Sometimes a Diagnosis is Skin Deep
By Kelly Evans-Hullinger, M.D.
Recently I saw a patient who had experienced two consecutive days of pain in his right upper abdomen. I questioned him, looking for clues of gallstones, liver mass, or maybe an ulcer in the small bowel, but his answers did not fit my expectations. The pain was located under his right ribs and radiated into his back, just as I would expect of gallbladder disease; but it was not triggered by eating, and the way the patient described the pain did not fit the profile of an abdominal disorder. Then, a lightbulb went off; I needed to look at his skin.
I examined his right back, and sure enough there it was: a cluster of red, blistering, lesions that the patient had not yet noticed. This was not gallbladder or liver disease; it was shingles.
Shingles is a skin eruption caused by a reactivation of the varicella zoster (or chicken pox) virus. In people who have had chicken pox earlier in life, the virus goes dormant in a spinal nerve. For most of us, it never again causes a problem, but in some people the reactivated virus can spread to areas of the body following the distribution of that spinal nerve, causing a painful blistered rash which looks like chicken pox.
The pain caused by shingles often occurs prior to the visible skin outbreaks making it easy to misdiagnose. In my few years of practice I have discovered shingles in patients complaining of ear pain, abdominal pain, and low back pain.
When administered early, antiviral medication can limit the duration of shingles and reduce the risk of post-herpetic neuralgia, a pain in the affected nerve distribution which lasts long after the rash resolves. At its worst, post-herpetic neuralgia can be a debilitating and life-long condition.
Fortunately, we have a highly effective vaccine that greatly reduces the risk of having shingles. The current shingles vaccine is FDA approved for people 50 and older and is much more effective than the previous version of the vaccine.
Thankfully, widespread childhood chicken pox vaccinations started in the late 1990s so decades from now, shingles may be a rare relic of the past in the United States. Until then, I will always remember to look skin deep when investigating a patient’s new pain.
Kelly Evans-Hullinger, M.D. is part of The Prairie Doc® team of physicians and currently practices internal medicine in Brookings, South Dakota. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.