A narrative review and clinical anatomy of herpes zoster infection following COVID-19 vaccination

Ramsay-hunt-syndrome associated with unilateral parotitis following COVID-19 vaccine: a case report

BACKGROUND

Varicella-zoster-virus (VZV) reactivation is a recognized complication following COVID-19 vaccination; however, Ramsay-hunt-syndrome (RHS) rarely has been reported.

CASE PRESENTATION

This case presents a 36-year-old immunocompetent man with features of RHS three weeks following the second dose of the BBIBP-CorV (Sinopharm) vaccine. Interestingly, he developed acute unilateral parotitis on his left side and the ultrasonography showed a 55*44*18 mm parotid gland with decreased parenchymal echogenicity. He was treated with valacyclovir, and after seven days he was discharged. Also, his parotitis was resolved by day 29 following the presentation of the first symptoms with no further complications.

CONCLUSION

The possibility of VZV reactivation after COVID-19 vaccination is an important point and it should be noted that this reactivation might present in unusual clinical scenarios.

Neurological manifestations associated with COVID-19 vaccine

INTRODUCTION

Coronavirus disease 2019 (COVID-19) has spread rapidly, giving rise to a pandemic, causing significant morbidity and mortality. In this context, many vaccines have emerged to try to deal with this disease.

OBJECTIVE

To review the reported cases of neurological manifestations after the application of COVID-19 vaccines, describing clinical, analytical and neuroimaging findings and health outcomes.

METHODS

We carried out a review through bibliographic searches in PubMed.

RESULTS

We found 86 articles, including 13 809 patients with a wide spectrum of neurological manifestations temporally associated with COVID-19 vaccination. Most occurred in women (63.89%), with a median age of 50 years. The most frequently reported adverse events were Bell's palsy 4936/13 809 (35.7%), headache (4067/13 809), cerebrovascular events 2412/13 809 (17.47%), Guillain-Barré syndrome 868/13 809 (6.28%), central nervous system demyelination 258/13 809 (1.86%) and functional neurological disorder 398/13 809 (2.88%). Most of the published cases occurred in temporal association with the Pfizer vaccine (BNT162b2), followed by the AstraZeneca vaccine (ChAdOX1-S).

CONCLUSIONS

It is not possible to establish a causal relationship between these adverse events and COVID-19 vaccines with the currently existing data, nor to calculate the frequency of appearance of these disorders. However, it is necessary for health professionals to be familiar with these events, facilitating their early diagnosis and treatment. Large controlled epidemiological studies are necessary to establish a possible causal relationship between vaccination against COVID-19 and neurological adverse events.

An insight into COVID-19 host immunity at single-cell resolution

Host immunity helps the body to fight against COVID-19. Single-cell transcriptomics has provided the scope of investigating cellular and molecular underpinnings of host immune response against SARS-CoV-2 infection at high resolution. In this review, we have systematically described the virus-induced dysregulation of relative abundance as well as molecular behavior of each innate and adaptive immune cell type and cell state during COVID-19 infection and for different vaccinations, based on single-cell studies published in last three-four years. Identification and characterization of these disease-associated specific cell populations might help to design better, efficient, and targeted therapeutic avenues.

Herpes zoster in the context of immune reconstitution inflammatory syndrome in patients with rheumatic diseases: a single-center retrospective study

Immune reconstitution inflammatory syndrome (IRIS) experienced in rheumatology practice is diverse and includes opportunistic infections such as herpes zoster (HZ). This study aimed to explore the risk of HZ in patients with rheumatic diseases in the perspective of IRIS. The study retrospectively reviewed the clinical courses of 20 patients with HZ and investigated the IRIS triggers such as the reduction or discontinuation of immunosuppressive drugs within 3 months and coronavirus disease 2019 (COVID-19) vaccination within 4 weeks prior to HZ development. Disease activity of the underlying rheumatic disease at HZ onset was evaluated using the physician's global assessment. Thirteen patients developed HZ after reducing or discontinuing immunosuppressive drugs, with mild and stable disease activity. In four of these cases, disease activity increased after dose reduction or discontinuation, and HZ subsequently developed. Two of the seven patients who did not reduce or discontinue immunosuppressive drugs received the COVID-19 vaccination. Fifteen patients (75%) had at least one of the two IRIS triggers. Four of the five patients who developed HZ without any IRIS triggers were at HZ risk. To conclude, IRIS, caused by the reduction or discontinuation of immunosuppressive drugs, may be involved in the development of HZ in rheumatology practice.

[Clinical presentation and treatment of herpes zoster and postherpetic neuralgia]

Herpes zoster (HZ) is a common disease caused by reactivation of varicella zoster virus. Diagnosis is usually based on the typical clinical presentation. Standard treatment includes antiviral, topical and analgesic therapies. As a complication, postherpetic neuralgia (PHN) can result from acute HZ infection, particularly in older and/or immunocompromised people. This can seriously impair the quality of life of those affected and requires adequate analgesia. In addition to the genesis, clinical presentation and treatment recommendations for HZ and PHN, this article also deals in particular with the vaccination prophylaxis recommended by the standing vaccination commission of the Robert Koch Institute (STIKO).

