Central Journal of Family Medicine & Community Health

Cite this article: Morgan UO, Etukumana E, Jiman A (2017) Postherpetic Neuralgia in a 77-Year-Old Male: The Impact of Traditional Beliefs and Practices on Management. J Family Med Community Health 4(3): 1109.

Abstract

Postherpetic neuralgia is a chronic pain syndrome and the most common complication of herpes zoster and often diagnosed when pain persists in a dermatomal pattern up to three (3) months after the herpes zoster vesicular eruption has healed. Myths have been known to be associated with herpes zoster infection and have played a negative role in the management of Herpes Zoster infection in some regions. While no treatment entirely prevents postherpetic neuralgia, early use of antiviral agents, effective analgesics, can help to reduce the severity and length of postherpetic neuralgia following herpes zoster infection.Data from a 77-year-old male patient managed for postherpetic neuralgia at the University of Uyo Teaching Hospital, Uyo, Southern Nigeria, is presented. He had sought care, prior to presentation, from a traditional healer. Health education and counselling were important aspect of management instituted for this patient.

Postherpetic neuralgia is a complication of herpes zoster, and is a common and debilitating condition. This report highlights the clinical evidence that prompt and early treatment of Herpes Zoster infection will reduce the incidence and duration of this distressing sequelae.

*Corresponding authorUduak-Obong M. Morgan, Department of Family Medicine, University of Uyo Teaching Hospital, Uyo, AkwaIbom State, Nigeria, Email:

Submitted: 16 February 2017

Accepted: 08 May 2017

Published: 10 May 2017

ISSN: 2379-0547

Copyright© 2017 Morgan et al.

OPEN ACCESS

Keywords•Elderly•Uyo – South-South Nigeria•Herpes zoster•Postherpetic neuralgia•Traditional beliefs and Practices

Case Report

Postherpetic Neuralgia in a 77-Year-Old Male: The Impact of Traditional Beliefs and Practices on ManagementUduak-Obong Morgan*, Etiobong Etukumana, and Abdulahi JimanDepartment of Family Medicine, University of Uyo Teaching Hospital, Nigeria

ABBREVIATIONSPHN: Postherpetic neuralgia; HZ: Herpes Zoster;

HAART: Highly Active Antiretroviral Therapy; HIV: Human Immunodeficiency Virus; ESR: Erythrocyte Sedimentation Rate: CDC: Centers for Disease Control

INTRODUCTIONPostherpetic neuralgia (PHN) is a chronic pain syndrome

and the most common complication of herpes zoster.There is currently no consensus definition for PHN. However, data that identify three distinct phases of pain (acute herpetic neuralgia, subacute herpetic neuralgia and chronic pain or PHN) in HZ suggest that PHN might be best defined as pain lasting at least 3 months after resolution of the rash [1]. It follows a complication of Shingles in 10-15% of patients, and can last for months to years [2]. A person’s life time risk of herpes zoster infection is 15-20%, with the highest incidence occurring in the elderly and the immune-compromised [3]. HIV infection is associated with a 10- fold increase in the risk of herpes zoster infection, and this risk remains increased even when taking HAARTs [3]. Postherpetic neuralgia occurs in approximately 30% of patient older than 80 years and in approximately 20% of patients 60 to 65 years. It is rare in patients younger than 50 years. Additional

risk factors include moderate to severe rash, moderate to severe acute pain during the rash, ophthalmic involvement, and history of prodromal pain [4,5].

Herpes zoster infection (shingles) results from the reactivation of varicella zoster virus infection. Within the spinal ganglia and sensory nerves lay clinically dormant varicella zoster virus acquired during the primary varicella (chicken pox) infection. The reactivation of the varicella zoster virus is associated with progressive decline in varicella zoster specific cell mediated immunity related to aging or conditions with diminished immunity such as cancer or diabetes. This reactivation and the accompanying inflammation lead to central nervous system dysfunction, which is manifested as debilitatory pain. In some patients, pain does not resolve when the herpes zoster rash heals but rather continues for months or years. It is stipulated to be due to persistent c-fiber nociceptor activity in the nerve cells, although some studies have also shown neural loss and scarring in nerves affected by herpes zoster injury [6].

The features of postherpetic neuralgia vary from mild to excruciating in severity, can be constant or intermittent, or triggered by trivial stimuli, patients complain of pain in response to non-noxious stimuli such as pressure from clothing, as was with the index patient; bed sheets, or the wind. It is boring and

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alienating in nature, chronic, inflatable and distressing. It can disrupt sleep, mood, work, activities of daily living and may lead to depression and decreased quality of life [1,7].

CASE PRESENTATIONThe patient, a 77-year-old male, of a tribe in Southern Nigeria,

presented with pain along the left chest wall of two months duration. His clinical condition started as painful blisters observed on the left side of his chest but with progressive extension to the left side of the back. He had told some members of his family and a few friends who told him the ailment was associated with an evil attack and could only be managed traditionally. He then went to a traditional herbal home where he was given some concoctions to drink and apply on the blistered surface. He had been doing this till about five weeks prior to presentation when blisters disappeared. He, however, observed that the pain persisted. The pain was described as severe (numeric pain rating score of 8), peppery in nature, constant, non-radiating, worse if touched by clothing and slightly relieved by a cocktail of analgesics (names unknown) he had bought over the counter. There was no history of fever, weight loss or similar clinical condition in the past. He also did not remember having any episode of chicken pox in the past. Patient believed that his clinical condition was caused by evil powers and feared he might die if the skin lesions joined or spreads across the mid trunk. He had been unable to sleep well and carry out his routine activities effectively due to the pain he had experienced since the onset of the illness. He expected a cure.

