Internal medicine

Pathology

Virus

Shingles

Disease

Coronavirus disease 2019 (COVID-19)

Infectious disease (medical specialty)

World Wide Web

Outbreak

Metropolitan area

Virology

Dermatology

Las vegas

2019-20 coronavirus outbreak

Computer science

Social media

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)

Medicine

Journal of Cosmetic Dermatology

On March 11, 2020, the World Health Organization declared COVID-19 a global pandemic. COVID-19 is a novel coronavirus with high infectivity and severe morbidity and mortality, especially for those over 70 years old and also for those with comorbid medical conditions such as lung disease and obesity.1 The entire world has been gripped with fear and practiced social distancing, masking, and quarantine of exposed or infected individuals in an effort to curtail the spread of the disease.2, 3 The new virus is characterized primarily by respiratory-related disease, but also may involve multiple organ systems; COVID-19 has caught the medical community by surprise due to its myriad of clinical manifestations. Additionally, COVID-19 has been associated with various cutaneous manifestations; associated cutaneous skin eruptions from natural COVID-19 infection are described as diffuse erythematous eruptions, widespread urticaria, and chickenpox-like vesicles.4, 5 Two vaccines were approved for use by the FDA on December 11th (Pfizer) and December 18th (Moderna) of 2020 to prevent COVID-19 infection and change the tide against this deadly pandemic.6, 7 At the time of our observation, two vaccines were authorized in the United States to prevent COVID-19: Moderna (94.5% effective) and Pfizer (95% effective).8, 9 Two doses of the aforementioned vaccines are required to reach optimal effectiveness. Side effects may emerge after the first and/or second dose, with common side effects including injection site pain and flu-like symptoms.10 Recently, a third vaccine by J&J has been approved for use, requiring only one dose; to our knowledge, there are no reported cases of shingles reaction to the J&J COVID-19 approved vaccine.11 In clinical trials, it was noted that the Moderna vaccine was associated with swelling in the area of facial filler injections in some patients.7 A suggested pathophysiologic mechanism involving angiotensin-signaling pathways has been posited as the etiology of filler-associated swelling; in fact, these patients have been successfully treated with angiotensin inhibitors.12 The initial Pfizer vaccine application mentioned no reported adverse facial filler reactions with vaccination.6 On 2/5/2021, the 1st case of Post-COVID-19 vaccine-related varicella-zoster virus (VZV) (Herpes Zoster (HZ) aka shingles) eruptions was seen in the Las Vegas Dermatology clinic and posted on our social media.13 Indeed on 2/16/2021, one of the authors was on local television and discussed a 2nd case of Post-COVID-19 vaccine-related HZ seen in the clinic.14 Since those initial patients, there have been a total of 5 other Post-COVID-19 vaccine-related cases seen in the Las Vegas Dermatology clinic. An additional 14 cases have been reported to us and confirmed with medical history and photographs via social media with a mean time of 6.85 days to the first signs/symptoms of shingles. (Table 1). However, in the literature, there has been only one other reported case of Post-COVID-19 vaccine shingles in Turkey.15 L shoulder injection site pain; 8–9 days PV: CP & tachycardia 12 days PV: "red blotches erupted" L axilla, L triceps, L scapula Chickenpox in 2nd grade, "hives from stress", no previous shingles vaccination, childhood rubella, measles at 47 y/o A-77-year-old man with a history of Psoriasis treated with Methotrexate, Crohn's Disease, and treated Aspergilloma presented to the clinic for evaluation of a severely painful, unilateral dermatomal herpetiform eruption in a T11 distribution from the right mid-abdomen, right flank, and right mid-back. (Figure 1) two days post his 1st dose of the Moderna COVID-19 vaccine—the patient initially developed pain in the area of what would become his shingles eruption. Per the natural course of his disease, the initial pain worsened to become severely painful 4 days post-vaccine with a classic HZ eruption seen in accompanying photographs. The patient was clinically diagnosed with Herpes Zoster and treated with a course of Valacyclovir for the virus; oral Gabapentin, Oxycodone, and topical Lidocaine 4% for the pain. Despite the shingles outbreak post-initial