Ocular manifestations of COVID-19

There is an increasing body of knowledge regarding how COVID-19 may be associated with ocular disease of varying severity and duration. This article discusses the literature on the ocular manifestations associated with COVID-19, including appraisal of the current evidence, suggested mechanisms of action, associated comorbidities and risk factors, timing from initial infection to diagnosis and clinical red flags. The current literature primarily comprises case reports and case series which inevitably lack control groups and evidence to support causality. However, these early data have prompted the development of larger population-based and laboratory studies that are emerging. As new data become available, a better appraisal of the true effects of COVID-19 on the eye will be possible. While the COVID-19 pandemic was officially declared no longer a "global health emergency" by the World Health Organization (WHO) in May 2023, case numbers continue to rise. Reinfection with different variants is predicted to lead to a growing cumulative burden of disease, particularly as more chronic, multi-organ sequelae become apparent with potentially significant ocular implications. COVID-19 ocular manifestations are postulated to be due to three main mechanisms: firstly, there is a dysregulated immune response to the initial infection linked to inflammatory eye disease; secondly, patients with COVID-19 have a greater tendency towards a hypercoagulable state, leading to prothrombotic events; thirdly, patients with severe COVID-19 requiring hospitalisation and are immunosuppressed due to administered corticosteroids or comorbidities such as diabetes mellitus are at an increased risk of secondary infections, including endophthalmitis and rhino-orbital-mucormycosis. Reported ophthalmic associations with COVID-19, therefore, include a range of conditions such as conjunctivitis, scleritis, uveitis, endogenous endophthalmitis, corneal graft rejection, retinal artery and vein occlusion, non-arteritic ischaemic optic neuropathy, glaucoma, neurological and orbital sequelae. With the need to consider telemedicine consultation in view of COVID-19's infectivity, understanding the range of ocular conditions that may present during or following infection is essential to ensure patients are appropriately triaged, with prompt in-person ocular examination for management of potentially sight-threatening and life-threatening diseases.

Association of Vestibular Neuritis Following COVID-19 Vaccination

Among the various side-effects of coronavirus disease 2019 (COVID-19) vaccinations, vestibular neuritis (VN) has been found to have some interesting association with the vaccinations. This paper mainly focuses on exploring different associations between COVID-19 vaccination and VN. A systematic search was conducted on electronic databases including PubMed, Google Scholar, and Cochrane using MeSH terms for case reports published until July 2023. A total of 6 case reports involving 7 individuals from 6 different countries were documented. Reports were analyzed to identify presenting symptoms, diagnosis, treatment, and pathophysiological mechanisms related to the relevant issues. The studies included a diverse range of individuals with ages ranging from 40 to 61 years, with an average age of 51 years and a male predominance. The average time between vaccination and symptom onset was 6.35 days. Prominent clinical features observed in the case reports included acute onset vertigo, nausea, vomiting, nystagmus, and gait instability. Diagnostic studies primarily involved vestibular test and brain imaging. Available treatment options consisted of vestibular suppressants, steroids and vestibular rehabilitation. This review highlights the diverse and clinically relevant associations between COVID-19 vaccination and vestibular neuritis. The findings underscore the importance of conducting further studies to explore the causative links in this correlation and gain a better understanding of the relationship.

Viral reactivation following COVID-19 vaccination: a review of the current literature

Currently, four vaccines for COVID-19 have been licensed by the European Medicines Agency: two viral vector-based vaccines and two mRNA-based vaccines. Since their approval, several cutaneous reactions related to vaccination have been reported in the literature. Among these, viral reactivations are one of the most frequent. The aim of this article was to investigate the current literature regarding viral reactivations following COVID-19 vaccination, focusing attention on pityriasis rosea (PR), herpes zoster and herpes simplex. A comprehensive literature search using various databases was performed and we included metanalyses, reviews, letters to the editor, real-life studies, case series and reports. A total of 48 articles involving 2067 patients were selected. Of these, 32, 6 and 17 articles reported varicella zoster virus (VZV) reactivation (1758 patients), herpes simplex virus (HSV) (238 patients) onset and PR (71 patients), respectively (some articles discussed more than one of these three reactivations). Possible pathogenetic mechanisms underlying viral reactivation are still not understood. Also, the possible correlations between vaccination and viral reactivation should be clarified. Certainly, vaccination should not be discouraged.

Clinical features and outcomes of COVID-19 patients with concomitant herpesvirus co-infection or reactivation: A systematic review

Background

Since the first case of COVID-19 was diagnosed in Wuhan, China in late 2019, concomitant infections with Herpesviridae were documented that were presented from simple skin manifestations to severe life-threatening conditions that may lead to mortality. In this systematic review, we have included studies conducted in different parts of the world to find out the association of clinical features and outcomes of COVID-19 infection and concomitant Herpesviridae infection.

Methods

A comprehensive search was conducted in electronic databases including Medline through PubMed, Cochrane database, Scopus and Web of science (core collection). Two review authors independently screened the articles and extracted data. The Risk of bias assessment was done by using RoBANS tool.

Results

A total of 919 studies were retrieved and 19 studies were included having data of 539 patients who were infected with both COVID-19 and Herpesviridae. Herpes Simplex-1, Varicella Zoster, Cytomegalovirus, Epstein-Barr virus and Human Herpes Virus-6 were the detected viruses in the included studies. Cytomegalovirus (CMV) reactivation was the most detected concomitant infection. In case of reactivation with more than one Herpes virus mortality among patients were detected along with single viral infection in some studies. Significant association was noted in dosage and usage of steroid and Herpesviridae reactivation in COVID-19 patients. Blood markers such as D-dimer, CRP along with length of stay in the ICU and usage of invasive mechanical ventilation were found to be the significantly associated markers.

