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In this issue of Annals of Rheumatic Diseases, Garcia-Doval and colleagues add to a flurry of recent studies examining the risk and outcomes of herpes zoster (HZ) among those patients who use anti-tumour necrosis factor (TNF) therapies. While the increased risk of infection due to granulomatous and select other intracellular pathogens has been clearly demonstrated in this setting,1,–,3 much less is clear with regard to viral pathogens.4 The reactivation of varicella zoster virus (HZ or shingles) is of public health concern given HZ's ability to cause substantial long-term pain, depression and disability due to postherpetic neuralgia (PHN).4 5 HZ is common; approximately one-third of the population will experience it during their lifetime, with 18% of cases resulting in PHN and 10% to 15% involving ocular tissues with potential for permanent visual loss. Rarely, HZ can disseminate and cause systemic complications and death, a risk heightened by HIV infection and other forms of severe immunosuppression.6 7 HZ rates increase substantially with age, as cell-mediated immunity to varicella virus wanes and as comorbidities associated with immunosuppression become more common. In the USA, HZ incidence rates range between 4 and 11/1000 patient-years in patients aged 50 and 80 years, respectively, with rates higher in women.6 7
Recently, a live-attenuated vaccine to prevent HZ (Zostavax, Merck, Whitehouse Station, New Jersey, USA) has been developed and approved for use in patients age 60 years or older, regardless of their HZ or varicella history.7 For rheumatologists, who frequently treat immunosuppresed individuals within this age group, the questions begin here: are my patients at increased risk for HZ due to their disease or their therapies? Should I avoid anti-TNF …
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