vaccination, the patient was still recommended to receive his second dose of the Moderna COVID-19 vaccine. A 65–year-old man with a history of shingles 35 years prior to presentation and long-standing hypertension was consulted for painful, erythematous, and clustered skin eruptions. Symptoms first began after his 2nd dose of the Pfizer COVID-19 vaccine, with pruritus 14 days post-vaccination, followed by increasing chest and back pain 3 days post-pruritus. The patient was diagnosed with HZ, later confirmed via VZV PCR, and was treated with a course of Valacyclovir for the virus, oral Gabapentin, and topical Lidocaine 4% for pain. He was the 4th patient seen in our clinic for HZ related to COVID-19 vaccination. Several other individuals contacted us via social media to share their experience, contributing to our list of Post-COVID-19 vaccine HZ eruptions (Table 1). HZ is attributed to reactivation of VZV. Primary infection with VZV results in chickenpox; once resolved, VZV establishes lifelong dormancy in multiple sensory ganglia and may re-emerge due to risk factors including increasing age, immunocompromised condition, and/or stress.16 Cases of shingles have also been seen in patients vaccinated to VZV.17 VZV and herpes viruses in general are distinguished by their ability to form latent infections. Kaposi's varicelliform eruption (KVE), also known as eczema herpetiformis, is a rare and potentially fatal reactivation of herpes virus in individuals with a history of atopic dermatitis; outbreaks of KVE have historically been seen when atopic patients were vaccinated for smallpox.18 Underlying skin conditions such as atopic dermatitis and psoriasis have also been associated with Kaposi's varicelliform eruption.18, 19 Two of our post-COVID-19 vaccinated patients have a chronic history of psoriasis and presented with earlier onset of shingles eruption compared to most other reported cases (Table 1). There have been a number of natural COVID-19 reported infections with HZ coinfection, including cases with ophthalmic involvement.20, 21 Several cases of vesicular eruptions in middle-aged patients have also been reported earlier in the course of COVID-19 infection.4 COVID-19 is associated with decreased number of lymphocytes throughout the course of infection including a decreased number of monocytes, eosinophils, and CD4/CD8 T cells.22 VZV has been shown to reduce the number of T cells, B cells, natural killer (NK) cells, and monocytes.23 It is still early in the course of vaccine distribution; besides personal experiences, delayed reactions of COVID-19 vaccination are incompletely understood. It is hypothesized that immunomodulation related to COVID-19 vaccination is associated with VZV reactivation seen in our patients. Recently, the University of Birmingham announced they will be investigating vaccine effectiveness in individuals with significant underlying diseases, transplant patients, people with liver or kidney disease, cancer, and inflammatory arthritis.24 Because of the associated morbidity and mortality seen in patients with COVID-19, and the high infectivity rate, society must be weary of misinformation by professional anti-vaccine activists that would increase vaccine hesitancy.1 Pre-clinical studies demonstrate mRNA vaccines elicit strong CD8/CD4 T-cell responses, with favorable safety profile in animals, and are rapid to design for emerging infectious diseases.25 Mass vaccination is the paramount goal, and the United States is anticipated to have enough vaccines available for all adults by the end of May 2021.26 It is likely that emerging epidemiological studies are underway. With a promising end to the pandemic, perhaps then we can better understand the relationship of COVID-19 vaccination and VZV reactivation. COVID-19 vaccination is the highest priority. Although there are no current recommendations from the CDC or other regulatory bodies, it is the authors' recommendation that at-risk patients (ie, patients over 50 years of age) obtain the shingles vaccine prior to COVID-19 vaccination. This article does not contain any studies with human or animal subjects performed by any of the authors. The authors are in compliance with the ethical standards of this journal. There is no conflict of interest of all authors. Medical images used in this publication were granted by the patient after informed consent.

20 Post‐COVID‐19 vaccine‐related shingles cases seen at the Las Vegas Dermatology clinic and sent to us via social media