Conclusion

Findings from this study will aid clinicians to assess and treat COVID-19 cases with co-infections.

Clinicopathological characteristics of cutaneous complications following COVID-19 vaccination: A case series

INTRODUCTION

Several vaccine-related cutaneous adverse events occurred following the widespread use of vaccines to prevent coronavirus disease 2019 (COVID-19). This case series reports 25 patients with de novo or accentuated dermatologic conditions after receiving the Sinopharm, Sputnik V, AstraZeneca, or BIV1-CovIran vaccine in Iran.

METHODS AND RESULTS

Twenty-five eligible patients with a mean age of 46.80 years were investigated. The cutaneous adverse events included pityriasis rosea, zoster, viral exanthema, urticaria, bullous pemphigoid, pemphigus vulgaris, and acute generalized exanthematous pustulosis. The manifestations appeared 14.45 ± 6.98 and 20.79 ± 22.18 days following injection of the first and second doses of COVID-19 vaccines, respectively. All patients experienced new cases of cutaneous disease other than two who developed flare-ups of lichen planus and psoriasis.

CONCLUSION

Several cutaneous reactions, ranging from allergic events to skin diseases, have been reported following the injection of COVID-19 vaccines. Focal injection-site reactions are the most common cutaneous adverse events; however, de-novo skin diseases and a flare-up of preexisting cutaneous disorders have also been described. Although many cases of COVID-19 vaccine-related cutaneous diseases have been published, our zoster/lichen planus and AGEP cases after vaccination are interesting. A more detailed understanding of cutaneous adverse events following COVID-19 vaccination will facilitate better diagnosis and management.

The potential association between herpes zoster and COVID-19 vaccination

Objective

Little is known about the dermatological manifestations associated with COVID-19 vaccines. The aim of the study was to determine how many cases of herpes zoster (HZ) occurred after COVID-19 vaccination and to see if there was a possible link.

Methods

A retrospective cohort study was performed by archive scan between 2016 and 2020, and between January 2021 and January 2022. Patients diagnosed with HZ were enrolled and their demographic and medical history including age, sex, previous systemic disease, history of COVID-19 vaccination prior to HZ symptom onset, COVID-19 vaccine type as mRNA or inactive, time to HZ onset after vaccination, and number of COVID-19 vaccines before HZ symptom onset were recorded.

Results

The average annual number of HZ cases from 2016 to 2020 was 271, but the number of HZ cases in 2021 was 338, reflecting an increase. The number of HZ patients with a known history of COVID-19 vaccination in 2021 was 117 and their mean age was 57.6 ± 14.2 years. Females were 59.8% (n = 70) and 28.2% (n = 33) had chronic diseases. A positive history of COVID-19 vaccination was present in 35.9% (n = 42) of HZ patients, 11.1% (n = 13) had received mRNA vaccines and 24.8% (n = 29) had received inactive COVID-19 vaccine. Mean time to HZ after COVID-19 vaccination was 24.6 ± 16.3 days.

Conclusion

An important finding of this study is the high rate (35.9%) of COVID-19 vaccination among people diagnosed with HZ. As COVID-19 vaccination may be associated with reactivation of varicella zoster virus, the vaccination history should be obtained in HZ patients.

Self-DNA driven inflammation in COVID-19 and after mRNA-based vaccination: lessons for non-COVID-19 pathologies

The coronavirus disease 2019 (COVID-19) pandemic triggered an unprecedented concentration of economic and research efforts to generate knowledge at unequalled speed on deregulated interferon type I signalling and nuclear factor kappa light chain enhancer in B-cells (NF-κB)-driven interleukin (IL)-1β, IL-6, IL-18 secretion causing cytokine storms. The translation of the knowledge on how the resulting systemic inflammation can lead to life-threatening complications into novel treatments and vaccine technologies is underway. Nevertheless, previously existing knowledge on the role of cytoplasmatic or circulating self-DNA as a pro-inflammatory damage-associated molecular pattern (DAMP) was largely ignored. Pathologies reported 'de novo' for patients infected with Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV)-2 to be outcomes of self-DNA-driven inflammation in fact had been linked earlier to self-DNA in different contexts, e.g., the infection with Human Immunodeficiency Virus (HIV)-1, sterile inflammation, and autoimmune diseases. I highlight particularly how synergies with other DAMPs can render immunogenic properties to normally non-immunogenic extracellular self-DNA, and I discuss the shared features of the gp41 unit of the HIV-1 envelope protein and the SARS-CoV 2 Spike protein that enable HIV-1 and SARS-CoV-2 to interact with cell or nuclear membranes, trigger syncytia formation, inflict damage to their host's DNA, and trigger inflammation - likely for their own benefit. These similarities motivate speculations that similar mechanisms to those driven by gp41 can explain how inflammatory self-DNA contributes to some of most frequent adverse events after vaccination with the BNT162b2 mRNA (Pfizer/BioNTech) or the mRNA-1273 (Moderna) vaccine, i.e., myocarditis, herpes zoster, rheumatoid arthritis, autoimmune nephritis or hepatitis, new-onset systemic lupus erythematosus, and flare-ups of psoriasis or lupus. The hope is to motivate a wider application of the lessons learned from the experiences with COVID-19 and the new mRNA vaccines to combat future non-COVID-19 diseases.

