Respond to this article

Picture Quiz: Chest pain with an immunological cause

Life threatening causes must be excluded first, say Benjamin James Sieniewicz and Rafe Chamberlain-Webber

A 72 year old man presented to the emergency department with five days of intermittent chest discomfort, associated with a tingling pain that radiated down his left arm. He had a history of ischaemic heart disease, and eight years before he had had bypass grafting of two coronary arteries. Other relevant history included type 2 diabetes, hypercholesterolaemia, chronic kidney disease, and surgery for bladder and bowel cancer.

Question 1—What four potentially life threatening diagnoses need to be considered and excluded?

Answer—Acute coronary syndrome; pulmonary embolism; aortic dissection; and tension pneumothorax.

His blood panel showed no evidence of cardiac necrosis (troponin <0.04 μg/l), although the electrocardiogram had some irregularities—T wave inversion in aVL, ST elevation in V1, and ST depression anterolaterally. Because of the possibility of an acute coronary syndrome and admitted the man for further monitoring and investigation.

Question 2—What further investigations would help to establish the cause for this man’s pain?

Answer—Full blood count, urea and electrolytes, and troponin; chest x ray; echocardiography; exercise treadmill test; computed tomography; computed tomography pulmonary angiogram; angiography.

His chest x ray scan showed some unusual shadowing in the left base, but all his blood tests were within normal ranges, in particular his full blood count showed no leucocytosis. The computed tomogram of his chest did not show a pulmonary mass lesion and only a small volume mediastinal lymphadenopathy was visible.

To investigate the likelihood of an ischaemic origin for this man’s symptoms an exercise treadmill test was performed. This showed only minimal ST changes, indicating that coronary artery disease was an unlikely culprit. Back in the ward, however, the man began to complain of worsening chest pain. Concerned, the junior doctor carried out a full examination and was surprised to discover the rash seen in figs 1¹ and 2².

Fig 1

Fig 2

Question 3—What is the cause of the man’s chest discomfort?

Answer—Reactivation of dormant varicella zoster virus resulting in T3 shingles.

Discussion

Herpes zoster or “shingles” is a disease caused by the reactivation of the dormant varicella zoster virus. The primary varicella zoster virus infection causes chicken pox. When a patient contracts chickenpox (varicella) he or she does not clear the causative virus. Instead, although the cutaneous vesicles have disappeared, the virus lies dormant in the nerve cell bodies until reactivated; it travels both centrally to the spinal cord and peripherally down the nerve axons to the skin. The cause of reactivation is not completely understood, however, immunosenescence (the decrease in cellular mediated immunity with age) and immunocompromise are the two most widely recognised factors. Shingles is a relatively common condition, affecting about a quarter of people at some point in their life and roughly half of people older than 80.

A flu like prodromal phase can occasionally be found at the start of an episode. More commonly, however, reactivation of the virus is heralded by a prodromal (early non-specific symptom) burning and tingling hyperparesthaesia in the dermatomal region supplied by the affected nerve. The pain during an acute attack may vary in character and severity and incorporate neuropathic phenomena such as allodynia (pain from a stimulus that would not usually cause pain). In most people, the characteristic erythaematous skin rash develops after a few days, however, this is not always the case (zoster sine herpete). The typical rash will not cross the midline and looks belt-like, according to the dermatome affected. The rash eventually becomes vesicular and crusts over before healing.

Treatment aims to limit the severity and duration of an attack and to reduce the risk of future complications. Strong analgesia is helpful acutely in conjunction with oral antivirals, such as famciclovir and valaciclovir, prodrugs that inhibit viral replication. Oral antivirals are only effective within 72 hours of the rash onset. Antivirals do not reliably prevent postherpetic neuralgia, a neuropathic condition caused by damage to the nerves during reactivation, which occurs in 9% of cases, but they can minimise the risk. Positive predictors for its development include old age and immunocompromised status but not necessarily the severity of pain or cutaneous symptoms experienced as in this case.

Two live attenuated varicella vaccines are currently licensed in Europe, however, Germany is the only European nation to offer a cohesive vaccination strategy aimed at varicella despite its recommendation since 1995 in the United States. The Joint Committee on Vaccination and Immunisation is currently reviewing the vaccination policy in Great Britain because several studies, including one published by the Society of Independent European Vaccination Experts, have favoured rolling out a routine vaccination policy, starting with adolescents.

Competing interests: None declared.

Patient consent obtained.

Provenance and peer review: Not commissioned; externally peer reviewed.

Benjamin James Sieniewicz foundation year 1 doctor
benjamin.sieniewicz@glos.nhs.uk
Rafe Chamberlain-Webber consultant cardiologist Cheltenham General Hospital, Cheltenham GL53 7AN
Student BMJ 2009;17:118 | March

      

 Printable version      Download PDF    E-mail this to a friend    Respond to this article    Request Permissions