Varicella Zoster Virus Reactivation in Central and Peripheral Nervous Systems Following COVID-19 Vaccination in an Immunocompetent Patient.

Abstract

Dear Editor, The increasing vaccination rate for coronavirus disease 2019 (COVID-19) worldwide is leading to concerns about adverse events. Reactivation of varicella zoster virus (VZV) as herpes zoster (HZ) after COVID-19 vaccination has been reported in a series of adult patients,1,2 especially in older subjects. VZV reactivation occurs as a wide clinical spectrum, from HZ to a central nervous system manifestation such as meningitis or encephalitis. Here we report a case of an immunocompetent young adult with both VZV meningitis and HZ following COVID-19 vaccination. A healthy 24-year-old male with normal cognition visited our emergency room (ER) presenting with a headache. His medical history was remarkable, with varicella as a child and aseptic meningitis at 12 years of age. He was vaccinated with the first dose of the PfizerBNT162b2 vaccine against SARS-CoV-2 into his left deltoid at 3 days prior to the visit. From the following day, myalgia and fatigue gradually developed. On the 4th day after vaccination, he decided to visit the ER because a headache started and small vesicles had formed on his left upper arm, just below the vaccine injection site. On presentation, the patient was febrile (37.7°C) with otherwise normal vital signs. He had no neurological deficit, but neck stiffness and positive jolt accentuation were observed. An erythematous patch with grouped vesicles suggestive of HZ was present on his left upper arm within the C5 dermatome (Fig. 1). Laboratory tests revealed a white blood cell (WBC) count of 5,700/μL (21% lymphocytes) in the complete blood count. The findings of other tests including a coagulation panel, electrolyte, chemistry panel, serology, urinalysis, and chest X-ray were within the normal ranges. Anti-VZV IgM/IgG, anti-cytomegalovirus IgM, and anti-HSV IgM antibodies were negative in the blood test. A cerebrospinal fluid (CSF) study was performed, which revealed an opening pressure of 180 mm H2O, WBC count of 11/μL, 98% lymphocytes, 50.6 mg/dL protein, and 53 mg/dL glucose, while the blood glucose level was 90 mg/dL. CSF polymerase chain reaction for VZV yielded a positive result, and a diagnosis of VZV meningitis was made. He refused admission, and so was treated with oral famciclovir. At the follow-up visit after a week, he reported a mild headache that lasted about 1 week, and then his general condition and fever had improved as the systemic VZV reactivation and meningitis resolved. This case illustrates the central and peripheral nervous system manifestations of VZV reactivation in an immunocompetent young adult following COVID-19 vaccination. To our knowledge, this is the first report of concomitant VZV meningitis and HZ following COVID-19 vaccination. Cases of HZ reactivation as adverse events following immunization were also observed during the prepandemic era for both inactivated virus vaccines such as influenza vaccines and attenuated virus vaccines such as Japanese encephalitis vacSeungyon Koh Hong Nam Kim Yoon Seob Kim Tae-Joon Kim