Herpes Zoster after COVID-19 Infection or Vaccination: A Prospective Cohort Study in a Tertiary Dermatology Clinic

Background

Herpes zoster (HZ) has been observed to occur after COVID-19 infection and vaccination; however, knowledge regarding the demographic data, clinical presentations, and treatment outcomes of HZ is limited.

Objective

To compare the demographic data, clinical manifestations, treatments, and outcomes of patients with and without HZ within 14 days of COVID-19 infection or vaccination.

Methods

This prospective cohort study involving patients diagnosed with cutaneous HZ was conducted at a dermatology clinic from October 2021 to January 2023.

Results

Among a total of 232 patients with HZ, the median age was 62.0 years and 59.1% were female. HZ developed in 23 (9.9%) and four (1.7%) patients after COVID-19 vaccination and infection, respectively. The mean duration from vaccination and the median duration from infection to HZ onset were 5.7 and 8.5 days, respectively. The proportion of female patients was significantly higher in the group of patients with COVID-19 vaccination or infection than in those without such a history (P = 0.035). Patients who developed HZ following the recent COVID-19 infection had a median age of 42.5 years, which was lower than that of the other groups. Dissemination occurred in 8.7% of the patients after COVID-19 vaccination. HZ recurrence was reported in five cases, of which 80% had been vaccinated or infected with COVID-19 during the previous 21 days. All patients had similar durations of antiviral treatment, crust-off time, and duration of neuralgia.

Conclusions

HZ after COVID-19 vaccination is more frequently observed in females, while HZ after COVID-19 infection tends to occur in younger patients. Disseminated HZ is more common in patients recently vaccinated against COVID-19. COVID-19 vaccination or infection may trigger recurrent HZ infection.

SARS-CoV-2 Vaccination and the Multi-Hit Hypothesis of Oncogenesis

Cancer is a complex and dynamic disease. The "hallmarks of cancer" were proposed by Hanahan and Weinberg (2000) as a group of biological competencies that human cells attain as they progress from normalcy to neoplastic transformation. These competencies include self-sufficiency in proliferative signaling, insensitivity to growth-suppressive signals and immune surveillance, the ability to evade cell death, enabling replicative immortality, reprogramming energy metabolism, inducing angiogenesis, and activating tissue invasion and metastasis. Underlying these competencies are genome instability, which expedites their acquisition, and inflammation, which fosters their function(s). Additionally, cancer exhibits another dimension of complexity: a heterogeneous repertoire of infiltrating and resident host cells, secreted factors, and extracellular matrix, known as the tumor microenvironment, that through a dynamic and reciprocal relationship with cancer cells supports immortality, local invasion, and metastatic dissemination. This staggering intricacy calls for caution when advising all people with cancer (or a previous history of cancer) to receive the COVID-19 primary vaccine series plus additional booster doses. Moreover, because these patients were not included in the pivotal clinical trials, considerable uncertainty remains regarding vaccine efficacy, safety, and the risk of interactions with anticancer therapies, which could reduce the value and innocuity of either medical treatment. After reviewing the available literature, we are particularly concerned that certain COVID-19 vaccines may generate a pro-tumorigenic milieu (i.e., a specific environment that could lead to neoplastic transformation) that predisposes some (stable) oncologic patients and survivors to cancer progression, recurrence, and/or metastasis. This hypothesis is based on biological plausibility and fulfillment of the multi-hit hypothesis of oncogenesis (i.e., induction of lymphopenia and inflammation, downregulation of angiotensin-converting enzyme 2 (ACE2) expression, activation of oncogenic cascades, sequestration of tumor suppressor proteins, dysregulation of the RNA-G quadruplex-protein binding system, alteration of type I interferon responses, unsilencing of retrotransposable elements, etc.) together with growing evidence and safety reports filed to Vaccine Adverse Effects Report System (VAERS) suggesting that some cancer patients experienced disease exacerbation or recurrence following COVID-19 vaccination. In light of the above and because some of these concerns (i.e., alteration of oncogenic pathways, promotion of inflammatory cascades, and dysregulation of the renin-angiotensin system) also apply to cancer patients infected with SARS-CoV-2, we encourage the scientific and medical community to urgently evaluate the impact of both COVID-19 and COVID-19 vaccination on cancer biology and tumor registries, adjusting public health recommendations accordingly.

Herpes Zoster Reactivation After mRNA and Adenovirus-Vectored Coronavirus Disease 2019 Vaccination: Analysis of National Health Insurance Database

BACKGROUND

Our study aimed to determine the risk of herpes zoster reactivation and coronavirus disease 2019 (COVID-19) vaccination (mRNA vaccine [BNT162b2] and adenovirus-vectored vaccine [ChAdOx1 nCoV-19]).

METHODS

This retrospective study analyzed herpes zoster cases diagnosed between 26 February 2021 and 30 June 2021 and registered in the National Health Insurance Service database. A matched case-control study with a 1:3 matching ratio and a propensity score matching (PSM) study with a 1:1 ratio of vaccinated and unvaccinated individuals were performed.

RESULTS

In the matched case control analysis, BNT162b2 was associated with an increased risk of herpes zoster reactivation (first dose adjusted odds ratio [aOR], 1.11; 95% confidence interval [CI], 1.06-1.15; second dose aOR, 1.17; 95% CI, 1.12-1.23). PSM analysis revealed a statistically significant increase in risk within 18 days following any vaccination (adjusted hazard ratio [aHR], 1.09; 95% CI, 1.02-1.16). BNT162b2 was associated with an increased risk at 18 days postvaccination (aHR, 1.65; 95% CI, 1.35-2.02) and second dose (aHR, 1.10; 95% CI, 1.02-1.19). However, the risk did not increase in both analyses of ChAdOx1 vaccination.

