Zoster sine herpete

[callmeanesthesia]

A previous patient came in with a new problem of severe right neck pain that wrapped around to the shoulder, about in a C4 distribution. Nothing on her C spine MRI to explain it, and her skin was hypersensitive to touch. Denied history of rash in the area but did have shingles several years ago on her face. Topicals weren’t helping and she got side effects with oral antineuropathics. She hadn’t had her shingles vaccine, so I told her to go ahead and get it, and that maybe it would help. Within 4 days of getting the shot, she says the symptoms started to resolve. On follow up about a month later, she still has a little hypersensitivity of the scalp but her severe nerve pain is gone and she is back to usual activities.
I thought it was pretty cool so I wanted to share.

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[painfree23]

Did u check Igm antibodies?

 

[callmeanesthesia]

Did u check Igm antibodies?

No. Would that even be positive 8 months later?

 

[SpineandWine]

Would a vaccine work 8 months later?
I suspected in a patient with similar patient but not sure how to prove (t7 distribution, negative thoracic MRI, tender to touch).
Just gave her some lidocaine cream, and neuropathic agent.

 

[lobelsteve]

How does a vaccine treat symptoms? Illogical.

 

[callmeanesthesia]

How does a vaccine treat symptoms? Illogical.

Symptoms of a persistent viral infection that lives dormant in the CNS and reactivates and causes symptoms. Of course this is pure speculation on my part but zoster sine herpete is pretty poorly understood anyway, and the vaccine is a fairly benign intervention that she was due for as standard preventative care anyway.

 

[Ducttape]

How does a vaccine treat symptoms? Illogical.

remember that shingles is reactivation of a latent infection. maybe she has underlying amount of activation....

 

[lobelsteve]

remember that shingles is reactivation of a latent infection. maybe she has underlying amount of activation....

And how does this treat acute pain?

 

[callmeanesthesia]

And how does this treat acute pain?

At this point it was chronic - 8 months - which is even more remarkable to me that it worked.
Pain possibly caused by lingering active virus, active enough to cause inflammation in the DRG but not active enough to trigger a full blown antibody response?

 

[lobelsteve]

My point is there is no mechanism that a vaccine treats pain. It prevents the virus from re-emerging.

 

[bedrock]

My point is there is no mechanism that a vaccine treats pain. It prevents the virus from re-emerging.

But at least he helped the patient by thinking outside the box. Important to do that now and then.

 

[lobelsteve]

But at least he helped the patient by thinking outside the box. Important to do that now and then.

I see this as a shared delusion. Placebo response or lucky timing. Aren't you protected for 1-2 years from shingles after having shingles.

 

[callmeanesthesia]

I see this as a shared delusion. Placebo response or lucky timing. Aren't you protected for 1-2 years from shingles after having shingles.

She was 4 years out from having had a confirmed case of shingles. It could be a coincidence, I acknowledge that. However, the allodynia seemed much more like shingles than a spinal issue. As you know, In a full shingles episode the virus reactivates, replicates, and travels down the nerve to erupt in vesicles, causing nerve damage along the way. However, zoster sine herpete is less well understood. In this patient, having had shingles 4 years ago and therefore having at least some residual immunity, her immune system may have been able to prevent a full reactivation but not fully suppress viral replication at the DRG, leading to a slow smoldering inflammatory process. Vaccination boosts the immune response, allowing for full suppression of the virus, and resolution of that inflammation.

 

[Orin]

The studies do suggest vaccination prevents PHN development (Post-licensure zoster vaccine effectiveness against herpes zoster and postherpetic neuralgia in older adults: a systematic review and meta-analysis), but I agree there are some PHN patients that seem to have a smoldering re-activation. They complain of a mild rash or show pockmarks of various ages with some looking more recent.

Regardless of that, I ask patients with PHN to please get the vaccine to prevent the next outbreak somewhere else and I will also try a longer course of antivirals at the initial visit for 1 - 2 months to see.