Severe New Pain With No Right to be There - Zoster Sine Herpete?
Over the years, I have had patients come in with severe one-sided regional pains with no good reason for it to be there. In each case, I have suspected Herpes Zoster prodrome and initiated antivirals with resolution without rash. I could never know for sure if I was right, but the patients have all been happy with outcome…
very recently:
35 year old lady came in with pain in left ear rather severe enough to bring her in - with a sense of fullness in ear as well:
- ear canal and drum look fine
- movement of tragus and pina does not cause pain
- is some tender over TMJ but patient could chew without any pain and there was good jaw opening.
- draws a line with her finger over the outer extent of the pain which extends onto the cheek - so pain is suspiciously circumscribed.
- does play hockey but denies any hit to the face/jaw
- no lymph nodes, rash, fever nor chills.
- no predisposing illnesses
- no Ramsay-Hunt - ie no rash in ear with “tinnitus, deafness, vertigo, vomiting, nystagmus, and disturbance of equilibrium” as per here
Comment - I am highly suspect of any herpes zoster / shingles prodrome if:
1) Unexplained one sided pain
2) Pain relatively severe - enough to bring patient in and almost neurogenic
3) Has a nerve distribution - can draw the line where there is pain and where there is not
I have started her on herpes zoster dose of Valtrex - ie 1 gm tid for next 5 days and if gets rash add prednisone - I guess time will tell.
Any zoster stories?
Addendum -
Curr Top Microbiol Immunol. 2010 Feb 26. [Epub ahead of print]
Neurological Disease Produced by Varicella Zoster Virus Reactivation Without Rash.
Gilden D, Cohrs RJ, Mahalingam R, Nagel MA.
suggests diagnosis can be made by ” Virological confirmation requires the demonstration of amplifiable VZV DNA in cerebrospinal fluid (CSF) or in blood mononuclear cells, or the presence of anti-VZV IgG antibody in CSF or of anti-VZV IgM antibody in CSF or serum.”
Popularity: 23% [?]