Case-control study of the effect of mechanical trauma on the risk of herpes zoster
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.37991.511829.F7 (Published 19 February 2004) Cite this as: BMJ 2004;328:439
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Physicians and other medical health care providers need to be more
cognizant to warn trauma patients of the events to expect after their
accident.
Recently I was in a MVA (motor vehicle accident) in which I sustained
moderate injuries to my ribs and surrounding area. Because no ribs
appeared to be fractured nor any major organs injured, the emergency
clinician I sought sent me home with only the "you'll be sore for a couple
weeks" and "I hope you've learned to wear your seatbelt."
Over the next week the pain increased, the swelling increased, and my
fears and confusion did likewise. It wasn't until I saw my own family
phyisican did I learn this was normal, and whats more, he went on to
specifically describe the exacting events going on in my body - using
sports and geological science, and culinary examples to make it clear.
THAT was appreciated and understood. I could leave knowing what my body
was experiencing and my fear diminished.
However, he failed to mention until I came back a week later again
concerned because the pain had increased, but in one specific area,
localized, that this was to be expected and common. So, again, now I was
feeling relief in knowing things were in the "normal healing process" and
I had no concerns. UNTIL, he asked about a rash...
I don't tend to look at myself in a mirror, not too impressed with
how age, gravity and obesity have effected my looks, so I couldn't confirm
or deny a rash, but I could confirm pain that felt like Herpes Zoster
Disease, once he identified it.
For the docs who read this.... PLEASE let your patients know ahead of
time what to expect, don't patronize them with the antiquainted mentality
that they don't want or need too much information. Let them be the judge
of that. At the very least, tell a relative.
For the patients of MVAs and other traumas to your bodies... demand
to know what to expect. I am in the health care profession, am recognized
as a peer to these docs, and still wasn't given sufficient information to
prepare me to be on top of things. My fear is too many people won't
return to docs for follow-up treatment, will not get treated for their
Herpes Zoster and suffer the painful long-term consequences. IF you have
had a rash, or no rash but an area of pain near the site where the injury
was sustained, it has an ache and soreness about it, sort of like tiny
knives at times, nerve-endings, shockings, seek medical services... in
all likelihood you too will have Herpes Zoster and it is treatable, the
earlier the better.
Competing interests:
None declared
Competing interests: No competing interests
We read the article describing the case-control study related to the effect of a mechanical trauma and the eruption of herpes zoster rash (1). Few weeks later a patient was examined at our clinic. We found this patient's case history as representative to that issue.
Mr. M, a 51 year old man, previously healthy, was injured during his work as a trailer driver. He fell down from the height of 4m'. As a result of a contusion to his chest wall two ribs (9-10) were fractured.
Nineteen days later he returned to the practice, complaining on severe pain, unrelated to movement or respiration. Beside slight tenderness over the injured area, no other sign was revealed in physical examination. In his next visit, two days later a rash in the vicinity of the injured area was clearly seen and diagnosed as herpes zoster along the corresponding dermatomes.
Five days later he noticed a bulge noticed in his abdominal muscle, in the contused side. A traumatic hernia was diagnosed as most probably due to a partial tear in the oblique muscle (inserted in 9-10 ribs). He was treated with analgesic and rest.
In our 15 year experience in the practice we have diagnosed herpes zoster several times and cared for patients with trauma quite as often. It is the first time we can point out on direct relationship between both, as it was followed prospectively from the time of the trauma. We assume that what makes the relationship strong is the severity of the trauma.
Competing interests:
None declared
Editorial note
The patient whose case is described has given his signed informed consent to publication.
Competing interests: No competing interests
Dear Editor
Thomas et al (1), in their Case-control study of the effect of
medical trauma on the risk of herpes zoster confirm the well established
association of trauma and zoster.
There are many important aspects of this association and it should be
a constant reminder of the possibility of post-traumatic pain being due,
not to the primary lesion being treated, but to the effects of the trauma
on the nerve(s) involved. The onset of the zoster vesicles along the nerve
distribution area clinches the diagnosis.
Chalier and Martins 1932 (2) formulated two circumstances in order to
associate trauma with the presence of Zoster,
1 Herpes zoster should appear in the region or within the range of
injury.
2 The disease should appear within one day to one month after the
injury.
