What further workup or vaccine is recommended for this patient with varicella zoster (shingles)?

Management of Varicella Zoster (Shingles): Further Workup and Vaccination

No Further Workup Required for Active Shingles

For a patient with active varicella zoster (shingles), no additional diagnostic workup is needed once the clinical diagnosis is established, and vaccination should NOT be administered during active infection. 1, 2

• The diagnosis of shingles is clinical, based on the characteristic dermatomal vesicular rash and associated pain 3, 4
• Laboratory confirmation (viral culture, PCR, or direct fluorescent antibody testing) is only necessary in atypical presentations or immunocompromised patients where diagnosis is uncertain 5, 6
• Immunomodulator therapy and live vaccines must not be started during active shingles infection 1, 2

Infection Control Assessment

The primary "workup" for a patient with shingles involves assessing contagiousness and implementing appropriate precautions:

• Determine if lesions are localized or disseminated - disseminated disease requires airborne and contact precautions with negative air-flow rooms until all lesions are dry and crusted 2
• For localized shingles, ensure complete covering of all lesions and implement standard precautions 1
• The patient remains contagious from 1-2 days before rash onset until all lesions have dried and crusted (typically 4-7 days after rash onset) 2
• Identify and protect high-risk contacts: pregnant women, premature infants, neonates, immunocompromised persons, and anyone without history of chickenpox or varicella vaccination 2

Postexposure Management of Contacts

If healthcare personnel or patients were exposed to this patient's uncovered lesions, implement the following protocol:

• Define exposure as close contact (same room or face-to-face contact, typically 5 minutes to 1 hour, but not transitory contact) 1
• Identify all exposed susceptible individuals using criteria for evidence of immunity (documentation of 2 doses of varicella vaccine, laboratory evidence of immunity, laboratory confirmation of disease, or birth in the United States before 1980 for non-immunocompromised, non-pregnant patients) 1
• Unvaccinated healthcare personnel without evidence of immunity should receive postexposure vaccination as soon as possible - vaccination within 3-5 days of exposure to rash might modify disease if infection occurred 1
• Healthcare personnel who received 1 dose of vaccine should receive the second dose within 3-5 days after exposure (provided 4 weeks have elapsed after the first dose) 1
• For pregnant or immunocompromised exposed individuals without evidence of immunity, administer varicella-zoster immune globulin (VariZIG) rather than vaccine 1

Vaccination Timing After Recovery

Live varicella-zoster vaccines should only be considered AFTER complete resolution of active infection:

• Therapy can be reintroduced only after all vesicles have crusted over and fever has resolved 2
• For immunocompromised patients on immunosuppressive therapy, varicella vaccination should be strongly considered in VZV-naïve patients on methotrexate monotherapy 1
• Vaccination can be considered in VZV-naïve patients on low-dose glucocorticosteroids, TNF inhibitors, anti-IL1, and anti-IL6 therapy, though the level of evidence is lower 1
• The recombinant zoster vaccine (Shingrix) is preferred over live attenuated vaccine (Zostavax) for future zoster prevention, particularly in immunocompromised populations 7

Common Pitfalls to Avoid

• Do NOT assume antiviral therapy makes the patient immediately non-contagious - viral shedding continues until lesions are fully crusted 2
• Do NOT allow healthcare workers with shingles to care for high-risk patients before lesions are fully crusted, even with covered lesions 2
• Do NOT administer live vaccines during active infection - this poses risk of vaccine-induced infection 1
• Do NOT overlook airborne transmission risk in healthcare settings, particularly with disseminated disease or immunocompromised patients 2
• Do NOT forget that immunocompromised patients may have prolonged viral shedding (7-14 days or longer) and extended contagiousness 2