P4200 - An Atypical Presentation of Herpes Zoster

Cooper Byers, ¹, Shajan Peter, MD², Brice Gorman, ¹, Maya Williams, ¹, Adisesha Reddy, MD, FACG^3
1University of Alabama, Tuscaloosa, AL; ²Basil I. Hirschowitz Endoscopic Center of Excellence, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL; ³GastroCare P.C., Tuscaloosa, AL

Introduction: Herpes Zoster Virus (HZV) is a disease involving the typically local reactivation of the Varicella Zoster Virus (VZV). Immunosuppressed host and aging are some factors that can contribute to reactivation. Symptoms commonly associated with HZV include localized pain or tingling and the formation of blisters or ulcers on the affected dermatome. In rare cases, VZV can present without a rash and has been labeled “Zoster Sine Herpete.” We present a case of zoster sine herpete affecting at least one thoracic dermatome.

Case Description/Methods: 49-year-old Caucasian female presents with a 7- to 8-day history of right upper quadrant abdominal pain without a rash. Because of the acute onset and severity of the pain, the patient was hospitalized. Pain was described as sharp, worsening, and radiating to the back without crossing the midline. Past medical history is significant for diabetes mellitus, hypertension, diverticulitis, cholelithiasis, and cholecystectomy. Tenderness in right hypochondrium was appreciated on exam, but no skin changes were noted. CBC, CMP, and UA were negative, but liver panel showed ALT of 84 IU/L and mildly elevated CRP of 1.202 mg/dL. MRI/MRCP of the abdomen was unremarkable except for fatty infiltration of the liver, and CT of the chest and abdomen showed mild atelectasis but was otherwise negative. A VZV titer test was positive, and the patient was given IV Acyclovir (895 mg) and discharged with PO acyclovir (800 mg). She responded well and the symptoms cleared up in 48-72 hours.

Discussion: Clinicians should consider HZV as a differential for cases even in which other common symptoms are absent, as quickly and accurately diagnosing herpes zoster in the absence of appreciable skin changes can be elusive. Cases that lack the typical presentation characteristics may benefit from confirmatory testing. There are multiple commonly used tests to detect VZV. The one utilized here detects anti-VZV IgM antibodies. Due to their low accuracy [48.2%], these tests may best be used to corroborate a diagnosis.¹ Clinicians should be cognizant of Herpes Zoster potentially presenting as acute abdominal pain without a rash. Our case illustrates an index of suspicion that resulted in a prompt initiation of appropriate treatment and total resolution of abdominal pain.


1. A Sauerbrei, U Eichhorn, M Schacke, P Wutzler, Laboratory diagnosis of herpes zoster, Journal of Clinical Virology, Volume 14, Issue 1, 1999, Pages 31-36, ISSN 1386-6532



Disclosures:


Cooper Byers, ¹, Shajan Peter, MD², Brice Gorman, ¹, Maya Williams, ¹, Adisesha Reddy, MD, FACG³. P4200 - An Atypical Presentation of Herpes Zoster, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.