Image of lungs

Scenario 3: A case of post-herpetic neuralgia in a frail older patient with chronic obstructive pulmonary disease

Betty’s story

An illustration of a patient file, with the patients’ name (Betty) and age (77) written on it An illustration of a patient file, with the patients’ name (Betty) and age (77) written on it

Betty*, 77, an ex-cigarette smoker with a 30 pack-year history, has chronic obstructive pulmonary disease (COPD). Read more about her history and experience with shingles and post-herpetic neuralgia (PHN).

*This is a fictitious name assigned to a real patient case for educational purposes only and does not substitute clinical judgment.

Patient history

Betty, 77, is a former cigarette smoker with a 30 pack-year history and lives independently. She has COPD and is managing her symptoms with inhaled corticosteroids and bronchodilators. Despite having a good level of daily functioning, Betty has a Rockwood Clinical Frailty Score between 3 and 4, experiences sleep disturbances, and her quality of life is impacted by tiredness during the day.

Four weeks ago, Betty presented with a three-day history of a painful, blistering rash in a dermatomal pattern localised to the lateral thoracic region. She described sharp, burning pain that preceded the onset of the rash. Additionally, she reported mild fatigue and discomfort during deep breathing; however, she denied experiencing any fever, nausea or other systemic symptoms. She was diagnosed with shingles.

Find out more

The patient voice

Read more about how patients may describe their experience with shingles

How might Betty’s comorbidities and age influence her risk of shingles and complications?

COPD is a chronic inflammatory lung condition characterised by airflow limitation, recurrent respiratory infections and systemic effects, including fatigue and immunological dysregulation.1,2 These factors heighten a patient’s susceptibility to secondary conditions, such as shingles, as they may contribute to the reactivation of latent varicella zoster virus (VZV).2,3 A prolonged history of corticosteroid use may further elevate the risk of shingles and complicate its clinical progression.2 Shingles may also exacerbate chronic conditions such as COPD and its symptoms, for example, dyspnoea.4

A diagram showing the reciprocal impact of COPD on shingles and vice versa. COPD (and other immune mediated diseases or medications such as corticosteroids) increases shingles susceptibility due to altered immune function. Shingles increases COPD complications such as exacerbation of COPD symptoms, dyspnoea. A diagram showing the reciprocal impact of COPD on shingles and vice versa. COPD (and other immune mediated diseases or medications such as corticosteroids) increases shingles susceptibility due to altered immune function. Shingles increases COPD complications such as exacerbation of COPD symptoms, dyspnoea.

Older people with chronic illnesses frequently experience more severe or prolonged symptoms of shingles due to an impaired capacity to mount effective immune responses to infection.6 Betty’s overall health status could exacerbate the symptoms of shingles. Both older age and chronic respiratory diseases, such as COPD, are established risk factors for the development and persistence of PHN, the most common complication of shingles.7,8

Find out more

Identifying patients at risk

Read more about which conditions put people at a higher risk of shingles

Clinical presentation

Four weeks after her shingles rash subsided, Betty was left with painful symptoms in the same lateral thoracic region and returned to your clinic.

A stylised illustration of Betty touching her shoulder where she is experiencing pain and describing her pain as running down her side like a bolt of electricity, pulsing, a sharp stab that never truly stops and that affects her sleep. A stylised illustration of Betty touching her shoulder where she is experiencing pain and describing her pain as running down her side like a bolt of electricity, pulsing, a sharp stab that never truly stops and that affects her sleep.

During the physical examination, you observe:

  • Betty is alert and orientated
  • Her vital signs are within normal limits
  • Chest auscultation reveals a mild wheeze bilaterally
  • Palpating the area that had been affected by the rash elicits significant pain, which Betty rates as 8 out of 10 on a numerical rating scale

Diagnosis

Ongoing nerve pain after the rash has resolved is suggestive of PHN, and the intensity and duration of pain leads you to diagnose Betty with PHN and start her on analgesics.

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Complications

Read more about PHN in people with shingles

Key considerations in pain management

Pain management for PHN requires careful consideration, particularly in older adults where age-related factors and comorbidities can influence treatment decisions and outcomes.

An image describing shared clinical decision making on pain management including considerations regarding nature of the pain, treatment options and side effects, relevance of COPD and treatment plan and multidisciplinary involvement. An image describing shared clinical decision making on pain management including considerations regarding nature of the pain, treatment options and side effects, relevance of COPD and treatment plan and multidisciplinary involvement.

