{"id":5711,"date":"2014-12-30T22:00:47","date_gmt":"2014-12-31T03:00:47","guid":{"rendered":"http:\/\/blogs.nejm.org\/?p=5711"},"modified":"2023-04-28T14:39:39","modified_gmt":"2023-04-28T18:39:39","slug":"common-curbsides-the-patient-with-recurrent-zoster","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/common-curbsides-the-patient-with-recurrent-zoster\/2014\/12\/30\/","title":{"rendered":"Common Curbsides: The Patient with “Recurrent Zoster”"},"content":{"rendered":"

\"\"Just in time for the New Year celebration, here’s\u00a0a curbside consult\u00a0I’ve received several times, probably because the answer isn’t in\u00a0most textbooks. As usual, the actual question is slightly edited, as well as lightly (and affectionately) annotated:<\/p>\n

Hey Paul \u2014 Quick question [of course]<\/em> \u2014 I have a patient with a history of irritable bowel, otherwise well, who had shingles on her lower back a few years ago, approximately L5-S1.\u00a0It was pretty bad, but ultimately improved on Valtrex.\u00a0Since then she’s contacted me several\u00a0times with recurrent zoster in the same distribution, each time it improves with more Valtrex. She’s not immunocompromised, HIV negative, not on steroids, etc.
\nShould she be on chronic suppressive treatment? If so, what drug and what dose? And how long should she be on it? Any role for the shingles vaccine? [Hey — you said “Quick question” — not “questions”!<\/em> She’s only 42.
\nThanks!
\nAnita [not her real name]<\/em><\/p>\n

There’s a reason doctors have\u00a0questions about their patients with frequently<\/em> recurring\u00a0zoster — it’s because the entity doesn’t really exist. That makes finding guidance for management extremely difficult!<\/p>\n

Even a single<\/em> recurrence is fairly uncommon in the same dermatome<\/a> — an outbreak may boost native immunity — which is why patients with a history of shingles were not included in the pivotal study of the live zoster vaccine.<\/a><\/p>\n

Recurrent zoster is rare enough that some question whether it makes sense to give the vaccine to people with a history of shingles, though in my experience these are understandably the patients with the greatest motivation to get vaccinated, so I’m glad the guidelines do endorse this practice.<\/a> And one population-based study did find that a single recurrences of zoster occurred in people with a history of shingles at about the same rate as an initial episode.<\/a> Prolonged pain was a risk factor for having another episode.<\/p>\n

So if it isn’t recurrent zoster most of these patients are experiencing, what is it? So far all of the cases I’ve been referred have been one of these three things:<\/p>\n

    \n
  1. Herpes simplex<\/strong>. This is far and away the most common mimicker. Obviously the skin lesions\u00a0can look a whole lot like zoster, and since HSV\u00a0is usually found in the oral or anogenital areas, the clinician and patient just don’t\u00a0think about it when clusters of vesicles crop up somewhere else. (It’s what our very young patient\u00a0summarized above had, of course.) Establishing the diagnosis is usually straightforward, either through a careful history\u00a0or viral culture\/DFA of an active lesion. Warning — some people with a history of “recurrent zoster” aren’t too thrilled to hear they have herpes instead, especially of the Type 2 variety, so caution when informing him\/her of this diagnosis. All kinds of relationship turmoil can ensue.<\/li>\n
  2. Post-herpetic neuralgia complicated by “neurodermatitis.”<\/strong> I put that last word\u00a0in quotes, because that really isn’t the most common use of the term, but it truly\u00a0fits. Here’s what happens — the patient with zoster has, as a manifestation of post-herpetic neuralgia, tingling and itching at the site. He\/She then scratches and picks at it relentlessly, until the skin is red and bumpy — which is then mistaken for “recurrent zoster.” These itchy red bumps really look nothing like shingles, and of course are associated with no viral replication, but the location right at the site of prior shingles fools people.<\/li>\n
  3. Wolf’s isotopic response.\u00a0<\/strong>I’m lucky to have a brilliant dermatologist<\/a><\/strong> as a colleague; he clued me in to this oddly\u00a0named entity, which is a fancy way of saying “a new skin disease at the site of an already healed, unrelated disease.” Turns out herpes zoster is the most common initial skin lesion, and then a whole host of other things can occur in that same site.<\/a><\/strong>\u00a0Despite the name, it\u00a0<\/span>has nothing whatsoever to do with radioactivity<\/a>,<\/strong> but sure will impress your friends if you mention it in casual conversation.<\/li>\n<\/ol>\n

    I’m sure this short list isn’t comprehensive, but you get the point. If you and the patient think it’s recurrent zoster happening over and over again, it almost certainly is something else, and the three entities listed above are a good place to start.<\/p>\n","protected":false},"excerpt":{"rendered":"

    Just in time for the New Year celebration, here’s\u00a0a curbside consult\u00a0I’ve received several times, probably because the answer isn’t in\u00a0most textbooks. As usual, the actual question is slightly edited, as well as lightly (and affectionately) annotated: Hey Paul \u2014 Quick question [of course] \u2014 I have a patient with a history of irritable bowel, otherwise […]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3,5,8],"tags":[218,256,466,1009],"class_list":["post-5711","post","type-post","status-publish","format-standard","hentry","category-health-care","category-infectious-diseases","category-patient-care","tag-common-curbsides","tag-curbside-consults","tag-hsv","tag-zoster"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/5711","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/comments?post=5711"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/5711\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/media?parent=5711"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/categories?post=5711"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/tags?post=5711"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}