Purpose: Giant cell arteritis (GCA) is a systemic vasculitis affecting medium-to-large blood vessels with bilateral irreversible blindness being the most feared complication. The pathogenesis begins with activation of dendritic cells in the arterial wall initiating a cascade of events, but the initial trigger for dendritic activation is not yet known. Infectious agents have been proposed, but none have been proven. We report a case of GCA manifesting with generalized granuloma annulare on the skin, scalp necrosis, and ischemic optic neuropathy after a live-attenuated Varicella-Zoster Virus (VZV) vaccine.

Study design: Observational case report.

Methods: A retrospective medical review of the patient’s clinical and surgical records including history, clinical examinations, and investigations was conducted. Virology polymerase chain reaction (PCR) was performed on the temporal artery specimen (Altona Diagnostics Inc.).

Results: A few days after an 88-year-old man received a live-attenuated VZV vaccine (Zostavax) on the advice of his primary care provider, he developed generalized pink-coloured patches on his back and trunks diagnosed as granuloma annulare by dermatology and confirmed with two skin biopsies. Three weeks after receiving the vaccine, he began to experience progressively worsening fatigue and decreasing appetite with unintentional weight loss of 50 pounds over the next three months. He also had new-onset right ear and right-sided scalp pain and the rash on his back and trunks worsened. Progression of these symptoms led to scalp necrosis and bilateral vision loss from ischemic optic neuropathy in the right eye and a central retinal artery occlusion in the left eye. Temporal artery biopsy was diagnostic of GCA and his systemic symptoms, skin, and scalp significantly improved with high-dose corticosteroid treatment. Virology PCR was performed on the temporal artery biopsy specimen and was negative for VZV.

Conclusions: GCA may develop in close temporal relationship with vaccination for VZV and may potentially be the initial trigger for dendritic cell activation. GCA should therefore be kept in the differential diagnosis for patients with constitutional symptoms and unexplained elevated inflammatory markers post-vaccination. Generalized granuloma annulare is a rare skin condition associated with GCA.

Granuloma annulare, scalp necrosis, and ischemic optic neuropathy from giant cell arteritis after varicella zoster vaccination

[Poster Abstract Booklet](https://drive.google.com/file/d/1AGitRGyG9W0FiZ2Xjz6RNO2h7C0XglOL/view)

[Surgical Video Abstract Booklet](https://drive.google.com/file/d/1B-IkojrZhXk4AgXzsEQyuE_FwPG1Lvpe/view?usp=sharing)

[To claim Section 2 credits for ePoster review complete this Poster Transcript](https://drive.google.com/open?id=1dSAjpIIqFqD4SUbpcc6-PzX65ZPFhA7O)