Varicella zoster virus reactivation and mRNA vaccines as a trigger

Abstract

To the Editor: We read with great interest the report by Channa et al,1Channa L. Torre K. Rothe M. Herpes zoster reactivation after mRNA-1273 (Moderna) SARS-CoV-2 vaccination.JAAD Case Rep. 2021; Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar “Herpes zoster reactivation after mRNA-1273 (Moderna) SARS-CoV-2 vaccination.” Currently, vaccination against SARS-CoV-2 is being carried out worldwide. As a consequence, a wide variety of cutaneous adverse effects after COVID-19 vaccination are being described.2Lee C. Cotter D. Basa J. Greenberg H.L. 20 post-COVID-19 vaccine-related shingles cases seen at the Las Vegas Dermatology clinic and sent to us via social media.J Cosmet Dermatol. 2021; 20: 1960-1964Crossref PubMed Scopus (41) Google Scholar Over the course of the last months, a fair number of herpes zoster cases developing after the administration of COVID-19 vaccines have been reported.1Channa L. Torre K. Rothe M. Herpes zoster reactivation after mRNA-1273 (Moderna) SARS-CoV-2 vaccination.JAAD Case Rep. 2021; Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar, 2Lee C. Cotter D. Basa J. Greenberg H.L. 20 post-COVID-19 vaccine-related shingles cases seen at the Las Vegas Dermatology clinic and sent to us via social media.J Cosmet Dermatol. 2021; 20: 1960-1964Crossref PubMed Scopus (41) Google Scholar, 3McMahon D.E. Amerson E. Rosenbach M. 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: 46-55Abstract Full Text Full Text PDF PubMed Scopus (609) Google Scholar, 4Psichogiou M. Samarkos M. Mikos N. Hatzakis A. Reactivation of varicella zoster virus after vaccination for SARS-CoV-2.Vaccines. 2021; 9: 1-8Crossref Scopus (88) Google Scholar, 5Rodríguez-Jiménez P. Chicharro P. Cabrera L.M. et al.Varicella-zoster virus reactivation after SARS-CoV-2 BNT162b2 mRNA vaccination: report of 5 cases.JAAD Case Rep. 2021; 12: 58-59Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar Varicella zoster virus (VZV) reactivation is triggered mainly by impaired cell-mediated immunity, whether it be age-related, disease-related, or iatrogenic. Vaccines are not a common trigger for VZV reactivation, and with the exception of VZV reactivation following the VZV vaccine, few cases have been reported. Rodriguez-Jiménez et al5Rodríguez-Jiménez P. Chicharro P. Cabrera L.M. et al.Varicella-zoster virus reactivation after SARS-CoV-2 BNT162b2 mRNA vaccination: report of 5 cases.JAAD Case Rep. 2021; 12: 58-59Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar reported 3 cases of herpes zoster following vaccination against hepatitis A, rabies, and influenza, respectively. To our knowledge, 52 cases of VZV reactivation following the COVID-19 vaccine have been reported to date. Interestingly, only 1 of 52 cases, was secondary to an inactivated vaccine, whereas the rest of them were secondary to mRNA vaccines (ie, Pfizer's BNT162b2 and Moderna's mRNA-1273)1Channa L. Torre K. Rothe M. Herpes zoster reactivation after mRNA-1273 (Moderna) SARS-CoV-2 vaccination.JAAD Case Rep. 2021; Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar (Table I). The majority of the cases developed after the first dose versus the second dose of the vaccine (35 vs 15, respectively; 2 unknown), and there was no significant sex predominance (22 women vs 20 men; 10 not specified). However, it must be taken into account that some of the series may suffer from a selection bias.Table IReported cases of VZV reactivation after COVID-19 mRNA vaccinationAuthorsnVaccine typeFirst doseSecond doseTime to onset (days)[range (median)]Age (years) [range (median)]SexLee et al2Lee C. Cotter D. Basa J. Greenberg H.L. 20 post-COVID-19 vaccine-related shingles cases seen at the Las Vegas Dermatology clinic and sent to us via social media.J Cosmet Dermatol. 2021; 20: 1960-1964Crossref PubMed Scopus (41) Google Scholar20mRNA-1273 (n = 14) and BNT162b2 (n = 6)1552-26 (6.9)37-77 (56)10 M, 10 FMcMahon et al3McMahon D.E. Amerson E. Rosenbach M. 