Tuesday, March 31, 2009

Bilateral shingles

I wished recently for a consult with Dr. House (in the form of Hugh Laurie with the patience of Mother Theresa). My patient felt awful for a week or so. She was having palpitations, her chest hurt terribly with any position change--say with settling back into bed--or with deep breathing, and the skin on the back of her neck hurt terribly. Her appetite was down, she had no pain with swallowing nor acid reflux, and generally felt unwell due to her newly diagnosed rheumatoid arthritis and Crohn's disease.

Her blood pressure was low and her pulse was up, no fever, her chest wall was not painful to touch, her lungs were clear, and her abdomen wasn't tender. Any movement of her torso caused her to cry out in pain. Her blood count and lab work were normal except for an expected elevation in her sedimentation rate (a non-specific measure of inflammation or infection in the body) due to her arthritis and colitis. A chest x-ray was clear, her thoracic spine films looked good, and the EKG showed no evidence of heart troubles.

Yikes, what on earth? Perhaps yeast in her esophagus? Yet she had no trouble swallowing food. Costochondritis (inflammation where the ribs meet the sternum)? No pain on pressing those joints. Acid gastritis? Her pain was positional and not affected a bit by eating. Heart pain? Nope, the pain was totally atypical. Pre-shingles nerve pain? Maybe in the neck, but not on both sides, and what did that have to do with her chest pain.

Two days later she broke out in shingles--on both sides of her head behind and on her ears. So much for conventional wisdom that shingles only affects one side. In fact, 4% of patients break out on both sides of their bodies. Meanwhile, she researched the side effects of Asacol (a medication used to decrease the inflammation of colitis) and found chest pain on the list. She quit the medication, and, within a day, her pain was gone.

So who needs House when patients use the Internet? I regret that I didn't start her right away on one of the drugs that work against shingles (Valtrex, Famvir, or acyclovir). House would've done that.

6 comments:

Dr. Smak said...

Great case, Judy!

kenju said...

I am so glad that when I had shingles, I was not among that small percentage who get them on both sides. One was bad enough!

Mauigirl said...

Shingles is (are?) nasty. That sounds like a very painful affliction when they get it on both sides like that!

DebS said...

I've had shingles bi-laterally for 3.5 months and always heard it could only be on one side. Glad to know I'm not the only one.

Stephanie Drumright said...

I am glad I found this. I had shingles in my hair (both sides) for months and cut my long hair off; thinking it might be heat rash. Then after a few months it moved down the back of my neck and down one side of my chest till it was in the center of my upper chest.

I have had it (off and on)while taking valtrex for 3 months on my chest. It seems to ebb and flow with stressful events in my life. I am afraid it will never go away.

Anonymous said...

Was diagnosed with bilateral shingles in the ER today. The rash is on my scalp, neck and face, so far, and is accompanied by a high fever. It was caught early enough to start acyclovir. The ER doc also added a prednisone "burst" of 60mg then several 40mg doses, and clindomycin(sp?) Within an hour of taking the first dose of prednisone, the fever broke and the pain that accompanies the rash lessened. Despite being one of the special 4% who get bilateral shingles, I feel lucky that I got treatment early enough to benefit from the drugs!!