By Eli A. Friedman, MD

Earlier this year, I spoke to a friend with a wonderfully functioning kidney transplant who was confused by a recent onset of severe, one-sided chest pain, associated with redness and blisters called “shingles.” Having to deal with an attack of shingles can be a startling and threatening event that comes as an unwelcome surprise, spoiling the happy renewal of life usually associated with a kidney transplant. Because shingles is often misdiagnosed during its first week, it is common for the patient to be confused and frightened early on and unclear as to exactly what is causing so much pain. This article provides information to prepare for and deal with shingles, should it come knocking on your door.

Who Gets Shingles?

First, shingles is not a rare or unusual complication that comes as an unwanted “extra” after a kidney transplant. While most adults know someone who has had a bout of shingles, there is still confusion as to what it is. According to the United States Public Health Service, each year approximately one million Americans suffer from shingles or herpes zoster, a painful infection caused by the Varicella virus, also known as chicken pox. Ten to 20 percent of Americans will have shingles at some point, usually after age 60. Anyone who has had chicken pox can get shingles – almost anyone more than five years old is at risk. The same chicken pox virus that has been inactive in your nerve root cells for decades can suddenly spring to life as an adult skin disease. When the virus “awakens” within the nervous system it causes a blistering rash and severe burning pain, tingling or extreme sensitivity to the skin, usually limited to one side of the body and lasting about a month. Once active, the germs travel along the nerve paths to the skin, leaving a path of destruction along the nerves in which they travel.

Why Does Shingles Develop?

Consider shingles an unwelcome traveler that tags along your transformed life after a kidney transplant. A healthy immune system usually keeps the Varicella zoster virus inactive. In people 65 years or older, even those considered healthy, their immune systems naturally weaken to some germs, such as herpes zoster, resulting in most cases of shingles. Typically, but not always, shingles attacks elderly people whose immune systems are stressed by another disease. As you probably guessed, in addition to the elderly, other people with weakened immune systems risk developing shingles, such as those with kidney failure on dialysis, HIV or AIDS, cancer (especially those receiving chemotherapy), and tissue and organ transplant recipients treated with immunosuppressive drugs [prednisone, cyclosporine (Sandimmune), Tacrolimus (Prograf) and azathioprine (Imuran)].

As a Transplant Recipient, Should I Worry About Catching Shingles?

No! Shingles is not contagious. Indeed, in one remarkable report published earlier this year from Louisiana State University Health Sciences Center in New Orleans, 98 percent of healthy individuals with no evidence of any symptoms had herpes virus in their tears and saliva at least once during the course of the 30-day study. This means, although we swim daily in a sea of herpes viruses, shingles only occurs when the virus in our body becomes active. Contact with an infected person will not cause shingles. However, though shingles is not contagious, contact with a person with shingles could lead to chicken pox in someone who has never had, or been immunized against, chicken pox.

Does the Shingles Virus Cause Genital Warts?

No! Shingles is caused by a particular type of herpes virus called Varicella zoster. Other kinds of the herpes virus cause genital herpes infections or cold sores. Specifically, Varicella zoster virus only causes chicken pox or shingles.

What Are the Symptoms of Shingles?

The first sign of shingles is usually a tingling feeling or itchiness of the skin, one week before the rash. Some people have a stabbing pain at the beginning while others only have pain after the rash begins. Caregivers may mistake the onset of localized pain as a muscle strain, prescribing a heating pad or ointments. By the time a rash breaks out, pain may be extremely severe to the extent that a major catastrophe such as a heart condition or gallbladder attack is misdiagnosed.

Strangely, the rash begins as a band or patch of raised dots that stays on one side of the trunk, face, abdomen, arms or legs. Thus, it is the limited extent of the painful rash that gives the doctor the signal that the infection is actually shingles. In fact, those familiar with anatomy recognize the rash follows the course of a nerve commonly on one side of the chest (front or back, like half of a belt) or on one side of the forehead and scalp. The word shingles comes from a Latin word meaning belt or girdle, and zoster is Greek for belt.

If a person gets herpes zoster in the forehead region, the facial nerve is infected calling for an emergency evaluation with an eye doctor. Since the facial nerve supplies parts of the eye, the virus may injure the cornea (front membrane of the eye) or damage the retina (back of the eye), as well as other parts of the eye.

