Varicella-zoster-virus belongs to the Herpesviridae family which tends to reactivate even many years after the primary infection and is capable of inducing different complications such as skin lesions to meningoencephalitis (11). Different presentations of VZV reactivation have been reported from characteristic skin lesions to RHS following COVID-19 vaccination. The exact pathogenesis of RHS following COVID-19 vaccination is not clear but some indirect links between herpes virus reactivation, COVID-19 vaccination, and autoimmunity could be drawn which needs more studies to be tested (11). Hyperviscosity induced by mRNA vaccinations is another suggested related mechanism (12). Nevertheless, this case report presented a healthy young immunocompetent man who developed RHS following Sinopharm vaccination.
His first symptoms were pain and skin lesions. Zona is the most reported presentation of VZV reactivation following COVID-19 vaccination. The systematic review by Desai et al gathered clinical data of 54 cases that developed reactivation of VZV following COVID-19 vaccination. The most reported vaccine was the mRNA vaccine and the mean interval between vaccination to presentation of symptoms was almost seven days (13). Additionally, the systematic review by Katsikas Triantafyllidis et al reported similar results on 91 cases. Comorbidities such as hypertension, autoimmune conditions, and, receiving immunosuppressants were considered risk factors for VZV reactivation. However, younger cases with no significant past medical history were also reported in the review similar to our case. They also found that valacyclovir was the most used treatment (14). The review article by Iwanaga et al gathered data from 399 reported cases of herpes zoster infection following COVID-19 vaccination. The majority of cases reported the herpes zoster infection following the BNT162b2 vaccine. The authors concluded that the duration since vaccination to VZV reactivation could be 1 to 24 days, as in our case it took 21 days (15).
Other than cutaneous manifestation of VZV reactivation among patients with COVID-19 or following vaccination, RHS has been rarely reported in the literature. There have been six cases of RHS presented after COVID-19 infection. Al Rida Ayoub et al just recently reported an interesting case of an asymptomatic 60-year-old man, who was diagnosed with COVID-19 based on a positive PCR test. Three days later he developed a skin rash and facial weakness and was treated with valacyclovir for RHS. The authors also made a thorough literature search and found five case reports of RHS presented among COVID-19 patients (16). The case reported by Mehta et al reported a 32-year-old man with left-sided lower motor neuron facial palsy which occurred after COVID-19 and eventually was resolved after five days of using steroids (17). The case described by Alonzo‑Correa was a 25‑year‑old woman with positive COVID-19 PCR who developed herpes zoster oticus, otalgia, and acute peripheral facial nerve palsy which consequently improved after administering steroids (18). Other three cases could be found in the review done by Al Rida Ayoub et al and it generally could be concluded that the management of most cases was administering valacyclovir with favorable outcomes (16, 19–21).
Additionally, RHS has also been reported following COVID-19 vaccination in three previously published articles. Rodríguez-Martín et al reported a 78-year-old woman who developed otalgia and other related symptoms including House-Brackmann grade IV right peripheral facial paralysis, three days after BNT162b2 mRNA vaccination (22). Woo et al described a 37-year-old man presenting with RHS two days after BNT162b2 mRNA vaccination. A swab sample from exudates was studied with PCR and it was positive for VZV (23). Finally, Lakhoua et al reported a 65-year-old who was presented with RHS seven days after BNT162b2 mRNA vaccination. He was treated with valacyclovir and pregabalin with improvement in lesions but he was still complaining of post-herpetic neuralgia at six-month follow-up (24). To the best of our knowledge, our case is the first describing RHS following Sinopharm vaccination in a healthy young man.
Our case had also parotitis which was evaluated with ultrasonography. Some case reports have described acute parotitis following the COVID-19. Lechien et al reported three cases with COVID-19 who developed parotitis. Symptoms lasted 3 to 10 days and all three were managed with paracetamol. MRI was done for three cases and intraparotid lymphadenitis was shown in all of them. It was suggested that intraparotid lymphadenitis due to COVID-19 could be the cause of the presentation of parotitis (25). A 32-year-old man with COVID-19 was reported by Taha Ismail and Mohamed Naser who had unilateral parotitis. Ultrasonography showed an enlarged and diffuse hypoechoic parotid gland structure. He received intravenous steroids and his symptoms were resolved on day seven (26). Also, Capaccio et al described a 26-year-old man with positive COVID-19 PCR who was initially presented with acute unilateral parotitis (27). Another 79-year-old man has been reported to be admitted due to COVID-19 and required non-invasive mechanical ventilation. Five days after admission he developed sudden unilateral parotitis and he expired after nine days (28). The treatment of parotitis in our case consisted of conservative management with analgesia which was resolved on day 29th with no further complications.
The interesting point of this case was the associated unilateral parotitis which rarely has been reported in association with VZV reactivation in the literature. It is not clear if these two problems are linked or not, however, it seems that both could be attributed to COVID-19. To the best of our knowledge, only two studies have reported simultaneous presentation of parotitis and VZV reactivation in adults (29, 30). The case reported by Banno et al described a 43-year-old man who had unilateral right parotitis simultaneous with ophthalmicus involvement due to VZV. The serologic test showed positive antibodies for VZV in the absence of r herpes simplex virus 1 and 2 and mumps. He was treated with valacyclovir, antibiotics, and, steroids which led to complete improvement in symptoms after three weeks (29). Additionally, the case reported by Tally et al was a 36-year-old woman with VZV ophthalmicus and unilateral left parotitis. The neck computed tomography confirmed the parotitis with no other concerning problem. She received valacyclovir, antibiotics, and, analgesia and she was symptom-free after three weeks follow-up (30). The exact mechanism of this simultaneous presentation is not known. The auriculotemporal nerve involvement following the VZV reactivation of the trigeminal nerve is one proposed theory. However, the immune response to the VZV reactivation, or also the possibility of autoimmunity following the COVID-19 vaccination might be another explanation (5, 31). Nevertheless, being familiar with such rare presentations could be useful for timely diagnosis and proper management.