Sunday, September 18, 2011

Chicken Pox Makes a Re-Visit

I was covering for another clinician in the urgent care clinic I worked in.  It had been a busy morning seeing all sorts of patients, but then after my lunch break it quieted down, I thought it was due to the torrential rainstorm going on outside.  But once the rain quit, it started getting busy again.
One of the patients I saw after the rain storm was a late 40ish Caucasian woman.  I walked into the exam room after the medical assistant had taken her vital signs. 
“Hi, my name is Sharon, I’m a physician assistant.  How can I help you?
“Well I’m Carla, first off.  The reason I’m here is due to this pain that I’ve been having on my right side of my waist and sometimes going down my right leg.  I saw my primary care physician on Monday (5 days ago) and he examined me and told me that I had sciatica on my right side.  He gave me some muscle
relaxants to take at night, but they aren’t helping.  Then yesterday these skin lesions showed up and they burn and itch like crazy.”
“Okay, let me see the lesions.”
With that, Karla lifted up her blouse and pushed down her waistband of her shorts.  She had erythematous macular-papular lesions in a linear fashion from her spine around the right side of her lower abdomen, which stopped at her abdominal midline.  The skin lesions on her posterior side had a few clear vesicles on them, the skin macules on her anterior side were not as well developed, they were just raised red macules in small groups spread along in a linear line.

 Karla has the typical presentation of herpes zoster, what is typically called shingles.  There are two presenting signs to this disease, one is the classic skin rash which is a macular-papular erythematous rash with clear vesicles on the top of the lesions along with acute pain.  The rash also typically forms into small groups of papules/vesicles and as they age they can become pustular.  They will eventually scab over, heal up and resolve. 
Shingles typically occurs in a dermatome, i.e. it travels along one nerve root (either right or left side) from the spinal cord and breaks out with lesions all along that nerve root as it travels around the body to the midline in front.  Generally, but not always, when herpes zoster breaks out it stays in one dermatome.  It typically breaks out along the thoracic or lumbar nerve roots.  It can break out elsewhere such as the cranial nerves (affecting the eye, face, ears).  If it affects the ear it is called Ramsey Hunt syndrome.  If it affects the eye, then the patient has to be seen by an ophthalmologist, due to their being potential complications associated with the virus attacking the ocular nerves, such as blindness. 
Most patients will also complain of pain along the same nerve root the virus will eventually break out from.  This prodromal pain can occur either days to weeks prior to the actual rash occurring. 

“These really itch like you can’t believe,” said Karla.  “Then I also noticed that when I touch them they have this funny feeling to them like my skin is somewhat numb or something, I can’t explain it.  What’s going on?”
“Well, Karla you have shingles, more specifically what we call herpes zoster.”
“Shingles?  I thought only old people got that?”
“Well actually any middle aged to older adult can get shingles.  It’s a reactivation of the chicken pox virus in your system.  You had chicken pox when you were younger and after it went away, the virus went into hiding, and in the case of the chicken pox virus it hid at the end of all of your nerve endings.  Then when your immune system wasn’t looking and was paying attention to something else going on in your system, the chicken pox virus took advantage of that opening and popped open with new viral lesions along the nerve root that it had been hiding along.  In your case one of your lumbar spine roots on the right side of your body.”
Karla stood there uncomfortable.  She was trying very hard not to itch her skin lesions.    “So are these things infectious to other people?”
“Yes, they are.  You can’t let anyone touch them, especially those lesions right now that are forming on your back side.  And you can’t be around anyone who hasn’t had chicken pox themselves or has not been vaccinated for it.”
“Are these going to spread anymore than where they are right now?”
“They could.  You could still have a batch of the lesions break out on the right side of your midline, right here where you have some redness to your skin.  It’s unlikely that the lesions will also break out in another area of your body.  They generally only break out in one dermatome. I’m going to give you a medication called acyclovir, you have to take it five times a day for one week.  I’m also going to give you some acyclovir cream to help with the itchiness.  You can apply the cream as frequently as you want.  After you apply the cream make sure to wash your hands really good.  Don’t be surprised if the lesions get worse before they get better.  Also many patients have pain that is much worse after the lesions have gone away and cleared up.  This is called post-herpetic neuralgia.  If you have this pain, it can be pretty bad, and if it shows up go to your primary care physician and tell him what happened.  He may have to give you some pain meds for this condition.”
“Oh, I just want to itch these things, between the pain and the itch I don’t know which is worse,” said Karla.
“One other thing, Karla.  After these lesions are all gone, I would seriously think about getting the shingles vaccine in about six months.  It’s rather expensive, but it can help prevent another potential outbreak for you.”
“Okay.  Thanks for the prescriptions.” 

When patients come in and are diagnosed with herpes zoster we give them a one week prescription of a medication called acyclovir.  They take this five times a day.  This medication helps to kill the herpes zoster and put it back into hibernation.  The cream is used to help control the itch (albeit not always effectively) associated with the lesions. 
Many patients unfortunately also have what is called post-herpetic neuralgia.  This can be very painful.  It is typically pain that is felt along the dermatome where the lesions broke out.  It can last for up to several months after the lesions have healed.  Patients who typically get this post-herpetic pain are those patients who are elderly, > 80 years of age.  But it has been known to occur in the younger age groups. 

Patients who are >50 years and older can now receive a vaccine to help prevent herpes zoster from breaking out.  The FDA has just recently changed their recommendations for this vaccine from age 60 and above to age 50 and above. 
With that she somewhat hobbled out of the exam room and out into the foyer of the clinic to meet up with her husband.  I could only hope she wouldn’t end up with post-herpetic neuralgia.

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