Shingles: Diagnosing Without Visible Rash Symptoms

Suspected shingles?

My mother is 65 years old and was diagnosed with nephrotic syndrome two years ago, after which she began treatment with immunosuppressants.
In February of last year, she suffered a stroke resulting in left-sided paralysis and aphasia.
Then, in August, she developed shingles.
Around July 12 of this year, my mother frequently expressed pain in an area similar to the shingles scar on her left flank.
The following morning, we noticed a small area of redness on the scar, which later subsided, but her pain increased compared to the previous day.
A day later, I took her to a medical center to check for a possible recurrence of shingles, but the emergency physician was unable to confirm it and there were no testing methods available since the rash was not visible.
I would like to ask the doctor if shingles can present without a rash, and how can we accurately diagnose it? We have already started antiviral medication and are on the second day of treatment.
After the first day of medication, red bumps appeared extending from the scar on her flank to an area on her abdomen without scars, which were painful but later subsided.
We have also been supplementing her with vitamin B12 since starting the medication, but so far, no rash has appeared, only pain.
The pain in her abdomen has also eased.
Is there any way for us to confirm if this is shingles?

Xiao Pan, 30~39 year old female. Ask Date: 2024/07/15

Dr. Wu Yuxin reply Dermatology

It is challenging to diagnose shingles; one must observe a dermatomal distribution of the rash or vesicles.
Although it is not always possible to see the typical dermatomal pattern, at least some rash or vesicles should be present.
In theory, it is possible to have shingles without visible rash or vesicles, but such cases are extremely rare.

Reply Date: 2024/07/15

More Info

Understanding shingles, or herpes zoster, particularly in patients with compromised immune systems, can be quite complex. Shingles is caused by the reactivation of the varicella-zoster virus, which remains dormant in the body after an individual has had chickenpox. In your mother's case, her history of kidney syndrome and subsequent use of immunosuppressive medication makes her more susceptible to infections, including shingles.

Shingles typically presents with a painful rash that follows a dermatomal distribution, meaning it appears in a specific area of the skin corresponding to a nerve root. However, it is important to note that shingles can sometimes occur without the classic rash, especially in immunocompromised individuals. This condition is referred to as "zoster sine herpete," where the pain and other symptoms may precede the appearance of the rash or may not appear at all.

In your mother's situation, the pain she is experiencing in the area where she previously had shingles could indeed be related to a recurrence or reactivation of the virus, even if a visible rash is not present. The fact that you observed redness in the area where the shingles scar is located, followed by a decrease in redness, suggests that there may be some inflammatory process occurring, possibly linked to the virus.

To diagnose shingles without visible rash symptoms, healthcare providers often rely on the patient's clinical history and the characteristic pain associated with shingles. In some cases, laboratory tests can be performed to confirm the presence of the varicella-zoster virus. These tests may include:
1. Polymerase Chain Reaction (PCR) Test: This is the most sensitive and specific test for detecting the varicella-zoster virus. It can be performed on fluid from blisters if they are present, or on blood or other tissues if no rash is visible.

2. Serology: Blood tests can check for antibodies against the varicella-zoster virus. However, this method is less definitive for diagnosing an active infection, as it may only indicate past exposure to the virus.

3. Clinical Evaluation: A thorough assessment by a healthcare provider, including a review of symptoms and medical history, is crucial. The presence of unilateral pain, especially in a dermatomal pattern, can be indicative of shingles.

Given that your mother has already started antiviral medication, which is typically prescribed to reduce the severity and duration of shingles, it is essential to monitor her symptoms closely. The fact that her pain has lessened after starting treatment is a positive sign, but it is still important to follow up with her healthcare provider for further evaluation.

In summary, shingles can present without visible rashes, especially in immunocompromised individuals. Diagnosis may require a combination of clinical evaluation and laboratory tests. If your mother continues to experience pain or if new symptoms arise, it is advisable to seek further medical attention to ensure appropriate management and to rule out other potential causes of her symptoms.

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