Herpes Zoster: A Patient’s Perspective

Abstract

My name is Ann Tuzi; I am 57 years old and I would like to tell my story. First of all I want to thank God for giving me a second chance at life although it left me with a condition, which I will tell you about. My journey started 13 years ago in 2002 when I was diagnosed with Burkitt’s lymphoma/leukemia (a rare cancer of the blood). I fought a big fight with that type of cancer, and it managed to go into remission, but in October 2003 I got shingles on the right side of my abdomen during one of my chemotherapy treatments. At first I didn’t know what it was but the pain was out of this world. We had to stop my chemo treatment and I was bedridden for 6 months. By the time I was referred to a pain clinic, it was too late; all the nerves of my waist had been damaged. So I was put on gabapentin 600 mg/day which helped a little but didn’t get rid of the pain. If that wasn’t enough, my shingles then spread to my right eye. So I was put in isolation for a week where they were able to treat that with famciclovir.

Commentary

• C. Peter N. Watson 

Ms. Tuzi has been my patient for 11 years. She has had medically intractable severe postherpetic neuralgia for 13 years, located in the right upper abdomen in the ninth thoracic dermatome region, which has left her with a severe, steady, burning pain, electric shock-like jabbing pain, and exquisite sensitivity of the skin. This is associated with Burkitt’s lymphoma and chemotherapy. Recurrence of zoster as occurred on the right forehead is uncommon and happens in about 5 % [1] and may attack the same dermatome [2]. In this instance this recurrence close to the first episode may reflect her state of immunosuppression.

On physical examination (Fig. 3.1), she has pale postherpetic scarring in the right ninth thoracic dermatome. There is very widespread loss of sensation to pin, cold, and touch but marked sensitivity of the skin to touch (dynamic mechanical allodynia) over only a rather small area, mostly over the worst scar. Over the decade that she has been my patient, she has had drug trials with gabapentinoids (pregabalin and gabapentin), tricyclic antidepressants (amitriptyline, nortriptyline, desipramine, and doxepin), serotonin norepinephrine re uptake inhibitors (duloxetine and venlafaxine), and a variety of opioids (morphine, oxycodone, hydromorphone, transdermal fentanyl, tramadol, and methadone) in keeping with guidelines for treating neuropathic pain. She has also had three oral cannabinoids, other anticonvulsants (phenytoin, lamotrigine, carbamazepine, and oxcarbazepine), and the antispasticity agent, baclofen. She has also used topical agents such as capsaicin and lidocaine. She has additionally had trials of acupuncture, laser therapy, and transcutaneous electrical nerve stimulation.

Fig. 3.1

Anterolateral view of the abdomen: A (dotted line) = area of dynamic mechanical allodynia (pain from skin stroking with cotton), B (solid line) = scarred areas, C (interrupted line) = area of sensory loss to pin, cold, and touch, D = umbilicus

The only thing that has helped her and that takes the pain from 10/10 to about 7/10 is a high dose of gabapentin in the form of 1200 mg every 6 h for a total of 4800 mg a day. She has been on that drug and dose unchanged for 5 years. The intractability of her postherpetic neuralgia may relate to the singular physical findings of an unusually extensive area of sensory loss (Fig. 3.1) which since only one ganglion is usually affected (Fig. 3.2) could relate to a long extent of rostrocaudal involvement of affected and atrophic dorsal horn of the spinal cord (Fig. 3.3) where many analgesics have an action. Immunosuppression associated with both Burkitt’s lymphoma and Epstein-Barr virus and also chemotherapy may play a role in this intractability as well as for the second episode of trigeminal zoster. Ms. Tuzi’s case illustrates the need for vaccination and particularly the use of a vaccine that can be used safely in patients who are immunosuppressed and which is currently undergoing clinical trials [4].

Fig. 3.2

Postherpetic neuralgia with fibrosis and nerve cell loss in the dorsal root ganglion, surviving ganglion cells in red, scarring in upper part of ganglion (arrows) (Masson trichrome × 10) [3]

Fig. 3.3

Postherpetic neuralgia showing atrophy of the dorsal horn of the spinal cord on the left side of the image (arrows) (H & E LFB × 2.5) [3]