Herpes Zoster Reactivation After COVID-19 Vaccination Reported in Some Patients With Autoimmune Inflammatory Rheumatic Diseases

Risk of stroke after herpes zoster in patients with autoimmune diseases
Risk of stroke after herpes zoster in patients with autoimmune diseases
Study authors reported on the reactivation of herpes zoster following mRNA COVID-19 vaccination in some patients with autoimmune inflammatory rheumatic diseases.

A potential association between vaccination against COVID-19 and herpes zoster (HZ) reactivation in patients with stable autoimmune inflammatory rheumatic diseases (AIIRD) was examined, and the results of the report were published in Rheumatology. Study authors noted that among patients with AIIRD who received the Pfizer-BioNTech COVID-19 vaccine, the prevalence of herpes zoster was 1.2%.

There are currently no comprehensive data regarding the safety of messenger RNA (mRNA)-based vaccines in patients with AIIRD.

Authors of the current report initiated a postvaccination monitoring study at 2 medical centers in Israel. Beginning December 2020, consecutive patients with AIIRD were invited to enroll in an observational study to assess potential adverse effects of mRNA vaccination. Control participants without AIIRD were also selected from the same sites. The trial is ongoing, though the results presented herein are from the first 6 weeks of follow-up for each patient. Patients and control participants were followed up with the development of HZ. Prevalence rates were calculated for each group.  

A total of 491 patients with AIIRD and 99 control participants were followed up with for 6 weeks after vaccination. Overall, 6 patients with AIIRD developed first-episode HZ after vaccination, at an overall prevalence rate of 1.2%. None of the control participants developed HZ. All patients who developed HZ were women with stable disease. Mean age of participants was 49±11 years and the distribution of AIIRD diagnoses was 4 with rheumatoid arthritis, 1 with Sjögren syndrome, and 1 with undifferentiated connective disease. Five cases developed HZ after the first vaccination dose, and 1 developed HZ after the second dose.

In the majority of cases (n=5), HZ infection was mild. However, 1 participant experienced HZ ophthalmicus, without corneal involvement; the patient had rheumatoid arthritis and was receiving treatment with tofacitinib during the study. No cases of disseminated HZ disease or postherpetic neuralgia were observed. Among the 5 patients who developed HZ after first dose, the second dose was completed without additional complications. Five patients received antiviral treatment for HZ infection, all of whom experienced symptom resolution within 6 weeks. One patient did not receive HZ treatment and reported symptom resolution within 3 weeks.  

These results suggest that a causal link may exist between COVID-19 vaccination and HZ reactivation among patients with AIIRD. However, epidemiologic studies are necessary to clarify this association.

Study limitations included an unstructured study design, the lack of inclusion of unvaccinated patients with AIIRD, the diagnosis of HZ not including histologic or molecular confirmation, and the potential underreporting of HZ cases among the general and AIIRD populations.

“While the causality between both events cannot be proved based on a small number of cases, further vigilance and safety monitoring of COVID-19 vaccination side effects is warranted,” the authors wrote. “Clinical registry of safety of COVID-19 vaccination among patients with AIIRD will provide further insight into this open question.”


Furer V, Zisman D, Kibari A, Rimar D, Paran Y, Elkayam O. Herpes zoster following BNT162b2 mRNA Covid-19 vaccination in patients with autoimmune inflammatory rheumatic diseases: a case series. Rheumatology (Oxford). Published online April 12, 2021. doi:10.1093/rheumatology/keab345