Sex: M
Vaccine: VARZOS
Symptoms: Rash, Rash pruritic, Smear test, Symptom recurrence, Varicella virus test negative
Clinical narrative: disseminated Herpes Zoster; disseminated Herpes Zoster with Zoster pneumonitis; recurrence of Myelodysplastic syndrome; full body rash/ rash as intensely pruritic and spreading quickly since it frst appeared on the trunk; examination showed papules; vesicles with involvement of the entire body, including the face, trunk, extremities, palms and sole; Bilateral inspiratory wheeze; hypoxic to 88% and required 2L O2 to maintain SpO2 more than 94%; small right pleural efusion; nodules in the bilateral lungs; This serious case was reported in a literature article and described the occurrence of herpes zoster disseminated in a 52-year-old male patient who received Herpes zoster (Zoster vaccine) for prophylaxis.   The patient's past medical history included myelodysplastic syndrome, allogenic stem cell transplantation (11 months ago) and chickenpox. Previously administered products included mycophenelate, cyclosporine and ruxolitinib.   On an unknown date, the patient received Zoster vaccine. On an unknown date, an unknown time after receiving Zoster vaccine, the patient experienced herpes zoster disseminated (Verbatim: disseminated Herpes Zoster) (serious criteria hospitalization and medically significant), viral pneumonitis (Verbatim: disseminated Herpes Zoster with Zoster pneumonitis) (serious criteria hospitalization and medically significant), myelodysplastic syndrome (Verbatim: recurrence of Myelodysplastic syndrome) (serious criteria hospitalization and medically significant), itchy rash (Verbatim: full body rash/ rash as intensely pruritic and spreading quickly since it frst appeared on the trunk) (serious criteria hospitalization), papule (Verbatim: examination showed papules) (serious criteria hospitalization), vesicle (Verbatim: vesicles with involvement of the entire body, including the face, trunk, extremities, palms and sole) (serious criteria hospitalization), wheezing inspiratory (Verbatim: Bilateral inspiratory wheeze) (serious criteria hospitalization), hypoxia (Verbatim: hypoxic to 88% and required 2L O2 to maintain SpO2 more than 94%) (serious criteria hospitalization, medically significant and clinically significant/intervention required), pleural effusion (Verbatim: small right pleural efusion) (serious criteria hospitalization) and lung nodule (Verbatim: nodules in the bilateral lungs) (serious criteria hospitalization). The patient was treated with aciclovir (Acyclovir), intravenous fluid (nos) (Intravenous Fluid) and cedazuridine + decitabine (Inqovi). The outcome of the herpes zoster disseminated, viral pneumonitis, myelodysplastic syndrome, itchy rash, papule, vesicle, wheezing inspiratory, hypoxia, pleural effusion and lung nodule were not reported.   It was unknown if the reporter considered the herpes zoster disseminated, viral pneumonitis, myelodysplastic syndrome, itchy rash, papule, vesicle, wheezing inspiratory, hypoxia, pleural effusion and lung nodule to be related to Zoster vaccine.     It was unknown if the company considered the herpes zoster disseminated, viral pneumonitis, myelodysplastic syndrome, itchy rash, papule, vesicle, wheezing inspiratory, hypoxia, pleural effusion and lung nodule to be related to Zoster vaccine.   Additional Information: Receipt Date: 02-Aug-2023 The patient with history of high-risk Myelodysplastic Syndrome (MDS) s/p allogenic stem cell transplant 11 months ago presented to the emergency department with two days of full body rash. The patient described the rash as intensely pruritic and spreading quickly since it first appeared on the trunk. No one else had the rash at home, but the patient's wife and son both contracted a self-limited viral upper respiratory tract infection in the last week. Examination showed papules and vesicles with involvement of the entire body, including the face, trunk, extremities, palms and soles. Bilateral inspiratory wheeze was present in all quadrants. The patient was hypoxic to 88% and required 2L oxygen by nasal canula to maintain SpO2 more than 94%. Chest X-ray showed a small right pleural efusion. Non- contrast chest CT showed greater than 50 nodules in the bilateral lungs. The patient was started on intravenous (IV) Acyclovir and IV fuids on day 2. Dermatology and Infectious Diseases physicians were consulted for care. A Tzanck smear of the lesion was positive. Aerobic, anaerobic and fungal culture of the unroofed lesions returned negative. Varicella zoster virus (VZV) qualitative polymerase chain reaction (PCR) of the lesions returned positive, while the Herpes simplex virus (HSV) 1 and HSV2 qualitative PCRs were negative. A plasma VZV PCR titer returned at 14,500. The diagnosis of disseminated Herpes Zoster with Zoster pneumonitis was made. The patient was treated with a 28-day course of IV Acyclovir. Follow up ophthalmologic examination did not show retinal necrosis. Follow up VZV DNA PCR was undetectable and the patient was placed on suppressive acyclovir 800 mg BID. The patient had been of immunomodulators (mycophenelate, cyclosporine, ruxolitinib) for four months due to successful stem cell transplant and normocellular marrow. Unfortunately, subsequent bone marrow biopsy showed recurrence of MDS with his original 5q-, -7, 17p- karyotype with 10% plasma cells and 5% blasts. Analysis of peripheral blood showed 65% donor chimerism. A shared decision was made to start the patient on Inqovi (decitabine and cedazuridine).  Our patient had childhood chicken pox, but never had a Herpes Zoster reactivation. In reviewing the patient's vaccine history, the patient only had one of two doses on recombinant Zoster vaccine and was originally scheduled for dose 2 the day after his hospitalization. In addition to the recurrence of MDS, the patient might had developed disseminated Zoster in part due to a signifcantly elevated percentage of T regulatory (CD4+CD25+FoxP3+) T cells.  This patient developed disseminated herpes zoster as a presenting symptom of the recurrence of MDS after stem cell transplant. The article corresponding to this case is not available for regulatory submission due to copyright restriction.