Scenario 4: Holistic care of an older adult with shingles and an undiagnosed immunocompromising condition
John’s story
John*, 76, has a history of high blood pressure, hyperlipidaemia and gout. Read more about his experience with shingles and how it led to the discovery of a previously undiagnosed human immunodeficiency virus (HIV) infection.
*This is a fictitious name assigned to a real patient case for educational purposes only and does not substitute clinical judgment.
Patient history
John, 76, lives alone and is generally fit and active. He has relatives living close by, an active social life and rarely attends the GP. He takes amlodipine for high blood pressure, atorvastatin for cholesterol and allopurinol for gout.
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Clinical presentation
John visits your clinic one afternoon and presents with a painful, localised rash on the side of his abdomen. The rash has been present for approximately a week and has shown no signs of resolution.
During the physical examination, you observe:
- A red and slightly blistered rash in a dermatomal distribution at T10
- Raised lymph nodes
- Hyperaesthesia in the area of the rash
- John is in visible pain and discomfort
Diagnosis
You diagnose John with shingles based on his symptoms and prescribe a course of antiviral treatment.
What risk factors for shingles can you already recognise in John at this stage?
Further investigation
John is concerned about why he developed shingles and requests a routine blood test.
Tests of full blood count; urea, electrolyte and lipid levels; liver function and HbA1c are performed. The tests reveal a low white blood cell count of 2.4 ×109/L and low neutrophil count of 0.8 ×109/L. You invite John back to the clinic two weeks later to discuss these results.
Holistic follow-up care for shingles involves considering potential immunosuppression
When John returns to your clinic, he is still experiencing pain in the area affected by the rash, which is taking longer than usual to resolve. You prescribe another course of antiviral treatment.
As John’s white blood cell count is so low, you refer him to the haematology department at the local hospital to try to ascertain the cause. There, an HIV test requested as part of the blood screen comes back positive. John is quickly referred to an HIV consultant for further management and assessment.
Reactivation of the latent varicella zoster virus (VZV) leads to the clinical manifestations of shingles and is associated with immune senescence or suppression of the immune system e.g. through immunosuppressive therapy, HIV infection, malignancy and/or increasing age.1 Moreover, shingles may act as an ‘indicator’ condition for undiagnosed HIV.4,5
Offering HIV tests to all patients with shingles, regardless of age, is therefore recommended by British HIV Association guidelines6 as part of the holistic management of shingles. This is supported by evidence from prospective studies showing ≥1 per 1000 individuals who experience shingles have undiagnosed HIV.6
Two key risk factors for shingles are:
Key learnings: John’s case
The prevalence of shingles is increased in people who are living with immunocompromising conditions such as HIV
While age and gout can influence the risk of shingles, the presence of such confounding risk factors should not prevent healthcare offering an HIV test to patients who may benefit from one
As shingles can be a presenting symptom of undiagnosed immunocompromised status, holistic management involves offering tests for immunocompromising conditions, such as HIV, and prompt referral to specialists when necessary
References
- UK Health Security Agency. Shingles (herpes zoster): The Green Book, chapter 28a (March 2024). https://assets.publishing.service.gov.uk/media/64c1153cd4051a000d5a9409/Shingles_Green_Book_on_Immunisation_Chapter_28a_26_7_23.pdf (accessed June 2025).
- Gauthier A et al. Epidemiology and cost of herpes zoster and post-herpetic neuralgia in the United Kingdom. Epidemiol Infect 2009;137:38–47.
- Yun H et al. Risk of herpes zoster in autoimmune and inflammatory diseases: implications for vaccination. Arthritis Rheumatol 2016;68:2328–2337.
- Sullivan AK et al. Feasibility and effectiveness of indicator condition-guided testing for HIV: results from HIDES I (HIV indicator diseases across Europe study). PLoS One 2013;8(1):e52845.
- Søgaard OS et al. Morbidity and risk of subsequent diagnosis of HIV: a population based case control study identifying indicator diseases for HIV infection. PLoS One 2012;7:e32538.
- British HIV Association. British HIV Association/British Association for Sexual Health and HIV/British Infection Association Adult HIV Testing Guidelines 2020. https://bhiva.org/wp-content/uploads/2024/10/HIV-testing-guidelines-2020.pdf (accessed June 2025).
- Oxman MN. Herpes zoster pathogenesis and cell-mediated immunity and immunosenescence. J Am Osteopath Assoc 2009;109(6 Suppl 2):S13–S17.
- Murdoch, H et al. Introduction of a national herpes zoster (shingles) immunization programme and impact on neuropathic pain. EJP 2014;18:1217-1218.
- 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, April 11–15, 2025; Vienna, Austria. Abstract PO230.
- 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.
- Marra F et al. Risk factors for herpes zoster infection: a meta-analysis. Open Forum Infect Dis 2020;7:ofaa005.
- World Health Organization. Guidelines on the treatment of skin and oral HIV-associated conditions in children and adults. 2014. Evidence and recommendations on herpes zoster. https://www.ncbi.nlm.nih.gov/books/NBK305402/ (accessed June 2025).
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July 2025 | NP-GB-HZU-WCNT-250015 (V1.0)