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Zoster Immunosuppression Adjustment LN — ESENeph MCQ

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ModerateGlomerulonephritisZoster Immunosuppression Adjustment LNESENeph

A 43-year-old woman with lupus nephritis is on maintenance mycophenolate 1 g BD, hydroxychloroquine 200 mg OD, and prednisolone 7.5 mg. She develops herpes zoster (shingles) affecting the T4 dermatome. She is started on oral valaciclovir. Regarding her immunosuppression, what is the recommended approach?

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Correct answer: E — Temporarily reduce or hold MMF; continue prednisolone and HCQ

Herpes zoster in an immunosuppressed patient with LN warrants temporary reduction or holding of MMF to allow immune recovery while continuing antiviral treatment. Prednisolone should be continued (acute withdrawal risks adrenal crisis and LN flare). Hydroxychloroquine should be continued as it has immunomodulatory rather than immunosuppressive effects and provides ongoing lupus disease control. The MMF dose can be cautiously restarted once the acute zoster episode has resolved (typically after completion of the antiviral course and crusting of vesicles). Complete cessation of all immunosuppression risks LN flare, which would be more dangerous than the zoster episode.

Reference: KDIGO 2024 – Lupus Nephritis; BSR 2017 – Vaccination and Infections in Immunosuppressed Patients