In the majority of cases, after less than a week skin spots become fluid-filled blisters. These blisters dry and crust within two weeks, and no longer contain any virus. From the first sign of discomfort to the loss of scabs, shingles typically lasts a month. In some cases, pain associated with herpes zoster can continue months or years in a fatiguing disorder called post-herpetic neuralgia (PHN).

Is a Correct Diagnosis Usual?

Your transplant team has seen so many shingles patients that the usual case is easily recognized and clinical diagnosis is accurate. Early in its course, or when an unusual part of the skin is involved, lab tests may be needed to confirm diagnosis. Growing the virus in a culture from swabs of skin blisters is possible but relatively difficult. A direct immunofluorescence assay (a test that detects the virus antibodies) is more sensitive, less expensive, and faster than a viral culture. For most cases, a culture is not used because diagnosis is obvious. PHN pain persisting more than 30 days after the rash is gone can be a miserable problem, especially in as many as 50 percent of older patients. In one study, PHN was 15 times as common in those more than 60 years of age as in younger patients. Patients may experience a light pain, known as allodynia (even a light touch causes intense pain), that can continue for months and occasionally years. Brain and spinal cord disorders and paralysis of nerves that may result in a droopy eyelid or side of the face were risks before the introduction of antiviral drugs. Rarely, shingles becomes a body-wide disease with profound sickness, including pneumonia.

What Is the True Risk of Shingles for Kidney Transplant Recipients? Can You Die From Shingles?

Remember how common shingles is in the general population as you try and balance your added risk after a kidney transplant. A Korean study of 561 kidney transplant recipients in 2002, noted an average follow-up of 64 months, 34.2 percent had 193 virus infections of all kinds, of which Varicella zoster virus accounted for 29 percent. Life-threatening generalized herpes zoster infections occurred in three cases while a “new” case of chicken pox occurred in six recipients. The good news is none of the shingles patients died.

Is There a Treatment for Shingles?

Yes! A clear benefit of early diagnosis of shingles is rapid treatment with reduced pain and discomfort as well as faster healing and limited spreading of the disease. It has also been suggested that if treatment is begun within two or three days of developing a rash, risk of PHN is reduced. There is no disagreement that a patient with herpes zoster on the face should see a physician immediately, because eye infection can lead to blindness. The main treatment for shingles is one or more antiviral drugs taken orally (three to five times a day for seven to 10 days), such as acyclovir (Zovirax), famciclovir (Famvir) and valacyclovir (Valtrex). Transplant recipients should continue taking prednisone to minimize inflammation. Pain relievers and antidepressant medications are given to ease pain, which if severe, may require a nerve block.

What We Don’t Know for Sure

Should Every Patient With Herpes Zoster Get Antiviral Therapy?

Those at highest risk for complications, such as elderly, immunosuppressed, transplant recipients and those with eye involvement should begin antiviral drugs.

After 72 Hours, Is It Too Late to Begin Antiviral Therapy?

No. Drug trials offer a scientific answer to this question. Consensus among nephrologists advises the earlier antiviral therapy is begun, the more likely a good clinical response. Some patients benefit from these drugs even when treatment is started after three days.

Can Shingles be Prevented?

In 1995, a shingles vaccine using the Varicella zoster virus Oka strain was introduced for children in the United States. Since then, trials in Australia, Europe and America have not reached a single conclusion as to whether the vaccine works. Currently, vaccines combining measles, mumps and rubella (German measles) are under evaluation. However, there is currently insufficient evidence to recommend kidney transplant recipients and/or dialysis patients undergo vaccination for shingles.

Conclusions and Recommendations

Kidney transplant recipients have a real risk of developing shingles at any time during their treatment with antirejection drugs. Shingles is diagnosed clinically, but a special test, the direct immunofluorescence assay, may be helpful in atypical cases. Acyclovir, valacyclovir and famciclovir are approved for treatment of herpes zoster and are safe and effective. Antiviral therapy is vital when the eye is involved. No single treatment works for PHN and consultation with a pain-management specialist may be needed. In the large majority of transplant recipients, the outlook for rapid recovery from shingles is the rule, as was the case for my friend.

Dr. Friedman is Chief of the Division of Renal Disease for State University of New York, Downstate Medical Center and serves as Chairperson of the AAKP Medical Advisory Board.

This article originally appeared in the May 2005 issue of aakpRENALIFE, Vol. 20, No. 6.

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