Scenario 5: Prolonged complications and social impact from herpes zoster ophthalmicus in a family carer with type 2 diabetes
Laxmi’s story
Laxmi*, 67, is the sole carer for her husband who has dementia. Laxmi has type 2 diabetes, which she manages sub-optimally with medication. Read more about her experience with shingles, its complications and the impact it had on her quality of life and ability to care for her husband.
*This is a fictitious name assigned to a real patient case for educational purposes only and does not substitute clinical judgment
Patient history
Laxmi, 67, has lived in Edinburgh for 40 years after moving there from Nepal. She is the sole carer for her husband, who is 10 years older and has dementia. They have two children who both live in London.
Laxmi has a 15-year history of type 2 diabetes. She takes long-acting and short-acting insulin, oral antidiabetic medications and a statin, but her blood glucose control is sub-optimal.
Find out more
The interplay of shingles and diabetes
Clinical presentation
Laxmi visits your clinic and presents with a several-day history of a painful, vesicular rash localised to the left side of her face, consistent with a dermatomal distribution. She tells you that her eyelid and eye have become progressively more swollen and painful and that her vision is blurred. She is finding it difficult to care for her husband and voices concerns about her ability to cook safely and do the shopping for them both.
During the physical examination, you observe:
- A blistering red rash over the left side of her face, forehead, scalp and eyelid
- Redness of the left eye and reduced visual acuity
- Severe and intense distress and pain
- High blood sugar with a blood glucose level of 15.6 mmol/L
- Raised lymph nodes
Diagnosis
You recognise the symptoms of herpes zoster ophthalmicus (HZO) and urgently refer Laxmi to the ophthalmology services at the local hospital for a same-day assessment. You also prescribe a course of oral antiviral treatment.
HZO: A medical emergency
Laxmi is started on lubricant eye drops and analgesics for symptom relief and referred to ophthalmology as an emergency. She is prescribed antiviral eyedrops by her ophthalmology team and followed up as an outpatient.
Such emergency specialist care is needed as HZO can lead to serious and lasting ocular complications, including moderate to severe permanent vision loss.4
Around 4–20% of patients with shingles have HZO and around half of patients with HZO develop ocular disease.4 Common manifestations of ocular disease include conjunctivitis, keratitis, and uveitis, whereas optic neuropathy and retinitis are less common.4
Figure adapted from Litt J, et al. Infect Dis Ther. 2024;13(7):1439-1459.
Ongoing symptoms require further interventions
Laxmi returns to your clinic after 4 days. She is still in a lot of pain and the analgesics she is taking aren’t helping. She asks for urgent help at home as she can no longer dress her husband, bathe him or cook safely.
Laxmi’s ongoing pain requires continued management. In older individuals, shingles is associated with an increased risk of developing post-herpetic neuralgia, which may persist for up to a decade in some cases.5
Given Laxmi’s difficulties caring for her husband, you contact the duty team at the local social services to organize emergency help for Laxmi and her husband. Social services conduct an urgent visit the next day and set up an emergency care package. Carers and district nurses attend during the day for the next few weeks until Laxmi’s symptoms become more manageable.
Managing diabetes in the context of shingles
It is known that shingles may impact diabetes control and contribute to glycaemic deterioration.2 People with diabetes who experience shingles use more healthcare resources such as outpatient visits, hospitalisations and medications for diabetes, after the shingles episode than they did before the shingles episode.2 As a result of this and due to her elevated blood glucose levels, you advise Laxmi to increase the dose of her insulin following her shingles episode.
Key learnings: Laxmi’s case
Immunocompromising conditions and some other acute and chronic conditions, such as diabetes, increase the risk of shingles and its complications1-3,7
HZO is a medical emergency with the potential for serious ocular complications. Suspicion of HZO requires urgent ophthalmological referral and assessment4
In complex cases like Laxmi’s, a wide range of support might be needed, including specialists and social care
References
- Huang CT et al. Association between diabetes mellitus and the risk of herpes zoster: a systematic review and meta-analysis. J Clin Endocrinol Metab 2022;107(2):586–597.
- Muñoz-Quiles C et al. Risk and impact of herpes zoster on patients with diabetes: a population-based study, 2009–2014. Hum Vaccin Immunother 2017;13(11):2606–2611.
- Papagianni M et al. Herpes zoster and diabetes mellitus: a review. Diabetes Ther 2018;9(2):545–550.
- Litt J et al. Herpes zoster ophthalmicus: presentation, complications, treatment, and prevention. Infect Dis Ther 2024;13(7):1439–1459.
- Johnson RW et al. The impact of herpes zoster and post-herpetic neuralgia on quality-of-life. BMC Med 2010;8:37.
- Johnson RW and Rice ASC. Clinical practice. Postherpetic neuralgia. N Engl J Med 2014;371(16):1526–1533.
- Mahmood A, et al. Incidence rates of herpes zoster in immunocompromised adults aged 18 or older in England: a large retrospective cohort study using data from the Clinical Practice Research Datalink (2012-2019). Presented at ESCMID 2025, April 11-15 2025; Vienna, Austria. Abstract (PO230)
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