Listen to the Patient…

Notes from the Xanadu Clinic, Norfolk Island, South Pacific

The patient is a 65 yo man with a one week history of intense lancinating pain in the right upper quadrant.  He was examined by his internist who suspected gall bladder disease and ordered an abdominal ultrasound.  It was negative, so an abdominal CT scan was scheduled.  Between the ultrasound and the CT scan the patient developed a rash on the abdomen and back.  He attributed it to one of the new drugs he was prescribed for his abdominal symptoms.

I saw him today for elective surgery of a skin cancer.  I greeted him with “How are you today?” He answered, “Not so good” and told me about his pain.  I checked his rash.

Right Upper Quadrant

Right Mid-Back

The prodrome of herpes zoster can last from a few days to as long as two weeks or more and can mimic many somatic illnesses.  Gall bladder disease, heart attack, kidney stones, migraine, the list goes on.

In this case, expensive tests* were ordered and they contributed to a significant delay in diagnosis of his thoracic herpes zoster.  By the time he was seen, he was outside of the therapeutic window when appropriate antivirals can be effective.

*Estimated cost of scans
CT of Abdomen  $1800 – 2100 (USD)
Ultrasound of Abdomen ~ $900 (USD)

Reference:  Strangely, little attention has been given to the prodrome of HZ in the medical  literature.  The following abstract is the only pertinent one we could find.

Nair PA.  Herpes zoster: mistaken for radiculopathy and back pain. J Indian Med Assoc. 2012 Jun;110(6):399.
Pramukhswami Medical College and HM Patel Centre for Medical Care and Education, Karamsad 388325.
Abstract:
Herpes zoster should be considered as one of the differential diagnosis in acute pain of short duration on one side of the body with or without skin lesions. Pain, a prodromal manifestation of herpes zoster may be mistaken for various disease conditions, leading to hasty unwise investigation, therapy. and surgical interventions. There is a need to identify prodrome and skin eruptions of herpes zoster, so that early antiviral therapy can be started in elderly patients who are at higher risk of developing postherpetic neuralgia.

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