As soon as the diagnosis of Zoster has been established, the
clinician can proceed to treat what can prove to be very severe and very
protracted pain in the affected area rather than undertake extensive
measures erroneously aimed at treating the original lesion as the prime
source of pain (Winstock, 1966) (3)
Yours faithfully
Donald Winstock (Retired Maxillo-facial surgeon)
1 S.L.Thomas, J.G. Wheeler, Andrew J Hall. Case control of the effect
of mechanical trauma on the risk of herpes Zoster. B.M.J. 21.02.04 No.
7437 .439
2 Chalier,J. and Martin,P.E. (1932) Journal Medicale Lyon,13,697.
3 Winstock, D. (1966) B.J. Oral Surgery Vol., 4,No 1,p.29 Post-
traumatic herpes zoster.
Competing interests:
None declared
Competing interests: No competing interests
My patient made a small movement to show how she had used her haunch
to move a heavy piece of furniture. This was two weeks earlier and she was
puzzled by the continuing pain. Oh, and her thigh was numb and then there
was this rash.
Of course it may just be coincidence, but only by recognising
associations can we learn.
My most memorable case occurred some years ago after the vigorous use
of a loofah. Sometimes the trigger doesn't need to be very traumatic.
Competing interests:
None declared
Competing interests: No competing interests
We have observed the occurence of Herpes zoster in many of our
patients particularly with immune supression,but a histry of trauma in
them was not obtained.In our own view,such an association between trauma
and herpes zoster should be best carried out in a tropical setting like
ours-Yola,Nigeria where the incidence is quite high.
Competing interests:
Association between trauma and Herpes zoster.
Competing interests: No competing interests
I found the article by Thomas et. al. interesting, but also somewhat
discomposing.
I have diagnosed and treated a very large number of patients with
shingles over the past decades, and I cannot remember a patient ever
telling me of trauma to the affected dermatome. I've always asked about
preceding injury to the location when the patients inquire about the cause
of their zoster (which they invariably do), and when I discuss the
pathophysiology of the condition. I ask the question because I've learned
that the patients expect this line of questioning, and are seeking a "real
world" reason to blame for their affliction. Scientific exegesis
concerning "reactivation of chicken-pox virus, etc, etc" never seems to
sit well with them.
After reading articles like this in journals I always assume I must
be living and practicing in a parallel universe. But I'll keep this
article in mind for future patients I encounter in my dermatologic realm.
Competing interests:
None declared
Competing interests: No competing interests
This young girl 27 yr old got pregnent and went for the MTP , after 5
days she noted vesicles in the right hip region and on examination they
were the vesicles of Herpes Zoster involving L5,S1,S2 roots she was
traeted with Acyclovir, steroid and analgesics and responded well with in
10days and now is asymptomatic.
I agree that surgical trauma was the precipitating factor of the same
region causing the Zoster
Competing interests:
None declared
Competing interests: No competing interests
Personal experience of rib trauma followed by shingles
I am a normally healthy, active, not overweight 62 year old woman.
A week ago (9 Sep 2016), following a couple of days of unexplained back and front pain round my torso, and a row of spots, I was diagnosed with shingles. Luckily the diagnosis was only two days after the spots appeared. so I was prescribed with acyclovir. I am now in discomfort and tired but have nothing like the symptoms I read about on the web. When describing the pain to friends I said it felt like having a broken rib. This got me thinking, since the pain under my right breast is precisely where I fell very hard on the side of the bath in June. The immediate pain was breathtaking and the pain continued for c. 6 weeks, with bruising. I presume I cracked a rib but didn't go to the doctor since I was aware there's not much that can be done and the pain was manageable with paracetamol.
But this made me wonder if there was a link between the pain from the broken rib and the current spots and pain in precisely the same place, since none of the other aggravating factors for shingles applied to me - I'm in good health and am actually in a rather less stressful situation than over the last few years. None of the information I had read on the web when I googled "shingles" suggested trauma. I then googled "trauma" and "shingles" and bingo - here is this paper. On the basis of my tiny sample size of one, I am persuaded that there is a causal link. My doctor did not ask if I had had an accident, I made the potential connection on my own, which I think makes the connection more convincing.
From my perspective my experience adds weight to the theory that trauma can cause shingles (of course I had chicken pox as a child).
Competing interests: No competing interests