  • Shingles, PHN and the subjective nature of pain

    The pain associated with the shingles rash is typically acute and temporary, involving both inflammatory and neuropathic mechanisms.9 PHN is neuropathic in nature and can be experienced as intense, burning sensations and allodynia.9 The pain can be persistent and sometimes disabling, which can have a significant impact on patients’ quality of life.9,10 There is currently no disease-modifying treatment for PHN.7 Pain management options can offer some relief but the evidence for certain treatments is limited and individual responses may vary.7

    The subjective nature of pain symptoms can also present a diagnostic challenge. In Betty’s case, her descriptions of intermittent pulsing and stabbing pain and “like a bolt of electricity” necessitated careful interpretation. Differential diagnoses of pain require exclusion through attentive listening and examination to identify the cause of the pain.

    Since patients may underreport symptoms, it’s important to assess pain thoroughly and consider differences in attitudes to pain in older adults, such as stoicism or normalisation of chronic discomfort.11

  • Treatment options and side effects

    Numerous pain treatments for PHN carry substantial side effect profiles. This is particularly challenging in patients with chronic comorbid conditions such as COPD.7,12 Concerns about side effects such as sedation, confusion and respiratory depression among individuals with COPD makes effective symptom management more challenging.12

    The National Institute for Health and Care Excellence stresses the importance of patient involvement in pain management and early clinical review of treatment choices to assess progress.13

  • Relevance of COPD in pain diagnosis and management

    Betty’s history of COPD introduced an additional complexity into her care. COPD created diagnostic ambiguity in the early phase, when thoracic pain could have been misattributed to pulmonary complications (such as pleurisy or pulmonary embolism) or musculoskeletal causes.

    The lack of a definitive biomarker for PHN introduces the possibility of misdiagnosis or delayed diagnosis, particularly in atypical presentations, and meticulous physical examination is warranted.

  • The potential for multidisciplinary support

    For patients with neuropathic pain, switching between different pain medications based on individual effectiveness and tolerability is common.14 Pain specialist referral may be warranted for PHN if pain is severe or significantly limits participation in daily activities.13 However, involvement of specialist care in acute pain management may vary by geography.

Key learnings: Betty’s case

An icon depicting post-herpetic neuralgia pain An icon depicting post-herpetic neuralgia pain

PHN is an important potential complication of shingles, particularly among high-risk populations, including older adults and individuals with chronic conditions such as COPD

An icon of an older person with mobility issues An icon of an older person with mobility issues

Comorbidities and frailty present considerable challenges in both the diagnosis and treatment of patients. Commonly prescribed medications for neuropathic pain may have side effects, such as sedation or respiratory depression, and may be poorly tolerated in individuals with comorbidities such as COPD.

An icon depicting pain radiating from a stylised head An icon depicting pain radiating from a stylised head

PHN has significant impact on quality of life and pain management represents a challenge. Differential diagnoses require exclusion through comprehensive clinical history taking, physical examination, and consideration of the characteristic dermatomal pattern of the pain.

References

  1. Agarwal AK et al. Chronic obstructive pulmonary disease. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023.
  2. Yang YW et al. Risk of herpes zoster among patients with chronic obstructive pulmonary disease: a population-based study. CMAJ 2011;183:E275–E280.
  3. Marra F et al. Risk factors for herpes zoster infection: a meta-analysis. Open Forum Infect Dis 2020;7:ofaa005.
  4. Yawn BP et al. Knowledge and attitudes concerning herpes zoster among people with COPD: an interventional survey study. Vaccines (Basel) 2022;10:420.
  5. Muñoz-Quiles C et al. Risk and impact of herpes zoster among COPD patients: a population-based study, 2009–2014. BMC Infec Dis 2018;18:203
  6. Bandaranayake T and Shaw AC. Host resistance and immune aging. Clin Geriatr Med 2016;32:415–432.
  7. Johnson RW and Rice ASC. Postherpetic neuralgia. N Engl J Med 2014;371(16):1526–1533.
  8. Forbes HJ et al. Quantification of risk factors for postherpetic neuralgia in herpes zoster patients. Neurology 2016;87:94–102.
  9. Feller L et al. Postherpetic neuralgia and trigeminal neuralgia. Pain Res Treat 2017;2017:1681765.
  10. Nair PA and Patel BC. Herpes zoster. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2025.
  11. Yong H-H et al. Development of a pain attitudes questionnaire to assess stoicism and cautiousness for possible age differences. J Gerontol B Psychol Sci Soc Sci2001;56:279–284.
  12. Bruckenthal P and Barkin RL. Options for treating postherpetic neuralgia in the medically complicated patient. Ther Clin Risk Manag 2013;9:329–340.
  13. National Institute for Health and Care Excellence. Clinical knowledge summary: Post-herpetic neuralgia. https://cks.nice.org.uk/topics/post-herpetic-neuralgia/management/management/ (accessed June 2025).
  14. National Institute for Health and Care Excellence. Clinical knowledge summary: Neuropathic pain. https://cks.nice.org.uk/topics/neuropathic-pain-drug-treatment/

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July 2025 | NP-GB-HZU-WCNT-250012 (V1.0)