Sex: M
Vaccine: VARZOS
Symptoms: Cellulitis, Cryoglobulins absent, Erythema, Escherichia infection, Escherichia test positive
Clinical narrative: This literature marketed report has been received from the authors of the published literature article, titled as stated below and refers to a 60 year old male patient. The patient's current conditions included hypertension, obesity, obstructive sleep apnea, and hyperlipidemia.  On an unknown date (reported as 6 weeks prior to symptom onset), the patient had received the ZOSTAVAX for prophylaxis (exact dose, site, route of administration, lot # and expiration date were not reported). On an unknown date (reported as "6 weeks post-vaccination"), the patient presented  to the authors' hospital with a 2-week history of generalized red/purple skin, itchy rash, and swelling of the tongue and mouth. The rash initially involved the arms and legs, then progressed into the torso and was associated with a severe burning sensation and swelling. The patient denied any history or symptoms of autoimmune, blood, connective tissue, or rheumatological disorders. He also denied any recent medication changes (concomitant medications included: vitamin D3 and multivitamin), travel, or contact with sicknesses. His right arm blood pressure was 117/79 mmHg, pulse was 87 per minute, oral temperature was 98.2 degrees Fahrenheit, and body mass index was 55.55 kg/mm2. Physical examination also revealed diffuse petechial rash involving the 4 extremities and the torso along with angioedema. Later on, he developed a full-thickness left mid leg ulcer due to a delicate skin breakdown with underlying edema. The rest of the physical examination was unremarkable. In view of the rapid rash progression and angioedema, he was admitted for further management. The patient's laboratory test results were unremarkable for complete blood count (CBC) and complete metabolic profile (CMP). Further blood work revealed elevated C-reactive protein (CRP) of 7.46 mg/dl and normal erythrocyte sedimentation rate (ESR) of 10 mm/h. He had negative antinuclear antibodies, cryoglobulin, and human human immunodeficiency virus (HIV) testing. The patient had no clinic evidence of antiphospholipid syndrome, coagulopathy or antineutrophil  cytoplasmic antibodies (ANCA)-related vasculitis, so these laboratory tests were not performed. Furthermore, the biopsy was pathognomonic for leukocytoclasis with no pathologic evidence of ANCA-related vasculitis. Additionally, no drugs had been used at the time, eliminating the possibility of drug-associated immune complex vasculitis. Left calf skin biopsy revealed mixed inflammatory infiltrate within and surrounding dermal vessels accompanied by leukocytoclasis, fibrinoid change within vessel walls, and erythrocyte extravasation confirming the diagnosis of leukocytoclastic vasculitis. The patient was managed with methylprednisolone 40 mg intravenously every 8 hours that was changed to a prednisone taper down dosage starting with 40 mg daily. He also received topical 0.05% clobetasol cream twice daily, diphenhydramine 25 mg every 8 hours, and trimethoprim (+) sulfamethoxazole (160-800 mg tablet) twice daily for superimposed bacterial cellulitis caused by Escherichia coli and methicillin-sensitive Staphylococcus aureus proven by skin culture from the left leg ulcer. His symptoms improved significantly and the rash continued to fade and finally healed with hyperpigmentation at 6-month follow-up visit. The reporters stated that the case of herpes zoster vaccination-related hypersensitivity vasculitis was very rare  and explained that rarity of this case is due to the length of time between vaccination and presentation. The authors concluded that the temporal correlation between symptom onset and the patient's inoculation with ZOSTAVAX led to the conclusion that the two were related. Upon internal review, the event of hypersensitivity vasculitis was considered to be medically significant.