Now that I’m 70, I’m eligible for the shingles vaccine. However, I take methotrexate (25mg weekly) for rheumatoid arthritis so am immunosuppressed and understand I should avoid live vaccines. Can you advise?
Linda Bernard, London.
Shingles (or herpes zoster) can affect anyone who has had chicken pox in the past — at least one in four people over 50 will develop it at some point.
It occurs when the chicken pox virus becomes active again, escaping from the spinal cord where it’s been locked away by the immune system.
But this time it causes a very different and potentially far more severe illness than the original chicken pox.
Shingles can affect anyone who has had chicken pox in the past — at least one in four people over 50 will develop it at some point in their later life
The first symptom is often pain, along with fever and a general sense of being unwell.
Finally, the characteristic shingles rash appears, initially as red bumps that then develop into painful blisters.
There are many reasons why the immune system may let go of its grip, allowing this to happen, anything from a broken leg to a bout of pneumonia, or chemotherapy or radiotherapy.
It can also occur if you’re taking medication that suppresses the immune system, such as steroids (for example, prednisolone) or methotrexate, the drug you’ve been prescribed.
The shingles vaccine is a live, though deliberately weakened (known as ‘attenuated’), virus — it won’t necessarily prevent shingles, but if you do subsequently develop it, the attack is far milder and less likely to lead to one of the main complications — long-lasting nerve pain.
However, because it’s a live virus it cannot be given to those who are immunosuppressed — whether through illness or treatment — because there’s a risk the viral infection will go wild and could even be lethal.
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The guidelines state that methotrexate, at a dosage of up to 25mg weekly, does not have such an immunosuppressant effect that the shingles vaccine (Zostavax) is forbidden outright.
It may still be an option for you on the basis that having rheumatoid arthritis and being on methotrexate themselves may raise your risk of shingles, which is well worth avoiding if possible.
But because there may be other factors in your health history that affect your immune system, it’s vital you take the advice of your GP or rheumatologist.
I have lymphoedema in my right arm following a mastectomy on my right breast.
Recently I became hot and cold and couldn’t stop shivering — my GP sent me to hospital, where I stayed for a week.
A tiny scratch on my finger had led to cellulitis. What is this, and what is its connection to the immune system and lymphoedema? Why did a tiny scratch cause such alarm?
Gemma Levine, London.
Cellulitis is a known complication of lymphoedema. It’s unpleasant and worrying but not sinister, as I will explain.
Lymphoedema — essentially the accumulation of fluid in the tissues — is caused by a problem with the lymphatic system, a network of tiny vessels that drain fluid, called lymph, from the body’s tissues and back into the bloodstream. Lymph is important for helping to defend the body against infection.
During your mastectomy, the surgeon removed many, if not all, of the lymph nodes in your right armpit.
Lymph nodes are small glands connected to the lymph vessels which act as a sort of filter, trapping any invaders, such as cancerous cells.
If there’s any sign the primary tumour in the breast has moved into these nodes, removing them will reduce the chance of the cancer recurring.
Because these particular nodes are linked to the lymph channels leading from the hand and arm on that side of the body, inevitably at least some of them will be permanently affected. And as the lymph fluid can’t now drain effectively, the arm swells.
Dr Scurr advises Ms Levine to wear good quality gloves when gardening in order to prevent any cuts to her skin becoming infected
The swelling can be reduced with a compression garment: a firm, elasticated tube that applies pressure to the area.
Lymphatic massage — carried out by specialists — can also help by moving fluid through the tissues of the arm back towards the shoulder and the heart.
You may well have had these treatments. Unfortunately, even if a treatment makes some difference to the swelling, the condition can compromise the normal protective mechanisms against infection in that area.
As a result, a small breach in the skin of the hand or arm may allow harmful bacteria to gain a foothold, setting up a soft tissue infection known as cellulitis.
The culprits are typically streptococci or staphylococci bacteria.
They can rapidly spread under the skin and invade the subcutaneous fat, resulting in a high temperature — this explains your feelings of being hot, cold and shivering — redness and heat in the area, along with further swelling.
There’s a risk the infection can continue to spread with sepsis (a potentially life-threatening condition where the body’s immune system goes into overdrive).
To prevent the spread of infection, you need prompt and vigorous treatment with antibiotics, which is why you were immediately taken to hospital.
The treatment is often continued for 14 days — via an intravenous drip for the first few days and by mouth after that — to be certain of eradicating all the bacteria.
I must stress that your immune system in general is not compromised by lymphoedema — the problem is localised to the area affected by the condition.
However, you will always be at risk from this, and so should take great care to avoid even the most minor injuries to your right hand and arm.
For example, be careful when cutting your nails, wear thick, good quality gloves when gardening or engaged in similar activities and do your best to avoid insect bites.