CONCLUSIONS

mRNA COVID-19 vaccination possibly increases the risk of herpes zoster reactivation, and thus close follow-up for herpes zoster reactivation is required.

Oral adverse events following COVID-19 and influenza vaccination in Australia

Vaccine hesitancy, spurred by misinterpretation of Adverse Events (AEs), threatens public health. Despite sporadic reports of oral AEs post-COVID-19 vaccination, systematic analysis is scarce. This study evaluates these AEs using the Australian Database of Adverse Event Notifications (DAEN). A secondary analysis of DAEN data was conducted, with the analysis period commencing from the start of the COVID-19 vaccination rollout in February 2021 and the inception of the influenza vaccine database in 1971, both through until December 2022. The focus of the analysis was on oral AEs related to COVID-19 and influenza vaccines. Reports were extracted according to a predefined schema and then stratified by vaccine type, sex, and age. Oral paresthesia was the most common oral AE after COVID-19 vaccination (75.28 per 10,000 reports), followed by dysgeusia (73.96), swollen tongue (51.55), lip swelling (49.43), taste disorder (27.32), ageusia (25.85), dry mouth (24.75), mouth ulceration (18.97), oral hypoaesthesia (15.60), and oral herpes (12.74). While COVID-19 and influenza vaccines shared most oral AEs, taste-related AEs, dry mouth, and oral herpes were significantly more common after COVID-19 vaccination. mRNA vaccines yielded more oral AEs than other types. Females had higher oral AE incidence. Most oral AEs did not differ significantly between COVID-19 and influenza vaccination. However, specific oral AEs, particularly taste-related, dry mouth, and oral herpes, were more prevalent after COVID-19 vaccination compared with seasonal influenza, especially in females and mRNA vaccine recipients.

Can Google Trends analysis confirm the public's need for information about the rare association of facial nerve paralysis with COVID-19 or the COVID-19 vaccination?

Facial nerve paralysis or Bell's palsy have been suggested as possible consequences of SARS-CoV-2 infections, as well as possible side effects of COVID-19 vaccinations. Google Trends data have been used to evaluate worldwide levels of public awareness for these topics for pre- and post-pandemic years. The results demonstrate a relatively low public interest in facial nerve paralysis in comparison to other more common COVID-19 related topics. Some peaks of interest in Bell's palsy can most likely be explained as triggered by the media. Therefore, Google Trends has shown public's relatively low awareness of this rare neurological phenomenon during the pandemic.

Safety after BBIBP-CorV (Sinopharm) COVID-19 Vaccine in Adolescents Aged 10-17 Years in Thailand

Coronavirus disease 2019 affected child health and impacted learning because of the resulting onsite school closures. This prospective cohort study included children aged 10-17 who received two 4 µg doses of BBIBP-CorV administered intramuscularly 21-28 days apart. To assess vaccine safety, 36,808 participants were then followed with paper- and web-based online questionnaire surveys that captured local and systemic reactogenicities following vaccine administration on days 1, 7, and 30. Among participants, 76% (27,880) reported reactogenicity within the first 24 h and 7 days following the first dose. Half (51.41%) of participants experienced pain at the injection site; the majority of cases were mild in severity. Injection site tenderness (37.93%) was another common local reaction. Fatigue (37.89%), myalgia (33.56%), and headache (26.76%) were the most common systemic reactions. On days 2-7 after the first dose, 25.85% of participants experienced adverse reactions. Following the second dose, reactogenicity was 7.6% and 1.09% within 24 h and between days 2-7. The majority of reactions were of mild to moderate severity. We report that two doses of the BBIBP-CorV caused mild to moderate side effects in adolescents in Thailand. The findings confirm the vaccine's safety profile in this age group.

[NEUROLOGICAL MANIFESTATIONS ASSOCIATED WITH COVID-19 VACCINE]

INTRODUCTION

Coronavirus disease 2019 (COVID-19) has spread rapidly, giving rise to a pandemic, causing significant morbidity and mortality. In this context, many vaccines have emerged to try to deal with this disease.

OBJECTIVE

To review the reported cases of neurological manifestations after the application of COVID-19 vaccines, describing clinical, analytical and neuroimaging findings and health outcomes.

METHODS

We carried out a review through bibliographic searches in PubMed.

RESULTS

We found 86 articles, including 13,809 patients with a wide spectrum of neurological manifestations temporally associated with COVID-19 vaccination. Most occurred in women (63.89%), with a median age of 50 years. The most frequently reported adverse events were Bell's palsy 4936/13809 (35.7%), headache (4067/13809), cerebrovascular events 2412/13809 (17.47%), Guillain-Barré syndrome 868/13809 (6.28%), central nervous system demyelination 258/13809 (1.86%) and functional neurological disorder 398/13809 (2.88%). Most of the published cases occurred in temporal association with the Pfizer vaccine (BNT162b2), followed by the AstraZeneca vaccine (ChAdOX1 nCoV-19).

CONCLUSIONS

It is not possible to establish a causal relationship between these adverse events and COVID-19 vaccines with the currently existing data, nor to calculate the frequency of appearance of these disorders. However, it is necessary for health professionals to be familiar with these events, facilitating their early diagnosis and treatment. Large controlled epidemiological studies are necessary to establish a possible causal relationship between vaccination against COVID-19 and neurological adverse events.

