The Neuroanatomical Basis of Unfamiliar Presentations of Herpes Zoster: A Review and A Case Report

Herpes zoster (HZ, shingles) is caused by reactivated varicella zoster virus, that travels along the peripheral branches from its dormant location in neurons of spinal and cranial sensory ganglia. HZ is well known for its skin vesicular eruptions and severe sensory neuropathy. Over the years, reports have described the occurrence of segmental paresis of skeletal muscles and the involvement of the large and small intestine, clinically resembling intestinal obstruction. The spread of the virus to the motor and autonomic nervous systems is discussed here based on the neuroanatomical pathways and with reference to the unfamiliar manifestations observed in a recently hospitalised HZ case. A 66-year-old male of Egyptian descent, initially developed muscle aches in the right loin, altered touch sensation in the overlying skin and bouts of stabbing pain. These were followed on day two by the appearance of an abdominal wall swelling, 10 × 12 cm, in the right lumbar region. On day four, he complained of nausea, bloating, abdominal distension, and constipation. Examination revealed reduced intestinal sounds, and CT scans showed distended intestine with gas and fluid levels. On day five, vesicular skin rash characteristic of HZ appeared along dermatomes of the right spinal nerves T10 to L1. Surgeons and medical practitioners should be made aware of these unfamiliar presentations of HZ, especially as these may precede the archetypal skin rash, to evade unnecessary surgical intervention.