Thursday, March 01, 2007

When Shingles Strike

In Monday's post, I mentioned a patient who had shown up out of the blue at the clinic with lesions on his scalp which raised my suspicions and caused his doctor to allege the potential diagnosis of herpes zoster infection, or shingles. We sent him to the ER for evaluation, isolation, and empiric treatment with IV antivirals until we could be proven wrong. Well, the doctor was correct in her diagnosis, and my patient is currently in isolation receiving intravenous treatment for herpes zoster. Phew! Another close call.

For those of you who are not aware, shingles is caused by the same virus which causes chicken pox. After a child has chicken pox, the virus becomes dormant and lives in the nerve tracts, or ganglia, which emerge from the spine. The virus is usually reactivated by stress, aging, or an immunocompromised state such as AIDS. The lesions will often manifest along a "dermatome", an area of skin innervated by one nerve. The classic area for such an outbreak is the trunk, curving from the spine to the sternum in a narrow band, but lesions can appear on the face, neck, arms, even in the eye or mouth. Post-herpetic neuralgia can result, wherein the patient may have short- or long-term pain in the affected area, long after the lesions have healed and treatment ended. The pain can often be debilitating, especually in the elderly.

In my patient's case, he had relapsed into intravenous drug use, had disappeared from care, stopped all antiretrovirals and other meds, and his immune system has been weakening by the day. I knew that he would crash and burn, it was just a matter of when, how, and whether he would have the presence of mind to seek care before it was too late. In his very atypical zoster infection---disseminated zoster---the lesions are few and mostly hidden on the scalp. Untreated, he may eventually have developed lesions on his liver and kidneys, eventually succumbing to liver failure and a most unpleasant demise.

Even though I have a cold, I went to the hospital on my way home from an abbreviated workday today to visit him. Donning a mask in the hospital to not infect anyone else (and washing my hands frequently), I added my two cents to his chart, warning the team to please refrain from restarting the patient on AIDS medications while he's hospitalized. Knowing him well, I need to assess his readiness and eventually start him on meds when I think we have a chance at success, otherwise it's an exercise in futility and could further deplete his chances for future treatment due to his already multi-drug resistant HIV.

Since he is in respiratory isolation due to the ability to spread varicella via respiratory droplets, he was already acclimated to people wearing masks upon entering the room. I informed him that I had a cold and that I was wearing the mask as much for his protection from my cold as for my protection from his illness. He nodded and smiled, looking small in his bed.

"It's a good thing you came to see me on Monday. You know that this is a very dangerous illness for you." I sat down on the empty bed next to him.

"Yes, I do," he replied. "They explained everything."

"You know why you're in isolation?"

"Oh, yes. They told me that, too. I'll be here about ten days." He frowned.

"I want you to know that even though you relapsed and started using [cocaine] again, I'm not angry. It happens. But you have to get serious about treating your HIV. You've been off of meds for a while now."

"I know, I know," he replied gravely. "I just got so tired of all the pills. Then I started shooting up, and that was that."

"OK, but you were smart enough to come see me, and now you're here. You know that this could have killed you. What would your kids do? When you get out of here, we have some serious talking to do, my friend."

He smiled. Under different circumstances, we would have hugged, but we hugged with our eyes instead, the mask hiding my smile which I'm sure he could sense.

"I haven't abandoned you. If you do your half of the work, I'll do mine, OK?" I head for the door and wash my hands at the sink.

"You go home and rest," he says almost maternally. "We'll talk next week."

"OK," I reply. "I'll be thinking of you."

I exit the room, leaving my mask on until I leave the patient care area. Stopping in the men's room, I wash my hands and look at my bedraggled face in the mirror.

"At least he's safe in a bed and we know where he is," I think to myself. Now this nurse needs some rest as well, or I'll be of no further use to anyone.

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