The Shingles Paradox
Friday, January 23, 2009
A few weeks ago, I saw two cases of Shingles in about half an hour; neither of which were the typical abdomen or back distribution. Now, I've seen Herpes Zoster across quite a few dermatomes; mostly the abdo and back, a few CN:V(I), as well as my personal favourite, S1.
The first bloke knows the owner, Top Cat, quite well, and they for a few minutes. I get called over for a second opinion; as the presentation is somewhat atypical. The bloke's got a 'rash' on his elbow. Every once in a while he gets some 'pimples' and they 'itch' at night. I've actually seen this location for Shingles before, but to be more certain I take quite a long history. Well, long by pharmacy standards, anyway. We establish that yes, the first time was the most severe, and it keeps recurring. Exactly in the right C5 dermatome. Unfortunately, it's been happening for a few months, so there wasn't a hang of a lot that either we or a doc could do, but we referred him for ongoing management nontheless.
The second guy comes in a few minutes later. He tells the shop assistant that he's got a 'rash down there', and he needs some cream. It's a bit red and sore. He asks if it's fungal as he peels down the waistband on the left side of his underwear just enough to reveal the superior edge. He's given some anti-fungal and a steroid to 'take the heat out of it'. And, if it doesn't calm down in two days, come back and we'll see why it's being problematic.
Two days later, the guy returns. The rash is still there, and it's a bit weepy now. He again peels down his underwear, but this time, whether accidental or not, a bit more of his inguinal area is visible. The rash has a sharp point. Uh oh, I think, that's not fungal at all. I ask him if it's on the other side. Nah mate, it's just on the left, and all through my... hair... y'know. I'm now pretty certain that it's Shingles, and send him next door to the docs. It was likely at either T12 or L1, and was, to be fair, a pretty atypical presentation. I think it was within 72hrs of outbreak, which is at least a promising sign for any anti-viral therapy.
I was cranky at myself for not clicking onto this diagnosis the first time round. My history was inferior to the one I'd taken for the first bloke. Why did I ask fewer questions? Was it because he was a younger athletic bloke likely to have tinea? Or perhaps because it was a 'down there' rash? I appreciate that within a pharmacy context that an examination was out of the question, and that actually viewing the rash, in that location, is rare.
Anyway, whilst I was quietly contemplating this at home the next day, four phrases that I'd learned in the previous year and a bit echoed around my brain ;
Same illness, similar patients, contrasting histories, two 'atypical' presentations, still same illness.
The first bloke knows the owner, Top Cat, quite well, and they for a few minutes. I get called over for a second opinion; as the presentation is somewhat atypical. The bloke's got a 'rash' on his elbow. Every once in a while he gets some 'pimples' and they 'itch' at night. I've actually seen this location for Shingles before, but to be more certain I take quite a long history. Well, long by pharmacy standards, anyway. We establish that yes, the first time was the most severe, and it keeps recurring. Exactly in the right C5 dermatome. Unfortunately, it's been happening for a few months, so there wasn't a hang of a lot that either we or a doc could do, but we referred him for ongoing management nontheless.
The second guy comes in a few minutes later. He tells the shop assistant that he's got a 'rash down there', and he needs some cream. It's a bit red and sore. He asks if it's fungal as he peels down the waistband on the left side of his underwear just enough to reveal the superior edge. He's given some anti-fungal and a steroid to 'take the heat out of it'. And, if it doesn't calm down in two days, come back and we'll see why it's being problematic.
Two days later, the guy returns. The rash is still there, and it's a bit weepy now. He again peels down his underwear, but this time, whether accidental or not, a bit more of his inguinal area is visible. The rash has a sharp point. Uh oh, I think, that's not fungal at all. I ask him if it's on the other side. Nah mate, it's just on the left, and all through my... hair... y'know. I'm now pretty certain that it's Shingles, and send him next door to the docs. It was likely at either T12 or L1, and was, to be fair, a pretty atypical presentation. I think it was within 72hrs of outbreak, which is at least a promising sign for any anti-viral therapy.
I was cranky at myself for not clicking onto this diagnosis the first time round. My history was inferior to the one I'd taken for the first bloke. Why did I ask fewer questions? Was it because he was a younger athletic bloke likely to have tinea? Or perhaps because it was a 'down there' rash? I appreciate that within a pharmacy context that an examination was out of the question, and that actually viewing the rash, in that location, is rare.
Anyway, whilst I was quietly contemplating this at home the next day, four phrases that I'd learned in the previous year and a bit echoed around my brain ;
- Shingles is like chicken pox; it happens in outbreaks around the community. (PBL Tutor/GP)
- Common things occur commonly.
- You're more likely to see an uncommon presentation of a common illness than a common presentation of an uncommon illness.
- Nothing but nothing will substitute for a good history and physical exam. Ever.
Same illness, similar patients, contrasting histories, two 'atypical' presentations, still same illness.
In the first case, it is easier to take the history. Especially both Top Cat and his 'friend' were probably talking about some TLAs.
In the second case - a 'diagnosis' has already been made by the person in question. In most pharmacy setting - especially dealing with an assistant - the person in question would always have the assumed common condition and be given the assumed common treatment.
Would you be able to take full history with someone in a pharmacy setting? Probably not, let alone a physical examination.
Would you be able to ask enough questions to point you in the correct direction? Highly likely.
It is the lack of diligence more than anything else. The presentation and the response would have been typical. It was only the location which was atypical.
Sometimes, it's just about going back to the basics. It would have been picked up if you were practicing pharmacy - the short cuts that you have learnt throughout the years that gets 95% accuracy with 10% of time. It is useful, especially in a pharmacy setting; and you can always use your medicine to confirm.
Don't be too hard to yourself... and don't over analysis your actions. Most of the time, there's a very simple answer.