PURPOSE: Previously, secondary prevention of herpes zoster required 
live-attenuated vaccination, which is contraindicated in immunocompromised 
populations. More recently, a recombinant subunit vaccine (Shingrix, 
GlaxoSmithKline, Research Triangle Park, North Carolina) was approved by the 
Food and Drug Administration. Iatrogenic varicella-zoster virus (VZV) infection 
is theoretically impossible as it does not contain a live virus. We present a 
case of acute retinal necrosis (ARN) and disseminated zoster after receiving the 
recombinant subunit vaccine.
OBSERVATIONS: A 65-year-old woman with past medical history of multiple myeloma 
treated with a previous autologous hematopoietic stem cell transplant and now 
with daratumumab and pomalidomide developed disseminated zoster and subsequently 
acute retinal necrosis weeks after receiving the zoster subunit vaccine. 
Molecular testing confirmed the presence of VZV, and the absence of herpes 
simplex virus, cytomegalovirus, and toxoplasmosis. The VZV was found to be 
genotypically wildtype and not related to the Oka strain used in the 
live-attenuated zoster vaccine. She was treated with systemic valacyclovir and 
intravitreal foscarnet.
CONCLUSIONS AND IMPORTANCE: This is the first report of VZV infection following 
the zoster subunit vaccine. The Advisory Committee on Immunization Practices 
(ACIP) has recommended the recombinant subunit vaccine over the live-attenuated 
vaccine due to its superior efficacy. The off-label use of the subunit vaccine 
in immunocompromised populations has been supported up to this point by studies 
demonstrating its relative safety. Though post-vaccination VZV infection or 
reactivation appears to be rare, clinicians should be aware of this potential 
complication to the recombinant subunit vaccine.