It was a hazy Wednesday in October, and T. Marie Landowski, a healthy, retired high school guidance counselor living in Fort Atkinson, Wis., was preparing to do some heavy-duty leaf raking at her rental property.
It was physically invigorating and satisfying to accomplish, but the next day, she felt a peculiar tingling on her skin under her right arm. Nothing looked wrong, so she dismissed it. Twenty-four hours later, though, she felt shooting pains in her upper chest and under her right breast. "Am I having a heart attack?" she wondered. She also felt a tight knot between her scapula and spine and thought perhaps she had pulled some muscles raking leaves the day before.
By Saturday, Marie was shocked to see a rash developing on the right side of her body, including her armpit, upper breast and her back, all the places where she had previously felt weird sensations. Amidst the rash were just a few spots forming into tiny water blisters, not very pronounced yet but enough to warrant a doctor's visit. Her physician diagnosed Marie with an early stage of shingles.
The virus causing shingles is the varicella zoster virus which also causes chickenpox. It is a herpes zoster virus, but not the same herpes virus that causes genital herpes which is sexually transmitted. Shingles is so named from the Latin word cingulum, meaning belt or girdle - in this case a belt of painful rash and blisters.
When a person recovers from chickenpox, the varicella zoster virus lies dormant or inactive within the nerve cells. Normally, a well-functioning immune system will keep the virus in this dormant state. However, if the immune system is not functioning properly or is compromised by unusual stress or serious illnesses, such as cancers, leukemia, lymphomas or HIV or if a person is taking immune-suppressant drugs like steroids or drugs taken after an organ transplant surgery, the virus can be reactivated and cause shingles.
Dr. Keith Graham of the Regional Medical Center in La Grande has been in internist for 30 years, 19 of those in La Grande. He's treated many cases of shingles in Union County.
"In general, it is a common malady in older people, and the thought is that it is because of the waning immunity to the varicella zoster virus in the later years of life," Graham said. "It's also true that anything that suppresses the immune system in any way can allow the virus to be activated, including extreme stress, as well as malignancies, chemicals and medications. The vast majority of people I see with shingles have them due to an underlying event or medication that has suppressed their immunity."
Marie's sudden onset and progression of shingles followed the classic pattern. First, one to five days of unusual skin sensations, which could include itching, burning, tingling or pain followed by seven to 10 days of blistering and two to four weeks of scabbing and healing.
"People say they start getting pain, and they think it's from something else," Graham said. "But then a day or two later, they start seeing the
In most cases, the blisters disappear without a trace, but in some instances there could be permanent scarring, a secondary staphylococcal infection of one or more of the blisters or a lingering change in the skin's natural pigment.
Lingering nerve pain called postherpetic neuralgia (PHN), is the maincomplication that occurs in older patients and can last for months or even years.
"In a lot of people shingles cause damage to the nerve where the virus erupts from and they have up to a couple of years of persistent pain in that nerve distribution after the eruption is gone," said Graham. "A lot of people will need pain medication for persistent pain for weeks or months. We often use gabapentin (a generic for Neurontin), an anti-epileptic drug that is useful for nerve related pain, or Lyrica, a similar drug. But most people end up taking an opioid like Vicodin or Percocet."
A mild case of shingles involves just a few blisters scattered on a small area of skin; a moderate case occurs when there is a wider area of skin affected with scattered blisters. A severe case of shingles happens when the rash and blisters merge together to form a solid, red belt or girdle of sores. If a patient has a severe outbreak of shingles near the eyes or ears, seek immediate medical attention from a specialist to prevent blindness or hearing impairment.
Shingles usually appears on one side of the body or face and always follows along dermatomes, band-like areas of skin mainly supplied by a single spinal nerve. Shingles usually appear along one or more dermatomes. For Marie, her shingles appeared along the T2 and T3 dermatomes. For an excellent body chart of dermatomes see http://apparelyzed.com/dermatome.html
"The location of the eruption depends on where the varicella zoster virus is lying dormant," said Graham, "but typically it's in one of the collections of nerve cells along the spinal cord. If that happens to be the cervical spine, it will erupt on the face. If it's on the thoracic spine it will erupt on the chest and arm, and potentially if it's the lumbar spine, it will erupt along the lower extremity on one side or the other."
