J Korean Med Sci.  2022 May;37(20):e165. 10.3346/jkms.2022.37.e165.

A Case Report of Herpes Zoster Ophthalmicus and Meningitis After COVID-19 Vaccination

• You IC
• Ahn M
• Cho NC

• KMID: 2530108
• DOI: http://doi.org/10.3346/jkms.2022.37.e165

Abstract

There are several reports that herpes zoster characterized by reactivation of varicella zoster virus (VZV) following coronavirus disease 2019 (COVID-19) vaccines can occur. Herein, we report VZV meningitis, herpes zoster ophthalmicus (HZO), and late neurotrophic keratitis after receiving a second dose of messenger RNA (mRNA) COVID-19 vaccine. A 74-year-old man developed a vesicular skin rash on the forehead, scalp, nose, and left upper eyelid with a severe headache. Five days earlier, he received a second dose of the BNT162b2 mRNA vaccine on his left arm. Ocular examination revealed conjunctival hyperemia and pseudodendrite in the peripheral cornea. VZV was detected in the cerebrospinal fluid using polymerase chain reaction. The patient was diagnosed with HZO and meningitis. The patient was treated with intravenous acyclovir and topical acyclovir ointment and levofloxacin 1.5% eye drops. One month later, he developed a central epithelial defect with a rolled margin, typical of a neurotrophic ulcer. Treatment with a therapeutic contact lens and a combination of topical recombinant human epithelial growth factor and ofloxacin ointment was initiated. At six months after vaccination, the slit-lamp examination findings were stable with a mild corneal superficial stromal haze.

Keyword

COVID-19 Vaccination; Herpes Zoster Ophthalmicus; Meningitis; Neurotropic Keratitis

Figure

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  Fig. 1 Photographs of herpes zoster ophthalmicus. Initial photograph showing erythematous grouped vesicle and crust on the left side of the face in 74-year-old man.The figures are published under agreement of the patient.

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  Fig. 2 Anterior segment photography of the patient at first day. Slit-lamp examination revealed multiple pseudodendrite with rarely staining with fluorescein in the peripheral cornea.

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  Fig. 3 Anterior segment photography of the patient at one month. Neurotrophic ulcer showing central corneal smooth, oval with heaped-up epithelium at border. The figures are published under agreement of the patient.

Reference

1. Katsikas Triantafyllidis K, Giannos P, Mian IT, Kyrtsonis G, Kechagias KS. Varicella zoster virus reactivation following COVID-19 vaccination: a systematic review of case reports. Vaccines (Basel). 2021; 9(9):1013. PMID: 34579250.

2. Maruki T, Ishikane M, Suzuki T, Ujiie M, Katano H, Ohmagari N. A case of varicella zoster virus meningitis following BNT162b2 mRNA COVID-19 vaccination in an immunocompetent patient. Int J Infect Dis. 2021; 113:55–57. PMID: 34587536.

3. Desai HD, Sharma K, Shah A, Patoliya J, Patil A, Hooshanginezhad Z, et al. Can SARS-CoV-2 vaccine increase the risk of reactivation of varicella zoster? A systematic review. J Cosmet Dermatol. 2021; 20(11):3350–3361. PMID: 34719084.

4. Barda N, Dagan N, Ben-Shlomo Y, Kepten E, Waxman J, Ohana R, et al. Safety of the BNT162b2 mRNA Covid-19 vaccine in a nationwide setting. N Engl J Med. 2021; 385(12):1078–1090. PMID: 34432976.

5. Iwanaga J, Fukuoka H, Fukuoka N, Yutori H, Ibaragi S, Tubbs RS. A narrative review and clinical anatomy of herpes zoster infection following COVID-19 vaccination. Clin Anat. 2022; 35(1):45–51. PMID: 34554601.

6. Psichogiou M, Samarkos M, Mikos N, Hatzakis A. Reactivation of varicella zoster virus after vaccination for SARS-CoV-2. Vaccines (Basel). 2021; 9(6):572. PMID: 34205861.

7. Ku CC, Besser J, Abendroth A, Grose C, Arvin AM. Varicella-Zoster virus pathogenesis and immunobiology: new concepts emerging from investigations with the SCIDhu mouse model. J Virol. 2005; 79(5):2651–2658. PMID: 15708984.

8. Thimmanagari K, Veeraballi S, Roach D, Al Omour B, Slim J. Ipsilateral zoster ophthalmicus post COVID-19 vaccine in healthy young adults. Cureus. 2021; 13(7):e16725. PMID: 34471577.

9. Crooke SN, Ovsyannikova IG, Poland GA, Kennedy RB. Immunosenescence and human vaccine immune responses. Immun Ageing. 2019; 16(1):25. PMID: 31528180.

10. Zheng F, Willis A, Kunjukunju N. Acute retinal necrosis from reactivation of varicella zoster virus following BNT162b2 mRNA COVID-19 vaccination. Ocul Immunol Inflamm. Forthcoming. 2021; DOI: 10.1080/09273948.2021.2001540.

11. Sahin U, Muik A, Vogler I, Derhovanessian E, Kranz LM, Vormehr M, et al. BNT162b2 vaccine induces neutralizing antibodies and poly-specific T cells in humans. Nature. 2021; 595(7868):572–577. PMID: 34044428.

12. Jastrzebski A, Brownstein S, Ziai S, Saleh S, Lam K, Jackson WB. Reactivation of herpes zoster keratitis with corneal perforation after zoster vaccination. Cornea. 2017; 36(6):740–742. PMID: 28410358.

13. Jabbour S, Shekhawat NS, Chen A, Woreta FA. Presumed herpes zoster ophthalmicus reactivation following recombinant zoster vaccination. Cornea. 2021; 40(2):248–250. PMID: 32947398.

14. Rehman O, Arya SK, Jha UP, Nayyar S, Goel I. Herpes zoster ophthalmicus after COVID-19 vaccination: chance occurrence or more than that? Cornea. 2022; 41(2):254–256. PMID: 34690265.

15. Jabbour S, Ashton C, Balal S, Kaye A, Ahmad S. The management of neurotrophic keratitis. Curr Opin Ophthalmol. 2021; 32(4):362–368. PMID: 33966014.