Image of DNA

Scenario 1: A high-risk patient

Ben’s story

An illustration of a patient file, with the patients’ name (Ben) and age (70) written on it

Ben* is 70 years old and was diagnosed with stage IV small B-cell lymphoma 6 years ago. Read more about his history and experience with shingles.

*Not patient's real name. This is a hypothetical case for educational purposes only and does not replace clinical judgement.

Patient history

Following routine medical examinations that revealed splenomegaly and thrombocytopaenia, Ben was diagnosed with stage IV small B-cell lymphoma with bone marrow infiltration. He was treated with an initial cycle of rituximab and bendamustine.

Four years later, Ben’s condition progressed to chronic lymphocytic leukaemia (CLL) with a 13q14 deletion. Further treatment with rituximab and bendamustine was administered to manage progressive thrombocytopaenia. This resulted in near complete clinical remission for 2 years.

During a follow-up appointment, large retroperitoneal lymph nodes were detected, and after extensive discussion and informed consent, Ben commenced treatment with the Bruton's tyrosine kinase inhibitor ibrutinib.

Which aspects of Ben’s history might increase his risk
of developing shingles?

  • Ben’s age

    Ben is 70 years old, which puts him at increased risk of shingles.1,2

  • Ben’s medical condition

    Ben was diagnosed with lymphoma, which progressed to CLL, meaning he is immunocompromised.3 Patients who are immunocompromised have a higher risk of shingles than individuals who are immunocompetent.2,3

  • Ben’s medication

    Patients receiving chemotherapy or other immunosuppressive medications are at a higher risk of developing shingles than patients who are not receiving such treatments.4

Find out more

Incidence

Read more about the impact of age on shingles risk

Identifying patients at risk

Read more about which patients are at risk

The importance of cell-mediated immunity

Read more about what aspects of the immune system are involved in controlling shingles

Clinical presentation

Shortly after starting ibrutinib therapy, Ben contacted your clinic reporting the sudden appearance of grouped blisters and itching around his lower left rib area that had developed over the previous 2 days.

An illustration of a man talking. He is saying “The rash appeared and it’s really painful. It feels like a deep, burning pain, a bit like I’ve pulled a muscle. Sometimes, it feels like more of a shooting stabbing pain, especially when something touches my skin.”

During the physical examination, you observe:

  • Grouped red vesicles in a unilateral distribution on an erythematous background
  • Stable vital signs and no indication of fever
A photo of the shingles rash on a person’s trunk

Find out more

The patient voice

Patients with lived experience of shingles have the best understanding of its wide-ranging impacts

Further investigation

Ben’s rash and associated symptoms are typical of shingles, meaning diagnosis is possible based on clinical features alone.5

Polymerase chain reaction (PCR) test

While investigations are not usually needed to diagnose shingles, a PCR test can be useful in cases of diagnostic uncertainty.5,6 PCR is the most sensitive method to detect varicella zoster virus in sampled material.6

Insights from PCR testing on differential diagnosis
PCR studies have revealed that herpes simplex virus (HSV) is incorrectly diagnosed as shingles in 4–20% of cases, highlighting the similarity between these conditions in their clinical presentation.6

An icon of a magnifying glass

Shingles rash

A photo of the shingles rash on a person’s abdomen

HSV rash

A photo of herpes simplex virus rash

Diagnosis

Based on Ben’s clinical presentation and assessment, he was diagnosed with shingles, and outpatient treatment was promptly administered. The infection resolved and Ben was able to continue his ibrutinib treatment.

Potential for complications

Ben recovered successfully from shingles, but as an immunocompromised patient, he was at a higher risk of developing complications than people who are immunocompetent.5,6 What complications might Ben have been at higher risk of?

  • Post-herpetic neuralgia

    Long-term pain known as post-herpetic neuralgia (PHN) is the most common complication of shingles, and the risk of developing PHN is up to 45% in patients with immunocompromising conditions.7

  • Systemic dissemination

    Systemic dissemination of shingles is a rare but serious complication, which can be fatal, and is considered a medical emergency.5,6 Immunocompromised patients such as Ben are at an increased risk of systemic dissemination.6

  • Other complications

    A wide range of other complications are associated with shingles.5 Serious complications, such as systemic dissemination, meningitis, encephalitis, myelitis and shingles in the ophthalmic distribution of the trigeminal nerve, may require immediate admission to hospital or referral for specialist advice.5

Find out more

Complications

Although shingles is usually self-limiting, patients can experience complications1,5

Key learnings: Ben’s case

An icon of a shield with a lightning bolt breaking it in two

Ben had lymphoma, which progressed to CLL, an immunocompromising lymphoproliferative disorder that puts him at increased risk of shingles2,3

A stylised icon of a rash in the form of lots of small red circles

Ben presented with a rash typical of shingles, meaning diagnosis was possible based on the clinical features, but a PCR test may be helpful in cases where diagnosis is unclear5,6

An icon of a hospital

Ben recovered successfully, but his immunocompromised status means his risk of developing complications was higher than that of patients who are immunocompetent5,6

References

  1. UK Health Security Agency. Shingles: The Green Book, chapter 28a (July 2023). https://assets.publishing.service.gov.uk/media/64c1153cd4051a000d5a9409/Shingles_Green_Book_on_Immunisation_Chapter_28a_26_7_23.pdf (accessed February 2024).
  2. Marra F et al. Risk factors for herpes zoster infection: A meta-analysis. Open Forum Infect Dis 2020;7:ofaa005.
  3. Yanni EA et al. Burden of herpes zoster in 16 selected immunocompromised populations in England: A cohort study in the Clinical Practice Research Datalink 2000–2012. BMJ Open 2018;8:e020528.
  4. Kawai K and Yawn BP. Risk factors for herpes zoster: A systematic review and meta-analysis. Mayo Clin Proc 2017;92:1806–1821.
  5. National Institute for Health and Care Excellence. Clinical knowledge summary: Shingles. https://cks.nice.org.uk/topics/shingles/ (accessed February 2024).
  6. Werner RN et al. European consensus-based (S2k) guideline on the management of herpes zoster - guided by the European Dermatology Forum (EDF) in cooperation with the European Academy of Dermatology and Venereology (EADV), Part 1: Diagnosis. J Eur Acad Dermatol Venereol 2017;31:9-19.
  7. McKay SL et al. Herpes zoster risk in immunocompromised adults in the United States: A systematic review. Clin Infect Dis 2020;71:e125-e134.

Adverse events should be reported. Reporting forms and information can be found at https://yellowcard.mhra.gov.uk/. Adverse events should also be reported to GlaxoSmithKline on 0800 221 441.

©2024 GSK group of companies. All rights reserved.

July 2024 | NP-GB-HZU-WCNT-240027 (V1.0)