House”, Palace Buildings, GB Road, Palakkad - 678 001, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.ijph_2017_21

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   Abstract 


Ever since the emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, science has unraveled much knowledge on SARS-CoV-2 which has led to extraordinary and unprecedented progress in developing COVID-19 vaccines. Several adverse cutaneous reactions, ranging from more common local injection site reaction, neutrophilic and pustular drug reactions to flare-up of preexisting dermatoses, have been reported with currently available vaccines. We report a case series of 7 patients who developed herpes zoster (HZ) following the first dose of ChAdOx1 nCoV-19 coronavirus vaccine (recombinant). HZ following vaccination is a rare entity. The occurrence of HZ in the patients presented in this series within the time window 1–21 days after vaccination defined for increased risk and postulated dysregulation of T-cell-mediated immunity, suggests that the ChAdOx1 nCoV-19 coronavirus vaccine (recombinant) could probably be a trigger for reactivation of varicella zoster virus to cause HZ in them.

Keywords: Herpes zoster, severe acute respiratory syndrome coronavirus 2, varicella zoster virus reactivation


How to cite this article:
Job AM, Sudhamani B, Mohan M, Mohanasundaram S N. Herpes zoster following vaccination with ChAdOx1 nCoV-19 Coronavirus vaccine (recombinant). Indian J Public Health 2022;66:83-5

How to cite this URL:
Job AM, Sudhamani B, Mohan M, Mohanasundaram S N. Herpes zoster following vaccination with ChAdOx1 nCoV-19 Coronavirus vaccine (recombinant). Indian J Public Health [serial online] 2022 [cited 2022 May 18];66:83-5. Available from: https://www.ijph.in/text.asp?2022/66/1/83/342599




   Introduction Top


As the mass vaccination program against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic is progressing in leaps and bounds across the world, so also have we been recognizing adverse cutaneous reactions (ACDR) following the administration of various vaccines currently available against SARS-CoV-2. These reactions may range from more common local injection site reaction, neutrophilic and pustular drug reactions to flare-up of preexisting dermatoses. We report a case series of 7 patients who developed herpes zoster (HZ) following first dose of ChAdOx1 nCoV-19 coronavirus vaccine (recombinant). HZ following vaccination is a rare entity. The occurrence of HZ in the patients presented in this series within the time window 1–21 days after vaccination defined for increased risk and postulated dysregulation of T-cell-mediated immunity, suggests that the ChAdOx1 nCoV-19 coronavirus vaccine (recombinant) could probably be a trigger for reactivation of varicella zoster virus (VZV) to cause HZ.


   Materials and Methods Top


Patients who presented to the outpatient department of our tertiary care center in South India between June 2021 and September 2021 in whom a clinical diagnosis of HZ was made were assessed in detail with respect to their COVID-19 vaccination status. Seven among the 10 patients identified were found to have had been vaccinated with ChAdOx1 nCoV-19 coronavirus vaccine (recombinant) within 21 days before the development of symptoms and/or clinical features suggestive of HZ. Their demographics, comorbidities, and past history suggestive of a varicella zoster infection were recorded and they were evaluated in detail with respect to clinical findings and complications and given standard of care treatment for HZ.


   Observation Top


The demographic data, comorbidities, ChAdOx1 nCoV-19 coronavirus vaccine (recombinant) vaccination timings, past history of varicella zoster and vaccination against varicella zoster in past, present clinical features, examination findings, and management are tabulated in [Table 1]. There were 4 females and 3 males in this case series with age ranging from 26 years to 65 years. Two among them had systemic comorbidities (diabetes and hypertension), however, well under control. No other risk factors such as those leading to a possible immunocompromised state, recent psychological and/or physical stressors could be identified in the patients. None of them had a history of receiving vaccination against VZV in the past or any preexisting dermatoses.
Table 1: Demographic and clinical profile, examination findings of patients in the case series

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Following the first dose of ChAdOx1 nCoV-19 coronavirus vaccine (recombinant) Covishield™, five patients reported pain at the site of injection and 3 patients had mild fever lasting <24 h. No other systemic or cutaneous adverse events were reported within 48 h of postvaccination period. Patients developed HZ within two to 16 days of the first dose of ChAdOx1 nCoV-19 coronavirus vaccine (recombinant) COVISHIELD™, with a mean duration of 9 days. Interestingly, it was observed that the vaccine was administered in all patients on the left arm intramuscularly and all patients developed HZ involving ipsilateral left thoracic dermatomes [Figure 1].
Figure 1: Crusted grouped vesicles distributed along the left T10 dermatome.

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All the patients were treated with antivirals (Acyclovir 800 mg 5 times a day for 1 week) and none of them developed complications of HZ during the follow-up period. Case 4 and case 7 had secondary pyoderma and irritant contact dermatitis following topical application of turmeric, respectively, at the time of first visit. Hence, they were additionally treated with oral and topical antibiotics. Three among the 7 patients who further received the second dose of the vaccine did not develop any significant systemic or cutaneous adverse reactions.

Owing to financial constraints, none of the patients could undergo testing for anti-SARS CoV-2 receptor binding domain spike protein following vaccination.


