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A 53-year-old woman presents to an emergency department in London after leaving her workplace due to what she describes as extremely severe and burning pain in her left upper abdomen, radiating to her left back. She explains that she has never experienced these symptoms before, nor has she had any previous acute illness requiring hospitalization.

Her past medical history includes indigestion and regurgitation, which her physician is investigating. Her family history offers no additional relevant information, and findings of a physical examination are unremarkable.

Her vital signs are within normal range, and findings of a general examination are unremarkable. However, palpation of her abdomen reveals a very tender, warm left hypochondrial region with hypersensitivity; there is no evidence of enlarged organs or visible skin lesions.

Clinicians perform an ECG and lab tests; results, including troponin level, are normal. After a urine test reveals microscopic hematuria, clinicians order CT of the kidneys, ureters, and bladder -- again, showing no abnormalities.

Given the patient's hemodynamic stability, and normal lab and imaging findings, clinicians make a provisional diagnosis of non-specific abdominal pain, and discharge her from the emergency department. She is advised to consult her general practitioner the following day for follow-up and to proceed with a gastroenterology referral to investigate her symptoms of indigestion and regurgitation.

Twenty-four hours later, the patient develops dry skin rashes affecting her left hypochondrial/loin area. She visits her general physician, who based on her clinical picture, makes a provisional diagnosis of herpes zoster.

The patient is started on a regimen of oral paracetamol 500 mg plus codeine phosphate hemihydrate 30 mg four times a day and oral acyclovir 800 mg five times a day.

One week later, the patient is fully recovered without any complications, and clinical examination 6 weeks later shows complete resolution of symptoms.

Discussion

Clinicians presenting this of an unusual presentation of herpes zoster note that atypical symptoms may delay diagnosis and result in less favorable outcomes.

Varicella-zoster virus (VZV) – first isolated in 1954 from the vesicular fluid of both chickenpox and zoster lesions in cell culture, causes two clinically distinct diseases: varicella (chickenpox) and shingles.

Primary infection typically occurs during childhood, resulting in varicella, an acute and highly contagious infection characterized by a generalized vesicular rash.

Like other alpha herpesviruses, VZV establishes latency in neural tissue following primary infection. Any reduction in the ability of an appropriate immune response – in the context of malignant lymphoma, HIV infection, or immunosuppressive therapy, for example -- could lead to reactivation of VZV, allowing the virus to travel from the sensory ganglia to the skin nerve terminals and spread to skin epithelial cells, leading to the clinical signs of herpes zoster.

Shingles generally affects older adults, presenting as localized cutaneous eruptions associated by neuralgic pain and usually involving a single dermatome that does not cross the midline. Thoracic, trigeminal, lumbar, and cervical dermatomes are the most frequent sites, but any area of the skin can be involved, the case authors note.

The lifetime risk of developing shingles is about 32%, and increases with advancing age and immunosuppression, such that about 50% of individuals will be affected by age 85.

While the diagnosis is generally clear-cut, atypical presentations of herpes zoster can have a range of severe and potentially devastating complications in immunocompetent as well as immunocompromised individuals. Diagnosis may be especially challenging in patients with such as glioma, zoster sine herpete, and bilateral herpes zoster.

Some patients may also have complications such as persistent herpes zoster‐associated pain or post-herpetic neuralgia (PHN). Reported are age over 50, female gender, zoster viremia detectable by polymerase chain reaction (PCR), severe or disseminated rash, and the presence of a prodrome and severe pain at the time of presentation.

Like herpes zoster, PHN is age dependent, with incidence increasing steeply after age 50, with figures in the general range of:

• 5/1,000 person‐years (PY) for individuals age 50-60

• 6-7/1,000 PY for ages 70-80

• Up to 10/1,000 PY for age over 90

In addition, in approximately 20% of patients older than 60, persist for more than a year.

A late diagnosis with possibly negative results may be avoided if clinicians have a low threshold of suspicion and initiate timely testing with immunofluorescence assay for VZV antigen or PCR assay, followed by adequate treatment, case authors write. This may involve different specialties including infectious diseases, dermatology, immunology, neurology, pain management, and psychological support.

The authors note that while in most patients, symptoms dissipate within a week with only simple analgesia, suggest that others may need antiviral medications like acyclovir, valacyclovir, famciclovir, and brivudine.

The effectiveness of the is highest for people in their 60s, at 64%, but then declines with age – to 41% for those 70-79, and 18% for those 80 and older.

In the U.S. however, the FDA in 2017 , which is now considered to be the preferred shingles vaccine, the case authors note. (Both vaccines are approved for adults ages 50 and over for the prevention of shingles and related complications, whether individuals have or have not already had shingles.)

Conclusion

The case authors conclude that since atypical presentations of herpes zoster can lead to delayed diagnosis as well as unfavorable outcomes, it is important to always keep herpes zoster infection in mind as a possibility in the assessment of patients presenting with acute onset of abdominal pain. The team also encourages reporting of atypical cases as a way to study different presentations and improve treatment as well as outcomes.

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