Learning Objective
- Identify the presentation of herpes zoster as a differential for chest pain
A 38-year-old presents to the outpatient department of a rural hospital in Burundi, East Africa, complaining of burning, left-sided chest pain for the past three days. The pain increases with exertion but is not completely relieved by rest. It is not associated with nausea or vomiting, but the patient recalls a recent episode of chills and sweats several days ago.
Vital signs show mild tachycardia at 105 but are otherwise normal. Cardiopulmonary auscultation is performed and is normal. It is performed over the clothes, as is culturally appropriate to respect the patient’s modesty. An EKG is performed and lesions are identified as seen in the images. The lesions are vesicles, grouped closely together along the left T6 dermatome. EKG is normal and a diagnosis of herpes zoster, commonly referred to as shingles, is identified.
Pathophysiology
Shingles is caused by the varicella zoster virus (VZV), which is the same virus that causes chicken pox. After the chicken pox lesions heal, the virus can lie dormant in a part of a nerve called the dorsal root ganglia. This virus can reactivate when the immune system is weakened. Chest pain can present two to three days prior to the skin manifestation.
Further Workup and Treatment
Herpes zoster can be a presenting sign of HIV infection, so the patient is screened for HIV, which is negative, and is started on acyclovir 800 mg by mouth, five-times daily for seven days. Oral pain medication is also prescribed, as well as instructions on topical pain control measures, including moist compresses.
Patient Education
Education about local wound care and counseling regarding herpes zoster is provided. The lesions are contagious when the vesicles open and before they completely crust over, so they should be kept covered and the patient should avoid contact with any susceptible contacts. The patient is specifically advised about the risk of transmission to family members and close contacts, as varicella vaccination is not part of the national vaccination schedule in Burundi.
Further Reading
Neurological Causes of Chest Pain
References
Karnath, Bernard, Mark D. Holden, and Nasir Hussain. “Chest pain: differentiating cardiac from noncardiac causes.” Hospital Physician 38 (2004): 24-27.
Saguil A, Kane S, Mercado M, Lauters R. Herpes Zoster and Postherpetic Neuralgia: Prevention and Management. Am Fam Physician. 2017 Nov 15;96(10):656-663. PMID: 29431387.
Leppard B, Naburi AE. Herpes zoster: an early manifestation of HIV infection. Afr Health. 1998 Nov;21(1):5-6. PMID: 12294921.
Published April 5, 2023
By Logan Banks, DO, FAAFP
Associate Professor of Medicine, Hope Africa University; Director of Medical Education, Kibuye Hope Hospital; Adjunct Faculty, Cox Family Medicine Residency
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