   Discussion Top


Ever since the emergence of SARS-CoV-2 pandemic, science has unraveled much knowledge on SARS-CoV-2 which has led to extraordinary and unprecedented progress in developing COVID-19 vaccines.[1] The first mass vaccination program started in India in January 2021 and now least 8 different vaccines candidates are currently available against the SARS-Cov-2, including the nonreplicating chimpanzee adenovirus vaccine vector (ChAdOx1) COVISHIELD™, inactivated human adenovirus Ad5 and Ad26 with Spike proteins inserts SPUTNIK V™ and Inactivated-virus vaccine COVAXIN™.[2]

Several ACDR has been reported ever since the use of these vaccines. A pragmatic review by Niebel et al. details various such reactions ranging from more common local injection site reaction, neutrophilic and pustular drug reactions to flare-up of preexisting dermatoses (e.g., chronic urticaria, psoriasis vulgaris, atopic dermatitis).[3] Other reported ACDRs include morbilliform rash, erythromelalgia, chillbains, pityriasis rosea, erythema multiforme, vasculitis, contact dermatitis, filler reactions, etc.[4] Advancing age, iatrogenic or disease related immunosuppression which translates to impaired cell mediated immunity may trigger VZV reactivation to cause HZ. In their meta-analysis on risk factors for HZ, Marra et al. noted that multiple risk factors placed individuals at an increased risk of HZ rather than one single risk factor.[5] In our series, 4 patients were above 50 years of age. The phenomenon of “immunosenescence” explains that advancing age places elderly population at risk for HZ due to the dampened effect of VZV-specific T-cell immunity (CD4, CD8, and memory T-cells) to a level below the clinical threshold of maintaining virus latency.[5] The current studies available in literature do not quantify the minimum age limit threshold for such an occurrence. However, a recent meta-analysis notes the incidence of HZ to be 6–8/1000 person-years at 60 years of age and 8–12/1000 person-years at 80 years of age.[6]

Vaccines are uncommon triggers for VZV reactivation. Three cases of HZ following vaccination against hepatitis A, rabies, and influenza have been reported by Rodríguez-Jiménez et al.[7] Our case series noted that HZ occurred within a time window 1–21 days after vaccination defined for increased risk and the reported T-cell-mediated immunity involvement suggesting that COVID-19 vaccination was a probable cause of occurrence of HZ.[8] As of September 2021, 52 cases of VZV reactivation following the COVID-19 vaccine have been reported to the best of our knowledge, most of them secondary to mRNA vaccines. Studies observing a robust cellular response with increased CD8+ T-cell and T helper Type 1 CD4 + T-cells after booster doses for Pfizer and Moderna vaccines may make the possible incidence of HZ reactivation following COVID-19 vaccination a contradictory phenomenon.[9],[10] Such an observed phenomenological paradox may suggest that VZV-specific CD8+ cells are not, temporarily, capable of controlling VZV after the massive shift of naïve CD8+ cells in the setting of SARS-COV-2 vaccination. Another possible hypothesis focuses on toll-like receptors signaling, which is often implicated in the reactivation process of herpes viruses as a maintenance mechanism in the host.[10]

The thoracic segment involvement in all our patients is an observation consistent with similar observation in earlier Indian studies. However, if the left thoracic segment involvement corresponding to the ipsilateral site of vaccination administration may not be discounted as a fortuitous event, it may be worthwhile exploring deeper into a possible pathogenesis leading to a “localized immunosuppression” which may have triggered the HZ in the patients presented in this series.

To the best of our knowledge, this is the first and largest case series describing HZ following the ChAdOx1 nCoV-19 coronavirus vaccine (recombinant) Covishield™. With this case series, we hope to create awareness among health-care professionals and encourage additional reporting of HZ after vaccination.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Skegg D, Gluckman P, Boulton G, Hackmann H, Karim SS, Piot P, et al. Future scenarios for the COVID-19 pandemic. Lancet 2021;397:777-8.  Back to cited text no. 1
    
2.
Kumar VM, Pandi-Perumal SR, Trakht I, Thyagarajan SP. Strategy for COVID-19 vaccination in India: The country with the second highest population and number of cases. NPJ Vaccines 2021;6:60.  Back to cited text no. 2
    
3.
Niebel D, Novak N, Wilhelmi J, Ziob J, Wilsmann-Theis D, Bieber T, et al. Cutaneous adverse reactions to COVID-19 vaccines: Insights from an immuno-dermatological perspective. Vaccines (Basel) 2021;9:944.  Back to cited text no. 3
    
4.
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. 4
    
5.
Marra F, Parhar K, Huang B, Vadlamudi N. Risk factors for herpes zoster infection: A meta-analysis. Open Forum Infect Dis 2020;7:ofaa005.  Back to cited text no. 5
    
6.
Bardach AE, Palermo C, Alconada T, Sandoval M, Balan DJ, Nieto Guevara J, et al. Herpes zoster epidemiology in Latin America: A systematic review and meta-analysis. PLoS One 2021;16:e0255877.  Back to cited text no. 6
    
7.
Rodríguez-Jiménez P, Chicharro P, Cabrera LM, Seguí M, Morales-Caballero Á, Llamas-Velasco M, et al. Varicella-zoster virus reactivation after SARS-CoV-2 BNT162b2 mRNA vaccination: Report of 5 cases. JAAD Case Rep 2021;12:58-9.  Back to cited text no. 7
    
8.
Psichogiou M, Samarkos M, Mikos N, Hatzakis A. Reactivation of varicella zoster virus after vaccination for SARS-CoV-2. Vaccines (Basel) 2021;9:572.  Back to cited text no. 8
    
9.
Pardi N, Hogan MJ, Porter FW, Weissman D. mRNA vaccines – A new era in vaccinology. Nat Rev Drug Discov 2018;17:261-79.  Back to cited text no. 9
    
10.
Katsikas Triantafyllidis K, Giannos P, Mian IT, Kyrtsonis G, Kechagias KS. Varicella zoster virus reactivation following COVID-19 vaccination: A systematic review of case reports. Vaccines (Basel) 2021;9:1013.  Back to cited text no. 10
    


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