Assessing the patient with ‘recurrent shingles’ – considerations of immune deficiency
This is a brief guide relating to patients having recurrent (twice or more in 1 year) episodes of shingles, who are also aged > 70 years. The current Green Book recommendation is to seek advice around tests / evaluation regarding whether the patient has an underlying immune deficiency to explain the propensity to recurrent shingles.
Please note that where there is concern around significant immune deficiency, live vaccinations are contra-indicated.
A clinical approach to evaluating for any significant immune deficiency in this setting would include:
- Confirm the diagnosis of recurrent shingles, wherever possible, by sending a blister swab for HSV & VZV. Recurrent herpes simplex is much more common than recurrent shingles – and often misdiagnosed, especially when it occurs at sites other than the lip. Recurrent herpes simplex would not be a contra-indication to shingles vaccination unless there was other evidence of immune suppression.
- Clinical evaluation: is there a history of severe / persistent / unusual / recurrent other infections at all to raise concerns about cellular immune deficiency? This may include oesophageal candidiasis / pneumocystis infections / opportunistic infections.
- If isolated shingles only – then is this classical appearance or very severe / multiple dermatomes and not responsive to conventional treatment?
- The most common cause for immune deficiency (especially in this age group) is secondary immune deficiency – so this includes lymphoma / haematological malignancy/ other malignancy / diabetes / immunosuppression medications like biologics & steroids etc – so these should be excluded clinically.
- HIV testing
- Check lymphocyte count on FBC (+/- consider checking CD4+ T-cell count on peripheral blood sample)
- Check immunoglobulins and electrophoresis.
If any concerns / abnormalities raised on above 7 checkpoints, then further evaluation as appropriate may be required (e.g. Infectious Diseases referral for HIV positive patients).
If no concerns / abnormalities in terms of the above, then it is highly unlikely that there is an underlying immune deficiency in the patient.
(Authors: Scottish Immunologists’ Group; March 2023) Charu Chopra
