key: cord-0699440-eqc0srca
authors: Koh, Seungyon; Kim, Hong Nam; Kim, Yoon Seob; Kim, Tae-Joon
title: Varicella Zoster Virus Reactivation in Central and Peripheral Nervous Systems Following COVID-19 Vaccination in an Immunocompetent Patient
date: 2021-12-30
journal: J Clin Neurol
DOI: 10.3988/jcn.2022.18.1.99
sha: dbd63c1c748d248c2c24943fae0f911edef467c6
doc_id: 699440
cord_uid: eqc0srca

nan

cine. 3 Previous studies of HZ development following COV-ID-19 vaccination found that patients experienced a mild and treatable course of HZ at 7-20 days, usually after the first dose. 1 VZV meningitis accompanying HZ rarely occurs in immunocompetent patients. VZV meningitis accounts for 5%-6% of all cases of VZV reactivation, 4 and sometimes progresses to encephalitis or cerebral vasculitis, which are considerably associated with neurological morbidity or even mortality. 5 Reactivation of VZV is largely dependent on T-cell-mediated immunity, which is known to be modulated by COVID-19 vaccination. 6 Immunocompromisation, either by acquired causes of immunodeficiency or immunosenescence, is a ma-jor contributor to VZV reactivation. 7 Previous reports have postulated that the mechanism underlying VZV reactivation includes immunomodulation causing a cytokine storm or lymphopenia, similar to the effect of COVID-19 infection 2 or a massive shift of naïve T cells to VZV-specific T cells causing an immune reconstitution inflammatory syndrome (IRIS)like phenomenon. 1 Although SARS-CoV-2-specific T-cell activity and VZV-specific T-cell activity were not investigated in our patient, we speculate that T-cell shifting caused by the COVID-19 vaccination in a healthy immune system can allow immune escape of the latent VZV infection.

Another outstanding feature in our patient is that the location of HZ coincided with the arm into which the COV-ID-19 vaccine had been injected. This pattern of HZ dermatomal distribution in the vaccinated arm is sometimes also seen in live attenuated varicella vaccination in children, 8 and was reported in a previous COVID-19-vaccinated patient. 9 In VZV-vaccinated children, the attenuated viruses replicated in the local injected arm are transported to the cervical dorsal root ganglia. Although our patient was actively immunized with VZV by varicella infection as a child, we assume that indolent VZV infection at the cervical ganglia was triggered by the systemic activation of inflammatory cascades by the COVID-19 vaccine. This coincidence observed in our patient also brings attention to the localized cutaneous adverse events of the Pfizer-BNT162b2 vaccine, known as the 'COVID-arm, ' which is a delayed hypersensitivity reaction involving perivascular lymphocytic infiltrates. 10 To our knowledge, this is the first report of central and peripheral nervous system complications of VZV reactivation in a patient vaccinated against COVID-19. This case underpins the importance of diagnostic evaluations of adverse events following immunization, even in immunocompetent patients.

This study was reviewed and approved by the Institutional Review Board of Ajou University Medical Center (IRB no. AJIRB-MED-EXP-21-328). The requirement for informed consent was waived by the board due to the retrospective nature of the study.

The datasets generated or analyzed during the study are available from the corresponding author on reasonable request. 

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The authors have no potential conflicts of interest to disclose.

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