Review of Systems and past medical history was not contributory. He had not been screened for retroviral disease before and expressed the desire to do so.

General examination revealed an elderly man who was not in obvious painful distress. He was not febrile (36.9oC), anicteric, acyanotic, not dehydrated, no digital clubbing, no peripheral lymphadenopathy and no pitting pedal oedema. There was an extensive healed scar on the left portion of the anterior chest wall, extending to the left mid portion of the back along T3 and T4 dermatomes. The surface showed varied pigmentation of both hypo - and hyper pigmented areas with increased skin sensitivity to both light and deep touch. There was no similar lesion in any other part of the body. Other systems showed no abnormalities. A diagnosis of postherpetic neuralgia was made. Patient was informed and educated on the likely cause of his symptom and the sequelae he was experiencing. He was told that his symptoms were not due to the work of evil people but could be due to several factors that cause a decrease in immunity including an advanced age. He was counseled on the need to report to the hospital during periods of ill-health and dissuaded from patronizing unorthodox medical practices. The following investigations to rule out other possible causes of the illness were requested for: Full blood count: Packed cell volume- 42%, total white cell count-4.2 x109/L, differential count- Neutrophils-48%, Eosinophils-03%, Basophils-02%, Lymphocytes-45%, Monocytes – 02%. ESR – 36mm/1st hour (5.7/1st hour), Urinalysis: no abnormality was detected, Fasting plasma glucose: 5.2 mmol/L, HIV serology: non-reactive. He was subsequently given the following medications:

Tablets Amitriptyline 25 mg to be taken at night for two weeks

Tablets Biobetic (methylcobalamin plus) to be taken once daily for two weeks

Patient said he no longer felt pains after about 8 weeks of clinic visit. Examination of the affected dermatomes showed marked improvement in skin sensitivity. He was reminded to visit a hospital whenever he had any clinical symptom and was discouraged from self-medication and patronage of herbal homes since their practices were not supervised. He was subsequently discharged from follow up.

DISCUSSION Myths have been known to be associated with herpes

zoster infection. For example, the Chinese describes the ring of shingles as a “creeping snake”. It is said that if this “snake” grows around the chest and abdomen, it will cause death. To kill this “creeping snake”, incense has to be burned in the affected areas [8]. This practice has led to patients presenting at the hospital with varying degrees of burn injuries. Myths have also played a negative role in the management of Herpes Zoster infection in some African settings. For example, in the patient’s tribe in South – South Nigeria, herpes zoster infection is generally thought to be an “affliction bead” placed on an individual by a presumed enemy and hence cannot be cured by western medicine. This “bead” must never be allowed to join or else the person dies. While there is no scientific evidence behind these claims, evidence has shown that prompt management of the acute illness within the first 72 hours reduces postherpetic neuralgia and thus, the initial management of herpes zoster infection that will reduce the incidence of postherpetic neuralgia is missed as most people afflicted with the illness do not come to the hospital in the acute phase [9]. A particular study showed that treatment of herpes zoster infection with 800mg of oral acyclovir within 72 hours from onset of the rash may reduce incidence of residual pain at 6 months by 46% in immunocompetent adults [10].

The index patient presented to a traditional healer in the acute phase and only presented in a health-facility when the painful sequelae was becoming really distressing. This encounter afforded the author the opportunity to educate the patient on the disease and to discourage him from traditional practices that may impact negatively on health.

Though old age is a risk factor for herpes zoster, he was screened for other factors that may lead to decreased immunity, hence precipitating the illness. These included a full blood count and erythrocyte sedimentation rate, fasting plasma glucose and retroviral disease screening test.

Theoretical models suggest that reducing pain during the acute phase of herpes zoster may stop the initiation of mechanisms that cause chronic pain, thus reducing the risk of postherpetic neuralgia [9]. However, once the pain develops, treatment focuses on preventing a chronic pain syndrome. Several medications have proven effective for postherpetic neuralgia and should be selected based on individual patient characteristics [1,11,13]. Many of these medications require dosing adjustments in older patients and in those with reduced creatinine clearance.

Tricyclic antidepressants such as amitriptyline, as was used in the index patient, desipramin and nortriptilin have pain-

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Morgan UO, Etukumana E, Jiman A (2017) Postherpetic Neuralgia in a 77-Year-Old Male: The Impact of Traditional Beliefs and Practices on Management. J Family Med Community Health 4(3): 1109.

Cite this article

modulating effects in neuropathic and other chronic pain states. They are the mainstay of treatment of postherpetic neuralgia and evidence supports their effectiveness [14]. The use of tricyclic antidepressants in the index patient was also due to its ability to improve sleep. Several studies have also shown evidence of analgesic efficacy for other orally administered therapies such as Opiod medications (including tramadol) and anticonvulsants (gabapentin and pregabalin) [1,10-12]. Topical agents have also been used in the treatment of postherpetic neuralgia. A Cochrane review that included a few small studies of topical lidocaine patches (Lidoderm) reported benefit in some patient, but found insufficient evidence to recommend them a first line therapy [15]. Based on other studies, capsaicin cream (Zostrix), which are derived from peppers provide limited reduction in postherpetic neuralgia [1,11,12]. Topical antiviral agents such as idoxirudine may reduce the prevalence of postherpetic neuralgia in immunocompetent patients but evidence is low [1].

Herpes zoster and its sequelae, postherpetic neuralgia, are preventable conditions. The center for disease control (CDC) and prevention recommends one dose of the herpes zoster vaccines (Zostavax) for persons 60 years and older [14,15]. Patients can be immunized without serologic testing and regardless of any history of varicella virus infection or herpes zoster. Co- administrations with other inactivated vaccines is also considered safe [14,15]. However, this is not a common practice in our environment.

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