Pain, like beauty, is sometimes only skin deep.
One example is a patient of “middle age,” who entered the emergency room with abdominal pain. Holding her right upper (abdominal) quadrant just below the ribs, she was visibly uncomfortable and had slight loss of appetite and nausea. Laboratory studies were normal – no liver or acute gallbladder disease was apparent. Because a gallstone remained a possibility, I asked a surgeon to take a look.
We sent her home with a pain prescription and requested that, unless symptom-free, she return the next day. She returned, worse and vomiting. The surgeon admitted her and a gallbladder scan (before ultrasound and CTs) showed a nonfunctioning gallbladder.
Again, 24 more hours found her worse and now tender in the upper-right quadrant. The surgeon asked the operating room about availability. On repeat examination, several red spots and skin blisters had appeared in the painful area. The operating room was immediately called – and canceled. This lady had shingles.
If we eliminate gravel rash, cuts, bruises, burns, insect bites and rashes with fevers, there isn’t much else wrong with the skin that brings folks to the ER. Oh, yes, there are a couple of really bad, fatal diseases of the skin, but they are so rare that they don’t rate mention. Shingles brings people in because of pain. While I absolutely abhor, hate and detest televised pharmaceutical advertising, the actor for Zostavax, the shingles vaccine, does a thoroughly credible job. Word needs to get out that shingles is just plain miserable.
The varicella-zoster virus causes chickenpox and shingles (aka herpes zoster); the latter is far more common in the older than-50 crowd. After infection from chicken pox, the virus may lie inactive, latent, in “dorsal root ganglia.” It’s a little like this: If the facial nerves and spinal cord are a home’s electrical entrance, then the ganglia are the distribution panel to that house’s circuits. Varicella-zoster hits only one circuit or one nerve. Also, the blistery rash and pain of shingles follow the nerve and are almost always unilateral (on one side). Nor does shingles cross the body’s midline.
Pain typically appears days before the rash – very rarely there’s no rash – a diagnostic horror. Typically, blisters (or vesicles) appear in a band-like distribution, more commonly on the lower chest or upper abdomen – in medical-speak, “a unilateral vesicular eruption within a dermatome.” Any area of the body can be afflicted with shingles: the eye, most serious of all, the ear, mouth, tongue, extremities, south of the waist – anywhere! Shingles in immunocompromised individuals is especially severe.
The rash usually resolves in two to four weeks. Pain, especially lasting more than three months, is termed postherpetic neuralgia and persists longer in those of increasing age. The Food and Drug Administration has approved the vaccine for use from age 50, while the Centers for Disease Control and Prevention recommends it for those 60 and older. The single-dose vaccine is pricey, costing about $200-or more. Studies in the U.S., Canada and the European Union show effectiveness of 60 to 70 percent, either by preventing shingles or lessening postherpetic neuralgia. Shingles is nasty, and postherpetic neuralgia can be months or years of unremitting narcotic-level pain.
www.alanfraserhouston.com. Dr. Fraser Houston is a retired emergency room physician who worked at area hospitals after moving to Southwest Colorado from New Hampshire in 1990.