Here is the case of a 25-year-old elephant trainer who developed “the worst headache of his life.” The case was made more confusing by the fact that he had been head-butted by a zebra several years earlier. Turns out the zebra were a bit of a red herring – for the doctors at the time, and for many of you. The correct diagnosis is… Herpes zoster, commonly known as shingles The internist assigned to the case, Dr. Bilal Ahmed, was able to make the diagnosis because when he examined the patient the next day, he saw the characteristic zoster rash above the patient’s right eye that had developed overnight. Nearly 200 people wrote in with their thoughts on what Dr. Ahmed might have seen to reveal the diagnosis when he looked at the patient. The first person to guess the correct diagnosis was Lotty Fulkerson of Massachusetts, a licensed practical nurse who has seen a lot of zoster. It was the combination of the patient’s terrible pain and the fact that the doctor saw something that told him the diagnosis that made her think it was probably shingles. Only three other readers guessed correctly. The Diagnosis Herpes zoster, also known as shingles, is caused by the re-emergence of the herpes virus that is the source of the childhood illness chickenpox. The term “shingles” comes from the Latin word “cingulum,” which means belt or girdle; the rash of herpes zoster often appears in a band or belt-like pattern. When the original chickenpox infection resolves, the virus doesn’t die but instead takes refuge in branches of the nerves just outside the spinal cord, where it will reside for decades. In up to a third of patients who have had chickenpox, it re-emerges, causing pain and a rash and sometimes more. Why these survivor viruses re-emerge is unclear, but it may be linked to a weakened immune system. Most of the time these outbreaks are painful but not life-threatening. The outbreaks usually last 10 to 14 days and resolve, even without treatment. But many who develop shingles can have pain long after the rash resolves. Treatment with antiviral drugs can make this painful complication less common but will not prevent it for everyone. However, outbreaks that occur around the face can cause a meningitis or encephalitis. And when the involved nerves are near the eyes, as in this case, the patient’s vision can be endangered if the rash spreads to the eye itself as well as the skin around it. Timely treatment with antiviral agents can limit the damage and preserve sight. How the Diagnosis Was Made When Dr. Ahmed asked the patient to remove the blankets from his face, a bed-matted head of dark curls slowly emerged. The patient sat up slowly, blinking in the dim light of the room. His right eyelid was swollen and drooped drunkenly over the pupil so that only the lower ridge of the greenish brown iris was visible on that side. The right side of his forehead was a bright red, as if he had a unilateral sunburn. And over the redness, Dr. Ahmed could see a sprinkling of bumps over his eye to just beneath the hairline. Shingles Versus Brain Abnormalities It was clear to Dr. Ahmed that the patient had zoster. Was there a link between this patient’s shingles and the asymmetric ventricles in his brain, which were revealed on a CT scan? Dr. Ahmed called the neurosurgeon and put the question to him. No, the neurosurgeon told him. If this guy has shingles — and it sounds like he does — then the asymmetry is probably something he was born with. And that makes sense, because he had no symptoms of increased pressure in the brain. I spoke to the patient recently. He is feeling well, and thanks to the high doses of narcotics he was given barely remembers his days in the hospital. He was treated with an antiviral drug, and his rash disappeared after a few more days. Despite the timely treatment, he started to have blurry vision while he was still in the hospital, and the outbreak left residual scarring in his eye that continues to cause blurry vision at times. And he lost a patch of hair that still hasn’t grown back. The Tincture of Time In this case, as in so many, time is a powerful and frequently undervalued diagnostic tool. The rash appeared days after the symptoms began; that is common in zoster. But without the telltale rash, there was only the pain and the abnormal CT, and that led his doctors to worry that his pain was the result of pressure building up in his brain. A truism in medicine is that when we hear hoof beats, we should think of ordinary horses as the cause rather than the rare zebra. In this case, time revealed that what looked like a zebra — an obstruction in the brain — was actually the everyday horse of herpes zoster. Source: http://well.blogs.nytimes.com/2012/11/30/think-like-a-doctor-the-circus-trainers-headache-solved/
