The Last Word - SHINGLES: A Case Study

Mira Steranka

My name is Mira Steranka, I am in my sixties and live in Mississauga. My story began a week after abdominal surgery in March of 2005. I woke up one morning with a bloody left eye. I was referred to an ophthalmologist (eye doctor) who was on call for emergencies, just to be told that I had shingles on the cornea of my left eye. I was prescribed four or five different eye drops that I had to administer almost every hour. Every couple of days I had to go for a follow up because the pressure in my eye was so high, that I could have gone blind if not treated properly. My eye was very sensitive to light and this made me extremely nauseous. I had to wear sunglasses even indoors.

Several weeks went by before I was able to sit and look at a computer screen. When I went on the internet and this is what I found:

“Shingles is a painful skin rash. It is caused by the varicella zoster virus. Shingles usually appears in a band, a strip, or a small area on one side of the face or body. It is also called herpes zoster.

Shingles is most common in older adults and people who have weak immune systems because of stress, injury, certain medicines, or other reasons. Most people who get shingles will get better and will not get it again. But it is possible to get shingles more than once.

Shingles occurs when the virus that causes chickenpox starts up again in your body. After you get better from chickenpox, the virus "sleeps" (is dormant) in your nerve roots. In some people, it stays dormant forever. In others, the virus "wakes up" when disease, stress, or aging weakens the immune system. Some medicines may trigger the virus to wake up and cause a shingles rash. It is not clear why this happens.”

As my luck would have it, when I was a small child I almost died due to a very bad case of chicken pox. Unfortunately, the virus “awakened” when my immunity dropped significantly due to the stress of my long abdominal surgery.

It took almost six weeks for my eye to get better. Imagine that you have an eyelash or sand in your eye and it is there 24/7 week after week. Some days the pain was so bad that I cried, because I did not know how to stop it. I thought that I would gouge my eye out just for the pain to stop. My eye eventually got somewhat better, but new outbreaks kept happening three to four times every year since. During an outbreak, blisters return to the cornea, my eye gets bloodshot, and the pain intensifies. The morning is the worst. The pressure in the eye is so high that it feels as if someone is pushing my eye out of the socket. When the pain is bad it makes me very nauseous. Under conditions of stress, outbreaks take much longer to go away. By now, my cornea is deeply scarred, I developed severe dryness, my eye tears constantly, and I have double vision. I have to use drops several times a day, which are not covered by insurance, as they are over the counter medications.

I changed my diet to include food with a high content of lysine and tried to alleviate stress but the outbreaks kept reoccurring. I was already on disability due to the chronic pain caused by a previous motor vehicle accident, and this additional pain was making my life even more miserable.

Four years ago, a night before my regular annual check-up, I saw a TV advertisement for shingles vaccine Zostavax. During the check up my family doctor mention the Zostavax vaccine to me. I immediately accepted his offer to receive the injection and ever since then the outbreaks have decreased significantly to one or two per year. I found out that the shingles vaccine (Zostavax) is an injection of a weakened form of the chickenpox virus that reduces the chances of getting shingles by about 50%. The vaccine also helps prevent the spread of the virus.

From my personal experience, I can tell you that the vaccine is the best way to reduce the chance of developing shingles or, in case shingles occurs to reduce chances of long-lasting pain (Post Herpetic neuralgia). The vaccine is available in pharmacies and doctors' offices. 


HOT OF THE PRESS
The Ontario Government in their budget on February 25, 2016 announced New Funding for Shingles Immunization. The government aims to make the shingles vaccine available to Ontario seniors between the ages of 65 and 70, free of charge. The investment will save eligible seniors about $170 in out-of-pocket expenses for the vaccine, and reduce emergency room visits and hospitalizations for vaccinated seniors


Dr. Angela Mailis

Dr. Angela Mailis

DOCTOR’S CORNER

Mira’s experience with Herpes Zosters (HZ) is a bad one. To under- stand the magnitude of the problem, let’s talk numbers. One out of three Canadians will experience an episode of HZ in their life- time. The numbers are one out of two for those aged 85 years and older. Complications that can severely affect the patient’s quality of life are:

  • Acute HZ pain (due to Shingles) causes loss of work and low quality of life
  • Post Herpetic Neuralgia occurs in 10-22% of those afflicted with acute HZ and can have several complications such as eye problems; scarring; and super infections (infections other than HZ). * Stroke

HOT NEW INFORMATION

HZ is a risk factor for Stroke (particularly in the first two weeks after HZ infection)

On the other hand, factors that increase the risk to develop HZ are:

  • Family History with blood relatives having HZ. One blood relative increases the risk 3-5 times. The risk is much higher with multiple blood relatives suffering from HZ.
  • COPD
  • Diabetes
  • Use of statins (such as Lipitor and other drugs that reduce blood lipids).

The National Advisory Committee on Immunization (NACI) has made the following recommendations in 2013 as to who should be vaccinated against HZ:

A) AGE GROUPS

HZ vaccine is recommended for the prevention of HZ and its com- plications in persons 60 years and older without contraindications, and may be used in patients aged 50-59

B) PREVIOUS VARICELLA ZOSTER VIRUS (VZV) HISTORY

HZ vaccine may be administered to individuals less than 50 years of age with a prior history of HZ.

C) In regards to a SECOND DOSE
for healthy persons previously
vaccinated with the HZ vaccine,
National Advisory Committee on
Immunization (NACI) states that
duration of protection remains unknown beyond five years; it is also not known whether booster doses of vaccine are beneficial.

D) IMMUNOSUPPRESSED PERSONS

Individuals with HIV, post-organ or hematopoietic stem cell trans- plant, or in those receiving high-dose corticosteroids, chemother- apy or immune-suppressing medications: If patients are going to be initiated on immunosuppressive medications, administration of HZ vaccine prior to immunosuppression should be considered. A period of four weeks should be allowed to elapse between vaccine administration and initiation of immune-suppressing medications or treatments. If the immune-suppressing medication is discontinued, a period from three days to greater than one year, depending on the specific medication, should elapse before vaccination with live attenuated vaccine such as HZ vaccine can be considered.

Individuals on low-dose immunosuppressive therapy: NACI recommends that it is reasonable to consider HZ vaccine in patients on lower doses of immunosuppressive agents: low-dose prednisone (< 20 mg/day), methotrexate ≤ 0.4 mg/kg/week, azathioprine ≤ 3.0 mg/kg/day and 6-mercaptopurine ≤1.5 mg/kg/day.

Individuals on anti-TNF biologics (such as those used in rheumatoid arthritis), may receive the HZ vaccine after review with an expert in immunodeficiency.

With these new guidelines it is easier for family doctors to guide patients when and whether they should have the vaccine.


Angela Mailis MD, MSc, FRCPC (PhysMed)
Director, The Pain & Wellness Centre, Vaughan
Consultant CIPP/UHN
Adjunct Professor, University of Toronto
Chair ACTION Ontario