Varicella-zoster virus vaccination–induced granulomatous dermatitis
Authors: Katalin Ferenczi, Adrienne Berke, Deanna Cichon, Ronald Jurzyk, Stephen C. Somach
Journal: Journal of the American Academy of Dermatology (2014)

To the Editor: Herpes zoster is caused by reactivation of latent varicella-zoster virus (VZV) and a live attenuated VZV vaccine is recommended in adults older than 50 years to reduce herpes zoster risk. The vaccine is usually well tolerated and adverse reactions–such as injection-site erythema, tenderness, pruritus, and burning–are rare. We report a 77-year-old woman who presented with an intermittently tender, slightly indurated, nonscaling, violaceous plaque on the upper aspect of her left arm. This began after receiving a herpes zoster vaccination at the site 9 months earlier (Fig 1). Her medical history included breast cancer treated by lumpectomy and radiation therapy, acoustic neuroma, hearing loss, and hypertension. A skin biopsy specimen from the plaque on the upper aspect of her left arm was taken. Histopathological examination showed an interstitial dermal inflammatory infiltrate composed of lymphocytes, histiocytes, eosinophils, plasma cells, and numerous giant cells (Fig 2). There was focal dermal fibrosis and collections of perivascular plasma cells. No evidence of foreign body was noted by polarized light examination and viral cytopathic effect was not identified. A VZV immunostain was negative for VZV antigen expression. Acid-fast bacillus, Fite, and periodic acid–Schiff stains were negative for infectious organisms. The development of a local granulomatous dermatitis confined to the site of vaccination is very rare. Vaccines that have been noted in association with the development of a granulomatous dermatitis include: tetanus vaccine, hepatitis B, and BCG vaccine.1Baykal C. Ozkaya-Bayazit E. Kaymaz R. Granuloma annulare possibly triggered by antitetanus vaccination.J Eur Acad Dermatol Venereol. 2002; 16: 516-518Crossref PubMed Scopus (33) Google Scholar, 2Ajithkumar K. Anand U. Pulimood S. Chandi S.M. George S. Jacob C.K. et al.Vaccine-induced necrobiotic granuloma.Clin Exp Dermatol. 1998; 23: 222-224Crossref PubMed Scopus (16) Google Scholar, 3Tan H.H. Seow C.S. A review of cutaneous granulomas and lupus vulgaris following BCG vaccination in a skin hospital in Singapore.Ann Acad Med Singapore. 2002; 31: 663-665PubMed Google Scholar Whereas pseudolymphomatous reaction has been recently reported as a result of herpes zoster vaccination,4Porto D.A. Comfere N.I. Myers L.M. Abbott J.J. Pseudolymphomatous reaction to varicella zoster virus vaccination: role of viral in situ hybridization.J Cutan Pathol. 2010; 37: 1098-1102Crossref PubMed Scopus (6) Google Scholar the development of granulomatous dermatitis such as we observed in our patient has not yet been described to our knowledge. In contrast, the development of a spectrum of granulomatous reactions arising at the site of previous herpes zoster lesions in immune competent and immunocompromised patients has been well appreciated.5Wright N.A. Torres-Cabala C.A. Curry J.L. Cutlan J.E. Hymes S.R. Post-varicella-zoster virus granulomatous dermatitis: a report of 2 cases.Cutis. 2014; 93: 50-54PubMed Google Scholar Given the location of the granuloma in our patient at the site of VZV vaccination, it most likely represents an immune reaction induced by the vaccination, akin to the granulomatous reaction that may occur at the site of previous herpes zoster lesions. Cutaneous granulomas have been reported to occur within weeks to years after herpes zoster infection, with the average interval between the acute infection and the appearance of granulomas of 6 months. In our patient, the granuloma appeared shortly after her VZV vaccination, in a time frame similar to that of postherpetic granulomas, further supporting the hypothesis that the process is analogous to the immunologic changes playing a role in the etiology of postVZV granuloma. To our knowledge, this is the first case of a granulomatous dermatitis occurring at the site of VZV vaccination. Whereas the development of granulomatous reactions at the site of prior herpes zoster lesions has been well appreciated, the occurrence of such changes at the site of VZV vaccination has not been reported to our knowledge. Our case raises the awareness and recognition of granulomatous dermatitis as a new adverse cutaneous reaction to VZV vaccination.