Managing Varicella Zoster Virus Contact and Infection in Patients on Anti-Rheumatic Therapy

Matthew Cates; Matthew Donati; Sophie Gillet; Andrew Ustianowski; James Galloway


Rheumatology. 2018;57(4):596-605. 

In This Article

Abstract and Introduction


Chickenpox and shingles can be more severe and occasionally life threatening in immunosuppressed patients. As such, some groups warrant a more detailed history, serological testing and consideration of prophylaxis following contact with the virus. Active disease may also require more aggressive treatment with antivirals. Guidance for the use of varicella zoster immunoglobulin has recently been updated by Public Health England with important implications for rheumatology patients.


Varicella zoster virus (VZV) is one of eight herpesviruses that are known to cause disease in humans. Primary infection occurs as chickenpox, also known as varicella, with fever and widespread rash. In otherwise well children, it is self-limiting and rarely life threatening, although encephalitis and pneumonitis can complicate the disease. Primary infection in adults, while much less common, is more frequently associated with complications and has a 25-fold increased mortality compared with children.[1] Following primary infection, the virus lies dormant in the nervous system and can reactivate later in life as shingles, also known as zoster. Shingles may be complicated by chronic pain (post-herpetic neuralgia) in the region affected, which occurs more frequently in older individuals.[2] Rarely, shingles can extend across multiple dermatomes or even disseminate systemically. Some forms of immunosuppression increase the risk of both severe primary infection in people without prior exposure to the virus and dissemination of infection following reactivation. This review discusses the assessment and management of immunosuppressed adults with rheumatic disease who are at risk of VZV infection or reactivation.