An 81-year-old man experienced five days of prodromic GI symptoms (distension, hyperactive peristalsis but no diarrhea, no emesis) prior to the onset of left lower-quadrant herpes zoster. The pain, which was unrelated to food intake, appeared to be the result of distension and was relieved by burping and passing gas. Recumbency made the pain worse; the patient felt better in an upright position and with exercise. He did not experience typical prodromal pain or tender localization. What is the explanation for this autonomic dysfunction with zoster?
—Frank S. Sutton, MD, Encinitas, Calif.

Herpes zoster, or shingles, is usually limited to one dermatome in the lumbar or thoracic distribution. The telltale rash is preceded by neuropathic pain that sometimes can mislead the clinician. I’m not sure whether this patient’s symptoms were associated with the zoster outbreak or were coincidental. In severely immunocompromised persons, shingles can affect the intraperitoneal cavity with symptoms that, when the varicella-zoster virus disseminates, mimic an acute abdomen, with disastrous consequences. The clinical course you relate sounds benign, so I’m doubtful that zoster caused the GI symptoms. Consider other diagnoses.
—Cedric W. Spak, MD, MPH (120-3)