Oral lesions after COVID-19 vaccination: Immune mechanisms and clinical approach

COVID-19 vaccination, although is a promising tool to overcome the pandemic, has side effects. There are increasing reports of oral lesions after COVID-19 vaccination. The aim of this review is to identify the occurrence of some oral lesions after COVID-19 vaccination, and highlight the underlying immune mechanisms involved. A narrative literature review was performed by searching electronic databases including PubMed, Scopus and Web of Science to investigate the oral lesions after COVID-19 vaccination. The inclusion criteria were original studies, including the case reports, case series, letter to the editor, and cross-sectional studies. The exclusion criteria included the studies which examined the oral lesions caused by COVID-19 infection. The information, including the number of participant(s) receiving vaccine, type of vaccine, dose number, side effect(s), time of onset following vaccination, healing time, treatment strategies for the existing lesions, and related mechanisms were then summarized in a data extraction sheet. The results of this review showed that some vaccines had side effects with oral involvement such as pemphigus vulgaris, bullous pemphigoid, herpes zoster, lichen planus, Stevens-Johnson syndrome and Behçet's disease. Future research needs to elucidate the physiopathology of oral manifestations after the COVID-19 vaccination, and better understand the risk factors associated with such responses. Sometimes vaccine's side effects may be due to the nocebo effect, which means that the person expects some adverse events to occur following the vaccine administration.

Oral Adverse Events Following COVID-19 Vaccination: Analysis of VAERS Reports

Background

Oral adverse events (AEs) following COVID-19 vaccination have been sporadically reported during the previous months, warranting further investigation for their prevalence and suspected relationship with vaccine-elicited immune response.

Methods

A retrospective analysis using the Vaccine Adverse Event Reporting System (VAERS) data was conducted to evaluate AEs within the oral cavity (mucosa, tongue, lips, palate, dentition, salivary glands) and AEs involving taste and other sensations. Oral AEs reported after receiving COVID-19 vaccination (test group) and seasonal influenza vaccination (control group) were extracted and cross-tabulated to assess their relative prevalence.

Results

Among the 128 solicited (suspected) oral AEs, oral paresthesia (0.872%) was most reported after receiving COVID-19 vaccines, followed by the swelling of lips (0.844%), ageusia (0.722%), oral hypoesthesia (0.648%), swollen tongue (0.628%), and dysgeusia (0.617%). The reported prevalence of oral AEs was higher in the COVID-19 vaccine group than in the seasonal influenza group. The distribution pattern of the most reported oral AEs was similar for both COVID-19 and seasonal influenza vaccines. Female sex, older age (>39 years old), primer doses, and mRNA-based COVID-19 vaccines exhibited a higher reported prevalence of oral AEs.

Conclusion

Within the limitations of this study, COVID-19 vaccines were found to be associated with rare oral AEs that are predominantly similar to those emerging following seasonal influenza vaccines. The most commonly reported oral AEs were oral paraesthesia (mouth-tingling), lip swelling, and ageusia, representing various pathophysiologic pathways that remain unclear. Taste-related AEs should be acknowledged in the context of the COVID-19 pandemic and the public should be adequately informed about a potential taste dysfunction after receiving the COVID-19 vaccination. Dentists and dental teams need to be aware of the prevalence, severity, and prognosis of oral AEs to inform their patients and increase public confidence in vaccines.

Innate immune suppression by SARS-CoV-2 mRNA vaccinations: The role of G-quadruplexes, exosomes, and MicroRNAs

The mRNA SARS-CoV-2 vaccines were brought to market in response to the public health crises of Covid-19. The utilization of mRNA vaccines in the context of infectious disease has no precedent. The many alterations in the vaccine mRNA hide the mRNA from cellular defenses and promote a longer biological half-life and high production of spike protein. However, the immune response to the vaccine is very different from that to a SARS-CoV-2 infection. In this paper, we present evidence that vaccination induces a profound impairment in type I interferon signaling, which has diverse adverse consequences to human health. Immune cells that have taken up the vaccine nanoparticles release into circulation large numbers of exosomes containing spike protein along with critical microRNAs that induce a signaling response in recipient cells at distant sites. We also identify potential profound disturbances in regulatory control of protein synthesis and cancer surveillance. These disturbances potentially have a causal link to neurodegenerative disease, myocarditis, immune thrombocytopenia, Bell's palsy, liver disease, impaired adaptive immunity, impaired DNA damage response and tumorigenesis. We show evidence from the VAERS database supporting our hypothesis. We believe a comprehensive risk/benefit assessment of the mRNA vaccines questions them as positive contributors to public health.

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

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.

Association of COVID-19 vaccination with herpes zoster: a systematic review and meta-analysis

BACKGROUND

Following COVID-19 vaccination, several herpes zoster cases have been reported, making it critical to explore the association between herpes zoster and COVID-19 vaccination. This is especially true in the context of increasing the number of participants enrolled to receive COVID-19 vaccination.

RESEARCH DESIGN AND METHODS

Three databases, including the Cochrane Library, PubMed, and EMBASE, were searched for relevant studies before 25 December 2021 according to preliminarily determined inclusion and exclusion criteria without any language limitations. Four cohort studies were included in this systematic review and meta-analysis.

