Preventing herpes zoster in immunocompromised patients: Current concepts

Cassandra Calabrese; Elizabeth Kirchner; James Fernandez; Leonard H. Calabrese

doi:10.3949/ccjm.91a.24019

Article Figures & Data

Tables

View popup

TABLE 1

Complications of herpes zoster

Complications	Comment
Postherpetic neuralgia	Most common complication of herpes zoster Manifests as persistent pain beyond 90 days of rash
Herpes zoster ophthalmicus	Vision-threatening complication from involvement of ophthalmic division of cranial nerve V High risk of vision loss if antiviral therapy is not promptly initiated
Acute retinal necrosis	Necrotic infection of the retina that often leads to profound vision loss Caused by herpes viruses, most often by herpes zoster or varicella
Ramsay Hunt syndrome (herpes zoster oticus)	Major otologic complication of herpes zoster from viral reactivation within the geniculate ganglion, with potential spread to cranial nerves V, VII, VIII, IX, and X Often manifests as the triad of facial palsy, ear pain, and otic vesicular lesions
Miscellaneous neurologic complications	Stroke syndromes, motor neuropathy, myelitis, encephalitis, central nervous system vasculitis
Disseminated infection	Disseminated varicella infection with potential for visceral target organ involvement with possible widespread cutaneous involvement

Based on information from references 1 and 2.

View popup

TABLE 2

Patient groups identified as immunocompromised by the Centers for Disease Control and Prevention

Patients with primary immunodeficiency states

Patients with hematopoietic stem cell transplant

Patients with solid-organ transplant

Patients with malignancies

Patients living with human immunodeficiency virus infection

Patients with immune-mediated disease states

Patients taking immunosuppressive medications

Based on information from reference 12.

View popup

TABLE 3

Summary of recommendations for recombinant zoster vaccine in immunocompromised groups

Group (recommendation source)	Recommendations
Hematopoietic transplantation (CDC)²³	Autologous: wait at least 3 months after transplant Allogeneic: wait at least 6 months after transplant Initiate RZV about 2 months before discontinuation of antiviral therapy^{^a}
Solid-organ transplantation (CDC)²³	Administer RZV prior to transplant (if possible) or 6–12 months after transplant when graft stable on maintenance immunosuppression^{^a}
Malignancy (CDC)²³	Administer RZV before to treatment (if possible) or when the immune system is not acutely suppressed or is likely to be most robust^{^a}
Rheumatic inflammatory and musculoskeletal diseases (American College of Rheumatology)²⁴	Administering RZV is strongly recommended for patients with rheumatic and musculoskeletal diseases age > 18 who are taking immunosuppressive medication
Inflammatory bowel disease (American College of Rheumatology)²⁴	All patients receiving Janus kinase inhibitor therapy should receive RZV Risk of herpes zoster should be considered with combinations of other immunosuppressive^{^b} therapies
Psoriasis (Medical Board of the National Psoriasis Foundation)²⁵	RZV should be given to all patients with psoriasis and psoriatic arthritis > age 50 and to patients < age 50 on tofacitinib, systemic corticosteroids, or combination systemic therapy^{^b}
Primary immunodeficiency diseases	No formal recommendations from societies as of now; per package insert RZV is indicated in adults age 18 and older who are or will be at increased risk of herpes zoster due to immunodeficiency or immunosuppression caused by known disease²⁶
HIV (CDC)²⁷	Patients with HIV ≥ age 18 should receive 2 doses of RZV at 0 and 2 to 6 months Consider delaying vaccination until the patient is virologically suppressed on antiretroviral therapy or until the CD4 count is > 200 cells/mm³ to ensure a robust vaccine response Patients with HIV ≥ age 18 should receive RZV regardless of previous history of herpes zoster or previous receipt of live zoster vaccine (no longer available) or therapy

↵^a Recommendations vary somewhat among societies; expert opinion was recently summarized.²⁸
↵^b Systemic immunosuppression refers to current treatment with prednisone (> 20 mg/day for more than 14 days), azathioprine (> 2.5 mg/kg/day), mercaptopurine (> 1.5 mg/kg/day), methotrexate (> 0.4 mg/kg/week), cyclosporine, tacrolimus, infliximab, adalimumab, golimumab, certolizumab, ustekinumab, or tofacitinib.
CDC = Centers for Disease Control and Prevention; HIV = human immunodeficiency virus; RZV = recombinant zoster vaccine