Background/Purpose: Herpes zoster (HZ) is an opportunistic infection caused by Varicella Zoster Virus (VZV); HZ is observed with increasing frequency in patients on immunosuppressive therapies. HZ is not only a morbid condition but is associated with a variety of complications. Prior literature has suggested that the risk of stroke may increase shortly after an incidence of HZ, but little is known about this association for patients with autoimmune (AI) disease who are at increased risk both for zoster and stroke compared to the general population.

Methods:

Medicare data (2006-2012) was used to identify patients with incident herpes zoster (HZ), defined by at least one ICD9 diagnosis code 053.xx from hospital discharge or outpatient HZ with a prescription for zoster drug within 7 days. Within the preceding 12 months (‘baseline’), they also must have had consecutive coverage with Medicare parts A, B, and D and could not have had any diagnosis code or treatment for HZ.  They must also have had ankylosing spondylitis (AS), inflammable bowel disease (IBD), psoriasis (PSO), psoriatic arthritis (PSA), or rheumatoid arthritis (RA) based on 2+ diagnoses from physician visits. Patients with prior stroke or the occurrence of HZ and stroke on the same day were excluded.

Follow-up started at the date of HZ diagnosis + 1 day. The outcome of interest was hospitalized ischemic stroke. The hypothesis tested was that the incidence of stroke immediately following HZ was increased compared to the incidence of stroke at later time points. Incidence rate of hospitalized ischemic stroke in risk windows of 6 and 12 months following the HZ event were evaluated. Poisson regression was to compute incidence rate ratios (IRRs) and to control for multiple potential confounders potentially associated with stroke, comparing the 1, 6 and 12 month periods after HZ to subsequent time periods.

Results:

A total of 50,929 patients with autoimmune diseases and incident HZ were eligible for analysis. The crude incidence rate of hospitalized ischemic stroke was 9.8/1000py in the 6 months after HZ, compared to 8.7/1000py in years 2-6. After multivariable adjustment for multiple stroke-related factors, the IRR for the risk in the first year compared to the second was 1.30 (1.05 – 1.61) compared to month 12-18. Examining the shorter risk window of 30 days after HZ, the IRR was 1.50 (1.06 – 2.12) compared to the pooled rate in years 2-6. Age, diabetes, hypertension, atrial fibrillation, prior TIA, and higher glucocorticoid doses were also significantly associated with higher stroke risk.

Conclusion:

In patients with autoimmune diseases, incident herpes zoster was associated with a 50% increase risk for stroke in the subsequent month. These data provide urgency for developing strategies to reduce the risk of VZV  in vulnerable immunosuppressed patients.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/herpes-zoster-and-the-short-term-risk-for-ischemic-stroke-in-patients-with-autoimmune-diseases/