If there is any good news about shingles it's this: according to the Center for Disease Control and Prevention people who get shingles will get it only once in their lifetime. However-and there always seems to be a qualifier-in rare instances some people have had it a second and third time.
If that isn't alarming enough, looming on the horizon and at risk for shingles is a billowing cloud of aging baby boomers. They represent the 99 percent of adults age 40 and older in the U.S. who have had chicken pox, which means they have the dormant virus for shingles. The second risk factor is age because about half of all shingles cases occur among men and women 60 years and older, and of those, 50 percent get shingles on their chest just like Marie did.
At present, 1 million cases of shingles are reported each year in the U.S. The CDC states that "almost 1 out of 3 people in America will develop shingles in their lifetime."
The figures published by pharmaceutical giant Merck, Sharp and Dohme Corporation, who have produced the shingles vaccine called Zostavax, are much more daunting-"1 out of 2 people will have shingles by the time they reach 85 years of age." Their web site at www.Shinglesinfo.com stated that the older a person is the more severe their outbreak of shingles is likely to be.
"Zostavax is approved by the Federal Drug Administration for people 50 years and up but the committee that issues guidelines for vaccinations has not made any recommendations for people younger than 60," said Graham, "so the current guidelines are to get the Zostavax starting at age 60 and older. It will boost the immunity to the varicella zoster virus and help prevent shingles."
Zostavax is a one-shot vaccination of the live varicella zoster virus and is used to prevent a shingles outbreak, not to treat shingles that have already erupted.
In Marie's case, her physician gave her a Zostavax vaccination, and he also prescribed an opioid for pain relief. Pain levels vary from person to person, but patients have reported feeling severe and sharp stabbing sensations, burning, throbbing and shock-like bolts of pain.
"My physician told me to take my prescription as needed and not try to tough it out," said Marie.
She was going to need it because the rash on her back burned and felt like she had broken her shoulder. It was a penetrating pain that went bone deep, and it continued as the rash expanded and actively blistered.
In addition to the shingles vaccine and pain medication, Marie's physician also prescribed an antiviral medication called acyclovir (Zovirax), one of three drug options designed to alleviate the symptoms of shingles.
"If you can get a person started on an antiviral drug within the first 72 hours then you have a chance of reducing the duration of the outbreak and a potential for prolonged pain, postherpetic neuralgia (PHN)," said Graham.
The varicella zoster virus is contagious to anyone who has not yet had chickenpox, but even then you have to come in direct contact with the fluid from an active blister in order to develop chicken pox.
"It's a reactivated virus so if you come in contact with someone who is not immune to chickenpox, they will get chickenpox," said Graham. "They won't get shingles. It can't be spread through coughing or sneezing because the virus is not in the respiratory tract. It can be spread by touching the (active) blister or if someone touched their own blisters, they would have the virus on their fingers and could transfer it to someone else that way. You don't want to be touching other people, particularly pregnant women."
Shingles is less contagious than chickenpox, and the risk of a person with shingles spreading the virus is low if the rash is covered, the CDC states. So if you have shingles, keep the rash covered when in company with other people. Wash your hands often and keep your fingernails clean and cut short. Scratching active blisters with dirty finger nails can cause a secondary staphylococcal infection and another visit to the doctor for antibiotics.
When in doubt, play it safe while in the active blister phase and avoid contact with anyone who has not had chickenpox, especially pregnant women, young infants and those whose immune systems are compromised by illness, chemotherapy, HIV and other conditions that lower immune response.
Early detection and a prompt visit to your internist will pay off.
"See a doctor as soon as you see eruption," said Graham. "The earlier you see a doctor the better chance you have of reducing the spread of the outbreak. Most people only get it once if they get it at all."
Home remedies that help
* Cool wet compresses for pain
* Soothing oatmeal baths
* Calamine lotion relieves itch
* Expose rash to the air, heals faster
* Topical local steroids relieve itch
* Antihistamines reduce itch