RESULTS

Compared with the placebo group, there was no evidence that the COVID-19 vaccination group was associated with increased incidence of herpes zoster (Risk ratio [RR]: 1.06; 95% confidence interval [CI]: 0.91 to 1.24). There is no evidence that the COVID-19 vaccination from Moderna is associated with the incidence of herpes zoster compared with vaccination from Pfizer (RR: 0.20; 95% CI: 0.01 to 2.99).

CONCLUSIONS

To date, there is no evidence of an association between covid-19 vaccination and herpes zoster.

Real-world evidence from over one-million COVID-19 vaccinations is consistent with reactivation of the varicella-zoster virus

BACKGROUND

Reactivation of the varicella-zoster virus (VZV), which causes herpes zoster (HZ, synonym: shingles) in humans, can be a rare adverse reaction to vaccines. Recently, reports of cases after COVID-19 vaccination have arisen.

OBJECTIVES

The aim of this study was to assess if the frequency of HZ is found to increase after COVID-19 vaccination in a large cohort, based on real-world data. As a hypothesis, the incidence of HZ was assumed to be significantly higher in subjects who received a COVID-19 vaccine (Cohort I) versus unvaccinated individuals (Cohort II).

METHODS

Initial cohorts of 1,095,086 vaccinated and 16,966,018 unvaccinated patients were retrieved from the TriNetX database, and were matched on age and gender in order to mitigate confounder bias.

RESULTS

After matching, each cohort accounted for 1,095,086 patients. For the vaccinated group (Cohort I), 2,204 subjects developed HZ within 60 days of COVID-19 vaccination, while among Cohort II, 1,223 patients were diagnosed with HZ within 60 days after having visited the clinic for any other reason (i.e., not vaccination). The risk of developing shingles was calculated as 0.20% and 0.11% for cohort I and cohort II, respectively. The difference was statistically highly significant (p < 0.0001; log-rank test). The risk ratio and odds ratio were 1.802 (95% confidence interval [CI] = 1.680; 1.932) and 1.804 (95% CI = 1.682; 1.934).

CONCLUSIONS

Consistent with the hypothesis, a higher incidence of HZ was statistically detectable post-COVID-19 vaccine. Accordingly, eruption of HZ may be a rare adverse drug reaction to COVID-19 vaccines. Even though the molecular basis of VZV reactivation remains murky, temporary compromising of VZV-specific T cell-mediated immunity may play a mechanistic role in post-vaccination pathogenesis of HZ. Note that VZV reactivation is a well-established phenomenon both with infections and with other vaccines (i.e., this adverse event is not COVID-specific).

Vestibular Neuritis Following COVID-19 Vaccination: A Retrospective Study

Objective

To determine if the COVID-19 vaccine can cause vestibular neuritis (VN).

Design

Retrospective study.

Setting

Vertigo outpatient clinic of the Department of Otolaryngology JR Tokyo General Hospital.

Participants:

378 patients who presented at the Vertigo clinic between July 2018 and March 2022

Results

23 out of 378 cases were diagnosed with vestibular neuritis. There was a significant seasonal bias of the onset of VN in 2021-3Q compared to other seasons. All 7 patients diagnosed with VN whose onset was 2021-3Q and 2021-4Q had received the BNT162b2 (Pfizer-BioNTech) vaccine within the previous 3 months and one patient diagnosed with VN whose onset was 2022-1Q had a history of COVID-19 infection six months earlier.

Conclusions

VN should be recognized as one of the side-effects of the BNT162b2 COVID-19 vaccination.

COVID-19 at a Glance: An Up-to-Date Overview on Variants, Drug Design and Therapies

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is a member of the Coronavirus family which caused the worldwide pandemic of human respiratory illness coronavirus disease 2019 (COVID-19). Presumably emerging at the end of 2019, it poses a severe threat to public health and safety, with a high incidence of transmission, predominately through aerosols and/or direct contact with infected surfaces. In 2020, the search for vaccines began, leading to the obtaining of, to date, about twenty COVID-19 vaccines approved for use in at least one country. However, COVID-19 continues to spread and new genetic mutations and variants have been discovered, requiring pharmacological treatments. The most common therapies for COVID-19 are represented by antiviral and antimalarial agents, antibiotics, immunomodulators, angiotensin II receptor blockers, bradykinin B2 receptor antagonists and corticosteroids. In addition, nutraceuticals, vitamins D and C, omega-3 fatty acids and probiotics are under study. Finally, drug repositioning, which concerns the investigation of existing drugs for new therapeutic target indications, has been widely proposed in the literature for COVID-19 therapies. Considering the importance of this ongoing global public health emergency, this review aims to offer a synthetic up-to-date overview regarding diagnoses, variants and vaccines for COVID-19, with particular attention paid to the adopted treatments.