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: 46-55Abstract Full Text Full Text PDF PubMed Scopus (609) Google Scholar10mRNA-1273 (n = 5) and BNT162b2 (n = 5)64NSNSNSPsichogion et al4Psichogiou M. Samarkos M. Mikos N. Hatzakis A. Reactivation of varicella zoster virus after vaccination for SARS-CoV-2.Vaccines. 2021; 9: 1-8Crossref Scopus (88) Google Scholar7BNT162b2527-20 (9)51-94 (77)4 M, 3 FRodriguez-Jiménez et al5Rodríguez-Jiménez P. Chicharro P. Cabrera L.M. et al.Varicella-zoster virus reactivation after SARS-CoV-2 BNT162b2 mRNA vaccination: report of 5 cases.JAAD Case Rep. 2021; 12: 58-59Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar5BNT162b2321-16 (5.4)39-58 (48)2 M, 3 FOthers2Lee C. Cotter D. Basa J. Greenberg H.L. 20 post-COVID-19 vaccine-related shingles cases seen at the Las Vegas Dermatology clinic and sent to us via social media.J Cosmet Dermatol. 2021; 20: 1960-1964Crossref PubMed Scopus (41) Google Scholar, 3McMahon D.E. Amerson E. Rosenbach M. 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: 46-55Abstract Full Text Full Text PDF PubMed Scopus (609) Google Scholar, 4Psichogiou M. Samarkos M. Mikos N. Hatzakis A. Reactivation of varicella zoster virus after vaccination for SARS-CoV-2.Vaccines. 2021; 9: 1-8Crossref Scopus (88) Google Scholar, 5Rodríguez-Jiménez P. Chicharro P. Cabrera L.M. et al.Varicella-zoster virus reactivation after SARS-CoV-2 BNT162b2 mRNA vaccination: report of 5 cases.JAAD Case Rep. 2021; 12: 58-59Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar9mRNA (not specified), mRNA-1273, and BNT162b2712-14 (5)36-81 (49)3 M, 6 FF, Female; M, male; NS, not specified. Open table in a new tab F, Female; M, male; NS, not specified. Surprisingly, most of the patients were middle-aged (ie, in their fifth to sixth decades of life), as someone would expect to observe the highest incidence rates among the oldest patients. Time to the onset of symptoms was highly variable, ranging from 1 to 26 days and showing a median of 6 days. The difference in the time of onset having received the first or the second vaccine dose was not consistent between the series. Lastly, the sample distribution was, overall, highly heterogeneous in terms of comorbidities, past history of herpes zoster, and previous VZV vaccination. VZV reactivation in patients infected with SARS-CoV-2 has been described. The suggested pathogenic mechanism was induced lymphopenia and the functional impairment of lymphocytes, particularly CD8+ T cells and natural killer cells. With regard to COVID-19 vaccines, it is postulated that, as a product of a massive shifting of naïve CD8+ cells, VZV-specific CD8+ cells are not temporarily capable of controlling VZV.4Psichogiou M. Samarkos M. Mikos N. Hatzakis A. Reactivation of varicella zoster virus after vaccination for SARS-CoV-2.Vaccines. 2021; 9: 1-8Crossref Scopus (88) Google Scholar The question of why VZV reactivation occurs almost exclusively with mRNA-based COVID-19 vaccines and not with viral vector or inactivated COVID-19 vaccines remains to be answered. We are aware that the relationship between COVID-19 vaccination, particularly with mRNA-based vaccines, and VZV reactivation could be coincidental. Nonetheless, as new evidence continues to emerge, it becomes harder to deny. In our opinion, clinicians should be aware of this possible adverse effect of mRNA vaccines. None disclosed. Herpes zoster reactivation after mRNA-1273 (Moderna) SARS-CoV-2 vaccinationJAAD Case ReportsVol. 15PreviewTo the Editor: We read with great interest the recent case series by Rodríguez-Jiménez et al,1 “Varicella-zoster virus reactivation after SARS-Cov2 BNT162b2 mRNA vaccination: report of five cases.” During this unprecedented era of scientific development and rapid administration of vaccines to combat COVID-19, cutaneous reactions have been increasingly reported.1 Reports of “COVID arm,” morbilliform rashes, and delayed local cutaneous reactions have recently been added to the growing literature on COVID-19 vaccination side effects. Full-Text PDF Open Access

Topics & Concepts