Shingling me out


It has to do with our skins

And it started with needles and pins

After six weeks of tingles,

I came down with the shingles

But it hasn’t cut down on my grins.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

This case concerns a 65 year old male with shingles.

I’ve seen two other patients with shingles here in western Nebraska so far. I started both on Valtrex during the first visit.  Easy diagnosis, any rash that follows the path of a skin nerve (dermatomal distribution) names the process.  Therapy of the immediate, acute phase of this problem is straightforward.

With this disease, I worry the most about post-herpetic neuralgia, which can happen after shingles. It happens mostly in the elderly, and sometimes they hurt till they die.  During my training, we had no good treatment.  Narcotics work for no more than a few weeks.  We didn’t know at the time that capsaicin cream and seizure medications work, and work well; although we had the tools available we didn’t know how and when to use them.  Generalists who tried to treat a patient with hopeless, severe pain would either burn out and retire or move, or send the patient to the neurologist, who would either burn out, retire, or move.  Now I only refer the patient out if I fail under my “3 strikes and I’m out” policy or if the patient requests.

If a patient, after shingles, shows up with pain where they had the rash, despite rash improvement, I will lightly stroke the area involved, and ask if it hurts. A positive finding, allodynia, pretty much cinches the diagnosis.  I like to start with capsaicin cream; available without a prescription, it depletes the structures of a particular part of the nervous system called the dorsal root ganglion of the chemical needed to transmit chronic pain signals.  If that doesn’t work,  I skip on to the anti-epilepsy drugs Depakote or gabapentin.

I can write publicly about this patient because I’m writing about me. Over the last six weeks I’ve had a tingling sensation, paresthesias, on the right side of the back of my neck.  Always worse under stress or time pressure, it came and went, and I ignored it.  I’d had something similar over the summer.  I consulted by phone with my doctor, who agreed that it could have been the prodrome, or warning signs, of shingles.  I took Valtrex and the rash never appeared.

This time, I decided to test the hypothesis, by ignoring the pins-and-needles that would crop up for no reason from time to time, last a minute or so, then disappear for no reason.

Last night, we were coming home from the movies when I noticed two sore spots on my neck, just the size of chickenpox. This morning, on rounds, I pulled my colleague into a room and showed him my rash.  He looked where I pointed at the front of my neck, followed  around to the back of my neck, confirmed my suspicion, and advised Valtrex.

Of course, a few milligrams of prevention is worth kilos of treatment, and the shingles vaccine, Zostavax, is a really good idea for anyone on Medicare. I plan to get mine when I visit the VA next week.

 

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3 Responses to “Shingling me out”

  1. Vicki Karno Says:

    Everyone 50 or over should get the shingles shot! My daughter got shingles at 42 and ignored it as a heat rash, until it went all the way down her backside. Don’t wait! You should know better. vicki

  2. walkaboutdoc Says:

    There was a question for a good long time about whether someone should get the shot if they’d had shingles already. Which I did, sometime last century. And it remains a question still. But, after 3 bouts with it, I’m getting the shot.

  3. Sbdriver1@aol.com Says:

    I am sorry to hear of your affliction but at least there is a prescription here is for you to get better in the form of a letter get well soon. As you can see my prose hasn’t improved but the thought is original.

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