Shingles - Nursing Case Study

Pathophysiology

• Primary mechanism: Shingles, or Herpes Zoster, is a reactivation of the Varicella Zoster Virus (VZV), which lies dormant in nerve cells after a person has had chickenpox. When the immune system weakens due to stress, disease, or aging, VZV can reactivate, traveling along nerve fibers to the skin, causing the characteristic painful rash.

• Secondary mechanism: The immune response to this reactivation of VZV causes inflammation and swelling of the affected nerve, leading to the severe pain (postherpetic neuralgia) commonly associated with Shingles.

• Key complication: In some cases, the virus can affect the eyes (herpes zoster ophthalmicus), leading to vision loss if not treated promptly. Additionally, if the virus spreads to other parts of the body, like the lungs, liver, or brain, it can cause serious complications such as pneumonia, hepatitis, or encephalitis respectively.

Patient Profile

Demographics:

68-year-old male, retired construction worker

History:

• Key past medical history: Diabetes Type 2, Hypertension, Mild Stroke 3 years ago

• Current medications: Metformin, Lisinopril, Aspirin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Intense pain and rash on the left chest region

• Key symptoms: Painful rash, fever, headache, fatigue, sensitivity to light, mild shortness of breath

• Vital signs: Blood Pressure 160/92 mmHg, Pulse rate 96 bpm, Respiratory rate 22 breaths per minute, Temperature 101.2 F.

Section 1

New Diagnostic Results:

Based on the patient's symptoms and the visible rash on the left chest region, the primary care physician ordered a Tzanck smear and Polymerase Chain Reaction (PCR) test to confirm the diagnosis of Herpes Zoster. The Tzanck smear identified multinucleated giant cells, a characteristic finding in Herpes infections. The PCR test result was positive for VZV, confirming the diagnosis of Shingles.

However, the physician was concerned about the patient's elevated blood pressure and mild shortness of breath. An EKG was ordered and showed signs of left ventricular hypertrophy, suggesting that the patient's hypertension may not be well-controlled. Lab results also showed a slightly elevated blood glucose level at 180 mg/dL and an HbA1c of 8.5%, indicating poor glycemic control. These results triggered concern for potential complications, considering the patient's history of diabetes and hypertension, and his current infection could exacerbate these conditions.

Given the patient's age, history, and the present implications of his lab results, the physician decided to refer the patient to a cardiologist for further evaluation and management of his hypertension. The patient was also advised to follow up with his endocrinologist to optimize his diabetes management. These steps were crucial in preventing complications associated with shingles, as well as his underlying chronic illnesses.

Section 2

Change in Patient Status:

A few days after initiating antiviral therapy for Shingles, the patient returned to the clinic with complaints of persistent pain and new onset of confusion. He reported that the pain was not subsiding and rated it as 8 on a scale of 10. He also mentioned episodes of forgetfulness and difficulty focusing since the last visit. His daughter, who accompanied him, echoed these concerns, adding that he seemed more irritable and had trouble sleeping.

On examination, his blood pressure was recorded at 165/95 mmHg, higher than his previous visit. His heart rate was 98 bpm, respiratory rate was 20 breaths per minute and oxygen saturation was 96% on room air. Repeat lab tests were ordered which showed a further elevated blood glucose level at 220 mg/dL. The physician also noted the patient's inability to accurately recall recent events during the mini-mental state examination. These changes in the patient's status were concerning, suggesting the possibility of uncontrolled hypertension, worsening of his diabetes, and potentially a Herpes Zoster-related complication known as Postherpetic neuralgia (PHN) or even central nervous system involvement. The patient was immediately referred to the emergency department for further evaluation and management.

Section 3

New Diagnostic Results:

In the emergency department, the patient underwent a thorough diagnostic workup. A CT scan of the head was performed to rule out any acute cerebral events. The scan showed no signs of cerebral edema, hemorrhage, or ischemia, which ruled out a stroke. However, there was mild cortical atrophy indicative of age-related changes. His electrocardiogram (EKG) showed a regular rhythm with no acute ischemic changes but reflected signs of left ventricular hypertrophy, likely due to longstanding hypertension.

Further, a lumbar puncture was done due to his new-onset confusion, which suggested possible central nervous system involvement by the Herpes Zoster virus. The cerebrospinal fluid (CSF) analysis showed a slightly elevated protein level at 55 mg/dL (normal range 15-45 mg/dL) and a normal glucose level at 60 mg/dL (normal range 40-70 mg/dL). This might suggest early signs of viral meningitis, often associated with Herpes Zoster, or it could be a result of an inflammatory response to the shingles.

These findings indicated uncontrolled hypertension, possibly early signs of viral meningitis, and complications with his diabetes, all of which needed immediate medical attention. The clinical team needed to formulate an immediate therapeutic plan to manage these escalating complications while considering the patient's worsening pain and confusion.

Section 4

Change in Patient Status:

Overnight, the patient's status deteriorated further. His pain levels continued to escalate, despite the administration of pain medication, and his confusion deepened, which was likely a reflection of the probable viral meningitis. The patient also began to exhibit signs of dyspnea, most likely due to the left ventricular hypertrophy that the EKG had indicated. His blood pressure readings remained high at 160/98 mmHg, indicating that his hypertension was still uncontrolled.

The patient's blood glucose levels were closely monitored due to his history of diabetes, and they began to show a significant increase, rising to 220 mg/dL (normal range 70-130 mg/dL), which was a clear indication of hyperglycemia. This could be due to the stress of the illness, poor glycemic control, or a combination of both. Given these new developments, it was clear that the patient's condition was becoming increasingly complex and required a careful and comprehensive management approach.

Section 5

New Diagnostic Results:

Upon a repeat lumbar puncture, the cerebrospinal fluid (CSF) analysis showed increased protein and white blood cells, confirming the suspicion of viral meningitis. The patient's MRI also revealed left ventricular hypertrophy, consistent with his EKG findings. The chest x-ray displayed mild pulmonary congestion, likely contributing to his dyspnea.

Lab results showed a further increase in blood glucose levels to 240 mg/dL, confirming worsening hyperglycemia. Also, the patient's HbA1c had risen to 7.8% (normal range: 4-5.6%), indicating poor glycemic control over the previous few months. The patient's blood pressure remained high, with current readings of 165/100 mmHg. A urine test also revealed proteinuria, indicating possible kidney damage due to uncontrolled hypertension.

These new diagnostic results indicated that the patient's condition was worsening and that multiple organ systems were being affected. It was clear that the patient required a more aggressive treatment approach, including strict glycemic control and management of hypertension, in addition to antiviral therapy for shingles and viral meningitis. The complexity of the patient's condition emphasized the importance of interprofessional collaboration and communication in his management.