Herpes zoster reactivation after mRNA-1273 (Moderna) SARS-CoV-2 vaccination

To 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.² Within the last 2 months, there have been a number of case reports additionally highlighting herpes zoster virus reactivation after administration of both the mRNA and inactivated versions of the COVID-19 vaccine. Both Eid et al³ and Bostan and Yalici-Armagan⁴ observed cutaneous herpes zoster reactions after COVID-19 vaccination in male patients in their 70s. Recently, Furer et al⁵ published a case series of patients with autoimmune inflammatory rheumatic diseases who presented with reactivation of herpes zoster virus after COVID-19 vaccination. We concur with Rodríguez-Jiménez et al¹ that the association of cases with herpes zoster after the COVID-19 vaccination is inconclusive and potentially coincidental, but we would like to add to the literature a report of a similar case in a patient that presented to our dermatology clinic.

Our patient is an 81-year-old Caucasian man with a past medical history of diabetes, hypertension, and coronary artery disease who presented with a dermatomal rash characteristic of herpes zoster 3 days after receiving the second dose of the mRNA-1273 (Moderna) COVID-19 vaccine. Interestingly, the patient had previously received 2 doses of the recombinant zoster vaccine (Shingrix; GSK), with his last dose in 2019. In addition, the patient reported having varicella as a child. At the time of presentation, the patient denied any recent trauma, medical/cosmetic procedures, medication changes, or foreign travel. His other medical history was otherwise unremarkable. No other household contacts were affected. The rash resolved 3 weeks after its initial presentation without any intervention.

This patient serves as an additional example of herpes zoster reactivation after the COVID-19 vaccination. Despite subtle differences in age and presentation of the current reported cases, we believe that we can add another case to the literature to make dermatologists and other clinicians aware of this potential side effect of COVID-19 vaccination. The pathogenesis of this reaction is currently unclear, but it is possible that the immunomodulatory response generated via these vaccines may lead to the reactivation of latent herpes zoster. Rodríguez-Jiménez et al¹ note that herpes zoster virus reactivation does not present as a common reaction in other current vaccination modalities. However, as clinicians, if we have learned anything from the last year, it is to expect the unexpected and adapt accordingly to provide the best care for our patients.

Conflicts of interest

None disclosed.