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Question

Difficulty: HardPreventive Care and Screening

A 42-year-old man comes to the clinic for a health maintenance examination. He has a history of end-stage renal disease secondary to IgA nephropathy and underwent a deceased-donor kidney transplantation 8 months ago. His current medications include tacrolimus, mycophenolate mofetil, and low-dose prednisone. He has a 22-pack-year smoking history and currently smokes one pack of cigarettes daily. He states he has not seen a primary care physician for routine preventive care in over a decade due to his focus on managing his renal disease, and he has received no vaccinations since childhood. Vital signs are within normal limits. Physical examination reveals a well-healed surgical scar in the right lower quadrant but is otherwise unremarkable. Which of the following is the most appropriate next step in preventive care for this patient?

  1. Administration of the recombinant zoster vaccineAnswer
  2. B
    Administration of the live-attenuated influenza vaccine
  3. C
    Screening for colorectal cancer with colonoscopy
  4. D
    Screening for lung cancer with low-dose computed tomography
  5. E
    Administration of the 23-valent pneumococcal polysaccharide vaccine (PPSV23) as an initial dose

Answer

Administration of the recombinant zoster vaccine
The correct intervention is the administration of the recombinant zoster vaccine (RZV). RZV is an inactivated vaccine that is explicitly recommended by the Advisory Committee on Immunization Practices (ACIP) for adults aged 19 years and older who are or will be at increased risk of herpes zoster due to immunodeficiency or immunosuppression. Because this patient is actively maintained on tacrolimus, mycophenolate mofetil, and prednisone following a renal transplant, he is highly vulnerable to reactivation of the varicella-zoster virus and urgently requires this vaccination.

Step-by-Step Solution

1
Assess the patient's demographic risk factors and clinical status.
The patient is a 42-year-old male with a 22-pack-year smoking history and severe immunosuppression due to a recent renal transplant (on tacrolimus, mycophenolate, and prednisone).
Age, smoking history, and immune status dictate the appropriate preventive screening and immunization schedules.
2
Evaluate the indications for cancer screening based on current guidelines.
Colorectal cancer screening starts at age 45. Lung cancer screening (LDCT) starts at age 50 for those with a ≥20\geq 20 pack-year smoking history. Both are premature for this 42-year-old patient.
Guidelines require specific age cutoffs to balance the benefits of early detection with the risks of overdiagnosis and procedural complications.
3
Determine the appropriate immunization strategy for a solid organ transplant recipient.
Live vaccines (like the live-attenuated influenza vaccine) are contraindicated. Inactivated vaccines are required. The pneumococcal series must start with a conjugate vaccine, not a polysaccharide vaccine. The recombinant zoster vaccine (RZV) is indicated.
Immunocompromised adults aged ≥19\geq 19 years are at high risk for herpes zoster and should receive the inactivated recombinant zoster vaccine. Proper sequencing is critical for the pneumococcal series to ensure robust immunogenicity.

Key Concept

Immunocompromised adults aged 19 years and older should receive the recombinant zoster vaccine (RZV). Live vaccines are strictly contraindicated in this population, and age-based cancer screenings (like CRC and LDCT) apply unless specific high-risk familial or anatomical syndromes dictate otherwise.
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Topics

Preventive Care and Screening

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