The risks of the shingles vac­cine

The Daily Telegraph - - Health & Features - James Le Fanu Please email your med­i­cal ques­tions con­fi­den­tially to Dr James Le Fanu at: dr­james@tele­

Pa­tients need to be in­formed of the po­ten­tial risk of this dev­as­tat­ing com­pli­ca­tion

The “hell­fire” of shingles is al­ways best avoided. While the char­ac­ter­is­tic rosy-red rash caused by the her­pes zoster virus usu­ally clears in a few days, the stab­bing, toothache-like pain of its af­ter-ef­fects, post-her­petic neu­ral­gia, may per­sist for months.

Those who have had one such episode might nat­u­rally be in­clined to have the shingles jab in an­tic­i­pa­tion of pre­vent­ing an­other. It would, how­ever, be pru­dent not to. For though it is cer­tainly very ef­fec­tive in re­duc­ing the risk of shingles by two thirds, it can “re­ac­ti­vate” resid­ual traces of the virus in the tis­sues.

This par­tic­u­larly ap­plies to those in whom the orig­i­nal episode in­volved the scalp and eye (her­pes zoster oph­thalmi­cus), in whom the vac­cine can in­duce an in­flam­ma­tory re­ac­tion in the cornea and retina, re­sult­ing in visual im­pair­ment. “Pa­tients need to be in­formed of the po­ten­tial risk of this dev­as­tat­ing com­pli­ca­tion,” ob­serves oph­thal­mol­o­gist Bruce Jack­son.

Sim­i­larly, par­ents need to be in­formed (though they are not) of the po­ten­tial com­pli­ca­tions of the HPV vac­cine Gar­dasil, rou­tinely ad­min­is­tered to ado­les­cent girls for the past decade. The ar­gu­ments over the pay­off be­tween its pu­ta­tive ben­e­fits in pro­tect­ing against cer­vi­cal can­cer ver­sus its ad­verse ef­fects, re­hearsed in this col­umn ear­lier this year, are high­lighted again by an over­view of the rel­e­vant ev­i­dence pub­lished last month.

Neu­rol­o­gist Dr Manuel Martine­zlavin of the Univer­sity of Buf­falo, writ­ing in the journal Im­muno­logic Re­search, sum­marises the find­ings of 10 stud­ies from around the world. “The de­scribed symp­tom clus­ters are re­mark­ably sim­i­lar,” he writes, and in­clude de­bil­i­tat­ing fa­tigue, headache, gut dis­tur­bances, faint­ing, weak­ness and mem­ory im­pair­ment. Their on­set soon af­ter im­mu­ni­sa­tion, sug­ges­tive of a causative role for the vac­cine, is bol­stered by their con­sis­tency, “in­de­pen­dently con­firmed by doc­tors in dif­fer­ent places, cir­cum­stances and times”.

This mer­its fur­ther in­ves­ti­ga­tion – but, in the mean­time, par­ents, rather than de­fer­ring to ex­pert opin­ion of the vac­cine’s safety, should pru­dently ac­quaint them­selves with the con­trary view.

Can’t feel my feet

The co­nun­drum of the pre­vi­ously fit and healthy woman in her early 60s who de­vel­oped numb­ness and a jel­ly­like feel­ing in both feet af­ter a cycling trip to France has elicited a cou­ple of pos­si­ble ex­pla­na­tions. The “ob­vi­ous” di­ag­no­sis of dis­turbed func­tion­ing of the sen­sory nerves (pe­riph­eral neu­ropa­thy) was ruled out by the find­ings of the rel­e­vant nerve con­duc­tion stud­ies. So what else might be re­spon­si­ble?

“I had a sim­i­lar prob­lem ex­ac­er­bated by walk­ing and hik­ing,” writes one gen­tle­man in whom it turned out to be due com­pres­sion of the tib­ial nerve as it passes be­hind the bony promi­nence of the in­ner an­kle into the foot. This tarsal tun­nel is equiv­a­lent to carpal tun­nel at the wrist, which causes pain and numb­ness in the hand, and may also re­quire sur­gi­cal de­com­pres­sion.

The fur­ther pos­si­bil­ity would be dis­turbed func­tion­ing of the small nerves in the skin – a small fi­bre neu­ropa­thy – of­ten ex­pe­ri­enced as a “wrin­kle in sock” or “peb­ble in shoe” sen­sa­tion. The nerve con­duc­tion stud­ies be­ing nor­mal, the di­ag­no­sis re­quires a skin biopsy that re­veals an ab­nor­mal ap­pear­ance of those small nerve fi­bres. There is re­gret­tably no spe­cific treat­ment, though drugs such as amitripty­line may be of value, along with lo­cal anaes­thetic (li­do­caine) plas­ters.

Un­der pres­sure

Fi­nally, com­bin­ing two themes of re­cent col­umns – the haz­ards of the overzeal­ous treat­ment of hy­per­ten­sion and the mer­its of com­ple­men­tary ther­a­pies – a York­shire reader com­mends acupunc­ture for low­er­ing the blood pres­sure. She felt duty bound to come up with an al­ter­na­tive to drugs and, even­tu­ally, her fam­ily doc­tor agreed to a trial of the needling treat­ment. That was Septem­ber last year, since when, to­gether with a cou­ple of booster ses­sions, her blood pres­sure re­mains in the rec­om­mended range.

There is, of course, no recog­nised phys­i­o­log­i­cal ex­pla­na­tion why acupunc­ture should have this ef­fect, which has been demon­strated in a for­mal clin­i­cal trial.

Be warned: the shingles vac­ci­na­tion can carry a risk of visual im­pair­ment

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