Neuro-Ophthalmic Implications of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Related Infection and Vaccination

ABSTRACT

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic created a unique opportunity to study the effects of infection and vaccination on disease. The year 2020 was dominated by infection and its consequences. The year 2021 was dominated by vaccination and its consequences. It will still take several years for full maturation of databases required for robust epidemiological studies. Therefore, this review on the implications for neuro-ophthalmology draws on resources presently available including reported adverse reactions to vaccination. Illustrative clinical cases are presented.The spectrum of pathology following infection with SARS-CoV-2 falls into 4 main categories: autoimmune, vascular, sequelae of brain damage, and miscellaneous. This review is exhaustive, but the most common conditions discussed relate to headaches and associated symptoms; vertigo, diplopia, and nystagmus; vascular complications of the eye and brain; cranial nerve (mono-)neuropathies; photophobia, ocular discomfort, and optic neuritis. Of the 36 main adverse reactions reviewed, vaccine-induced immune thrombotic thrombocytopenia is a novel complication requiring specific hematological management. Updated diagnostic criteria are summarized. It is relevant to remember taking a medication history because of side effects and to recognize the relevance of comorbidities. The clinical assessment can frequently be performed virtually. Consensus recommendations on telemedicine and the virtual assessment are summarized in a practical and compressed format.The review concludes with an epidemiological tetralogy to interrogate, in future studies, associations with (1) SARS-CoV-2 pandemic infection, (2) SARS-CoV-2 worldwide vaccination, and (3) the possibility of a rebound effect of infections in the pandemic aftermath.

Herpes zoster: A Review of Clinical Manifestations and Management

The Varicella-zoster virus (VZV) or human herpes virus 3 is a neurotropic human alpha herpes virus responsible for chickenpox/varicella and shingles/Herpes zoster (HZ). This review will focus on HZ. Since HZ is secondary to varicella, its incidence increases with age. In children and youngsters, HZ is rare and associated to metabolic and neoplastic disorders. In adults, advanced age, distress, other infections (such as AIDS or COVID-19), and immunosuppression are the most common risk factors. HZ reactivation has recently been observed after COVID-19 vaccination. The disease shows different clinical stages of variable clinical manifestations. Some of the manifestations bear a higher risk of complications. Among the possible complications, postherpetic neuralgia, a chronic pain disease, is one of the most frequent. HZ vasculitis is associated with morbidity and mortality. Renal and gastrointestinal complications have been reported. The cornerstone of treatment is early intervention with acyclovir or brivudine. Second-line treatments are available. Pain management is essential. For (secondary) prophylaxis, currently two HZV vaccines are available for healthy older adults, a live attenuated VZV vaccine and a recombinant adjuvanted VZV glycoprotein E subunit vaccine. The latter allows vaccination also in severely immunosuppressed patients. This review focuses on manifestations of HZ and its management. Although several articles have been published on HZ, the literature continues to evolve, especially in regard to patients with comorbidities and immunocompromised patients. VZV reactivation has also emerged as an important point of discussion during the COVID-19 pandemic, especially after vaccination. The objective of this review is to discuss current updates related to clinical presentations, complications, and management of HZ.

Zoster sine herpete following BNT162b2 mRNA COVID-19 vaccination in an immunocompetent patient

As a result of the COVID-19 pandemic, mRNA vaccination has become widespread. Recently, it has been suggested that instances of herpes zoster increase following mRNA COVID-19 vaccination. Herein, we describe the first case of zoster sine herpete (ZSH) after mRNA vaccination for COVID-19. A 60-year-old Japanese immunocompetent man presented with fever, fatigue, headache, cervical pain, and lumbar pain, which developed after receiving a second dose of BNT162b2 mRNA COVID-19 vaccination. Whereas most symptoms improved with symptomatic treatment, headache and numbness of the right forehead persisted in areas innervated by the trigeminal and second and third cervical nerves. Based on positive results of an enzyme-linked immunosorbent assay examination for anti-VZV IgM, ZSH was diagnosed, and amitriptyline improved the patient’s symptoms. Diagnosis of ZSH is challenging due to the lack of a characteristic herpes zoster rash. Physicians should be aware that ZSH can develop after mRNA vaccination.

Is COVID-19 infection triggering oral herpes zoster? A case report

Patients affected with COVID-19 are at risk of developing serious and life-threatening conditions. The clinical manifestations of COVID-19 were detected in asymptomatic cases to severe clinical symptoms with a major impact on the respiratory system. A few cases of cutaneous as well as an oral lesion of herpes zoster in patients with COVID-19 were reported in the literature. We present a case of the rapid appearance of the oral lesion as a manifestation of herpes zoster associated with COVID-19 infection. Our case highlights the importance of oral examination as well as oral care in patients with COVID-19 infection.

Herpes Zoster Following Covaxin Receipt

Background

Herpes zoster is a reactivation of varicella zoster virus infection. We presented this case since it occurred after the receipt of Covaxin vaccine. There are few case reports of herpes zoster after the receipt of COVID-19 vaccine in the literature.

Case Presentation

We presented a case of herpes zoster in a 72-year-old lady after she received the first dose of the vaccine for COVID-19. She had post-herpetic neuralgia.

Conclusion

It is evident that VZV reactivation is one of the untoward events of the COVID-19 vaccine. However, it is wise to do large epidemiologic studies to check how common herpes zoster is after the receipt of COVID-19 vaccine.

Oral Herpes Zoster Infection Following COVID-19 Vaccination: A Report of Five Cases

Recently, two cases of oral herpes zoster (HZ) following COVID-19 vaccines were reported. It was suggested that COVID-19 vaccine-related oral HZ cases might be missed or misdiagnosed as stomatitis or isolated oral herpes. In this report, five cases of oral HZ following COVID-19 vaccinations are presented. Four cases were observed on the hard palate (V2), and one case was found on the mandible (V3). Four patients did not receive any treatment for their oral HZ, but one patient also had skin reactions on her right orbit and ear and was thus treated with an antiviral drug. As these cases were seen during such a short period of time and in one practice, the relationship with the COVID-19 vaccination appears to be related.