You are a woman in her sixties. You struggle with stress and depression and lay awake at night. You have asthma and arthritis. As a child, you came down with chickenpox. You may not know it, but the virus that gave you chickenpox is inside you, waiting quietly, patiently for the chance to come back and bite you again — not as chickenpox, but as shingles. It’s just a matter of when it awakens. No doubt, it will strike at an inconvenient time, because there is never a convenient time for shingles to derail your life with its pain and misery. Hopefully your doctor has recommended that you get the vaccinations and hopefully you followed your physician’s advice. If so, then shingles should prove to be less painful and less inconvenient than if you did not. In this article, as in other health-related topics that I’ve blogged on, we’ll go a step deeper than what you might read in a magazine targeted to people of our age and background. I’ll be thorough and explain in detail what you might expect and how this came about in the first place. And if you are a man, you are not out of the woods, as I can personally attest having gotten shingles myself at the ripe old age of sixty-six.
Introduction
Shingles, like chickenpox, is an infectious disease that affects the skin and the nerves. And your skin is the largest organ in your body. The pathways that your nerves follow are like a metropolitan transit system that extends to every part of a city. And it is along these nerves that the skin lesions of chickenpox and shingles more or less emerge.
There are different ways that nerves can be classified, and the same type of nerve may be in more than one class. Some nerves require our conscious mind to operate. Others we depend on to keep us healthy and alive when we sleep. Some nerves are motor nerves that lead away from the brain, and some diseases attack these motor nerves and cause tremors or balance disorders. Other nerves are sensory nerves that bring information (such as temperature, pressure, vibration . . . and pain) to your brain. Shingles doesn’t cause people to lose their balance, but shingles does cause pain — often quite a bit of pain. So shingles affects the sensory nerves, and these nerves invariably end at the skin.
Both chickenpox and shingles are caused by the same virus: the varicella-zoster virus (VZV). A person cannot get shingles unless they first contract chickenpox. The general sequence is for a person to get chickenpox as a child and then shingles later — much later — in life. But if you are eighty years old and you’ve never had chickenpox or the vaccine for chickenpox, your first encounter with VZV will infect you with chickenpox, not shingles. However, almost everyone in the U.S. in that age cohort has had VZV either as a child or later in their life.
Because a virus is not a cell, but rather something called a virion, it is not truly alive. You may read on the labels of products that such and such disinfectant kills viruses, but that is technically not so, because a virus is not truly alive. A virion consists of some scraps of DNA or RNA surrounded by a hard protein shell called a capsid. The capsid may be within a fatty membrane with protein spikes to help the virion anchor itself to an actual nerve cell.
A nerve cell (i.e., a neuron) is alive like any other cell. It has the same basic functions as other cells — viz., metabolism (energy production), waste removal, and maintaining homeostasis, growth, and maintenance. Most neurons cannot reproduce, so the ones you depend on today are largely the ones you were born with, and they will serve you for better or for worse until you die. One remarkable thing is the size of neurons from the nerve cell’s body to the far end of the axon. While human cells are normally microscopic, nerve cells can be as long as two to three feet in the upper body and even longer in the lower body.
So, the VZV virion enters the soma, or main body, of the neuron. Once there, it sort of shuts down for weeks, months, years, or decades. In this location and in this state, your immune system is not able to detect it.
There are illnesses and conditions such as tuberculosis, thrush (which is actually a yeast), Herpes simplex virus (HSV-1) — aka Herpes Type I — and VZV that are known as “opportunistic infections.” These are conditions that someone has been exposed to but whose bodies are healthy enough day-to-day to keep these infections from being re-awakened. But situations that stress the body, such as burns, pregnancy, cancers, gunshot wounds, and other types of insult weaken the body and allow these conditions to re-emerge.1
In the meantime, these pathogens either “lay low” in some organ (as TB does in the lungs) or they avoid detection, blending in with countless other cells in the neurons of the nerves entering your spine.
When your body is stressed, the VZV may re-emerge. It’s not as though a switch is thrown, or that one virion crosses some red line. It’s more like a dam that holds back many tons of water beginning to weaken, or a bridge beginning to buckle.
Where on the body shingles may be found
From most common to least common, here is where a shingles outbreak may occur:
- One side of the chest or abdomen.
- Across the forehead or around one eye.
- Neck and shoulder extending to an arm.
- Lower back, hip or leg.
- Tail bone, buttocks and upper thigh.
It can also appear in unexpected places, such as the outer cartilage of the ear. A month ago, my wife Deena complained of pain in her left ear, between the opening of the ear and the eardrum (the cymba and the cava, to be exact). There was a good deal of pain, absent any blood or drainage whatsoever. She went to an urgent care clinic, which focused on her eardrum instead and discharged her without a diagnosis. The pain persisted.
With shingles, the pain often precedes a rash. And in some cases (Zoster sine herpete) there is pain with no rash at all, making an accurate diagnosis difficult. A week or ten days later, we noticed a dozen or more white papules clustered like a colony of bacteria, and she went to our PCP’s office. The doctor could not identify what they were and called in a colleague, who likewise had no clue. But this second doctor was concerned about the potential for cellulitis and prescribed an antibiotic.
Four or five days later, Deena was scheduled to see her dermatologist for an annual exam and mentioned the pain to her. The doctor immediately identified it as shingles and mentioned she had seen another patient that same day with shingles of the ear (herpes zoster oticus). In some cases a person can actually lose all or part of their hearing from herpes zoster oticus.
When medicine becomes an art
It is typical for doctors to run bloodwork when they see a patient in an ER or clinic. If there are changes to basic blood chemistry, such changes suggest only a mild inflammatory process, which might point to a dozen or more conditions. It is possible for a patient with shingles to show a mild liver inflammation as well. And that inflammation is only mild if the patient is in otherwise good health. If they are immunocompromised (e.g., undergoing chemotherapy) or they have a compromised liver from other causes such as alcoholism, this infection could be grave. Occasionally a doctor might run tests for protein analysis, which would assist in the diagnosis, and sometimes a spinal tap (i.e., lumbar puncture) is warranted.
Eventually, after two long weeks or so, the infection starts to clear up. One reason it does is that the scabs on the skin — which weep fluid capable of infecting others who come into contact with them — are already dying, as the lifespan of a skin cell is only two to four weeks. Another factor is that the patient’s immune system catches up faster than virions can travel down the nerves to infect new cells.
Young people can get shingles, too, and that’s another challenge when it comes to a diagnosis.
Footnote
1A doctor might hesitate putting thrust and the Varicella-Zoster Virus in the same sentence, but I wanted to make a point and in some real sense this is true.
