Skin and breast disease in the differential diagnosis of chest pain Author Muir, Jim, Yelland, Michael Published 2010 Journal Title Medical Clinics of North America DOI https://doi.org/10.1016/j.mcna.2010.01.006 Copyright Statement © 2010 Elsevier. This is the author-manuscript version of this paper. Reproduced in accordance with the copyright policy of the publisher. Please refer to the journal's website for access to the definitive, published version. Downloaded from http://hdl.handle.net/10072/33712 Griffith Research Online https://research-repository.griffith.edu.au ARTICLE IN PRESS 1 2 Skin and Breast 3 4 Disease in the 5 6 Differential 7 8 Diagnosis of 9 10 Chest Pain 11 12 a, b ½Q2½ Q3 Jim Muir *, Michael Yelland ½Q4½ Q5 KEYWORDS 13 14 Chest pain Skin diseases Herpes zoster PROOF 15 Breast Neoplasm 16 17 18 Pain is not a symptom commonly associated with skin disease. This is especially so 19 when considering the known skin problems that have a presenting symptom of chest 20 pain that could potentially be confused with chest pain from other causes. 21 22 PAINFUL SKIN CONDITIONS 23 24 Several extremely painful and tender skin conditions present with dramatic clinical 25 signs. Inflammatory disorders such as pyoderma gangrenosum, skin malignancies, 26 both primary and secondary, acute bacterial infections such as erysipelas or cellulitis, 27 and multiple other infections are commonly extremely painful and tender. As these 28 conditions manifest with obvious skin signs such as swelling, erythema, localized 29 tenderness, fever, lymphangitis, and lymphadenopathy, there is little chance of misdi- 30 agnosis of symptoms as caused by anything other than a cutaneous pathology. 31 Several skin tumors can be painful or tender. These include blue rubber bleb nevus, 32 eccrine spiradenoma, neuromas, neurilemmomas, glomus tumors, angiolipomas, 33 leiomyomas, dermatofibromas, squamous cell carcinomas and other skin malignan- 34 cies especially when perineural infiltration is present, endometriomas, and granular 35 cell tumors. Once again in almost all cases of pain related to a skin tumor a lesion 36 can be readily identified, often by the patient. For a painful skin condition to be mis- 37 diagnosed as cardiac, pulmonary, or other forms of chest pain, the pain must arise 38 in the absence of readily identifiable skin disease. 39 40 41 a South East Dermatology, Suite 10 1202 Creek Road, Carina Heights, Brisbane, Queensland 42 4152, Australia UNCORRECTED b ½Q6 School of Medicine, Griffith University, Logan, Australia * Corresponding author. 43 E-mail address: [email protected] (J. Muir). Med Clin N Am - (2010) -–- doi:10.1016/j.mcna.2010.01.006 medical.theclinics.com 0025-7125/10/$ – see front matter ª 2010 Elsevier Inc. All rights reserved. MDC646_proof 3 February 2010 9:25 pm ARTICLE IN PRESS 2 Muir & Yelland 44 HERPES ZOSTER 45 The classic condition to cause significant pain without obvious skin changes is herpes 46 zoster. Although herpes zoster affects 20% to 30% of people in their lifetime, up to 47 50% of those more than 80 years old will be affected.1 Herpes zoster is the reactiva- 48 tion of varicella zoster (chicken pox) virus that has lain dormant in the spinal dorsal root 49 ganglion since initial infection. This produces the well-known, dermatomally distrib- 50 uted eruption commonly known as shingles (Fig. 1). Most often unilateral and confined 51 to a single dermatome, herpes zoster can involve multiple dermatomes and be bilat- 52 eral. In severe cases, scarring and depigmentation may follow the healing of the acute 53 lesions (Fig. 2). There is often significant associated pain preceding, accompanying, 54 and following resolution of the skin eruption. Pain persisting more than a month after 55 the typical skin eruption is termed postherpetic neuralgia. 56 The pain is variable in intensity but can be severe. It may be localized or more 57 diffuse. The onset of pain is usually around 4 days before any skin lesions appear.2 58 This prodromal pain has been labeled as ‘‘preherpetic neuralgia.’’3 There may be 59 associated fever, malaise, and often tenderness or hyperesthesia in the affected 60 area. Obviously in the prodromal phase before the onset ofPROOF the skin lesions, the source 61 of this pain can be obscure and erroneously attributed to other causes. For example, 62 involvement of abdominal dermatomes can lead to the diagnosis of intraabdominal 63 pathology such as biliary colic,4 duodenal ulcer, appendicitis, or renal colic. A rare 64 presentation is where there is no skin eruption following the prodromal pain. This is 65 termed ‘‘zoster sine eruption’’ or ‘‘zoster sine herpete.’’ The diagnosis may be sup- 66 ported by demonstrating an increase in IgM and eventually IgG varicella antibody 67 titers.5,6 68 Of particular interest are reports of 6 zoster patients in whom pain preceded any skin 69 eruption for between 7 and more than 100 days. The distribution of the pain did not 70 always occur in the same dermatomes where the rash eventually developed.3 Clearly 71 it would be extremely difficult to diagnose the cause of such a pain before the onset of 72 skin signs. Pain from such an atypical presentation of zoster would be even more likely 73 to be attributed to other causes. 74 During this phase of pain without skin lesions, there is the likelihood that diagnoses 75 other than herpes zoster will be considered.7 Of especial pertinence to chest pain is 76 the fact that zoster-related pain is more likely in older patients and will more often 77 be severe. As older patients are also more at risk of chest pain from cardiac and 78 79 80 81 82 83 84 85 86 FPO 87 = 88 UNCORRECTED 89 90 91 92 print & web 4C 93 Fig. 1. Acute herpes zoster showing the typical changes of pustules on an erythematous 94 base in a dermatomal distribution. MDC646_proof 3 February 2010 9:25 pm ARTICLE IN PRESS ½Q1 Differential Diagnosis of Chest Pain 3 95 96 97 98 99 100 101 FPO 102 = 103 104 105 106 107 print & web 4C 108 109 Fig. 2. Healing shingles approximately 10 to 14 days after the onset of the eruption. 110 111 pulmonary causes, the increasing incidence of zoster withPROOF increasing age also adds to 112 the likelihood of diagnostic confusion. 113 Thoracic dermatomes are commonly affected. These features enhance the risk of 114 confusion with cardiac pain8,9 or pleurisy. Herpes zoster can be complicated by pleu- 115 ropericarditis and even complete heart block.10 Temporary electrocardiographic 116 abnormalities can be seen.11 117 Diagnosing herpes zoster during this prodromal phase is clearly difficult. Clues to 118 the diagnosis include a history of varicella or herpes zoster, the presence of localized 119 skin tenderness or hyperesthesia in the painful area, and the localization of pain to 120 a dermatome. Obviously all efforts would need to be made to exclude other serious 121 or indeed life-threatening causes of chest pain. Often the diagnosis is only made 122 with the onset of the typical skin lesions of grouped vesicles and pustules on an 123 erythematous base in a dermatomal distribution (see Fig. 1). Then the diagnosis can 124 usually be made on clinical grounds alone. Swabs from a blister base reveal varicella 125 zoster virus DNA when submitted for confirmatory polymerase chain reaction. Only 126 rarely is biopsy necessary. 127 Treatment is with pain relief and a variety of systemic antiviral agents (acyclovir, 128 famciclovir, valacyclovir). Treatment should be instituted within 72 hours of the 129 appearance of the rash and continued for 7 days.12 There is evidence that valacyclovir 130 is superior to acyclovir.13 The former agent has the advantages of better bioavailability 131 and less frequent dosing. 132 An episode of herpes zoster usually resolves completely within 4 weeks (see Fig. 2). 133 Scarring and depigmentation may occur (Fig. 3). There should be no confusion as to 134 the cause of pain once the typical skin lesions have developed. It should be noted that 135 there are case reports of herpes zoster being temporally associated with and perhaps 136 triggered by thoracic surgery with zoster arising in the surgical scars.14 137 Pain that persists or recurs more than a month after the onset of herpes zoster is 138 termed postherpetic neuralgia. It is more common in older female patients especially 139 if there was significantUNCORRECTED prodromal pain, a more severe rash, and more severe acute 140 pain.15 Again there is little risk of misdiagnosis of this pain as a history of acute herpes 141 zoster will be found. 142 Once established postherpetic neuralgia is notoriously difficult to treat. Treatments 143 used include gabapentin,16 pregabalin,17 topical capsaicin cream,18 tricyclic antide- 144 pressants,19 and in selected cases epidural injections of local anesthetic and 145 steroid.20 MDC646_proof 3 February 2010 9:25 pm ARTICLE IN PRESS 4 Muir & Yelland 146 147 148 149 150 FPO 151 = 152 153 154 155 print & web 4C 156 157 Fig. 3. Postherpetic scarring and depigmentation in a lower thoracic dermatome. 158 159 160 A condition little known outside of dermatologic circles is notalgia paresthetica. It is 161 characterized by itch and less commonly pain in the interscapular region of the back. 162 This is the area innervated by the posterior primary rami ofPROOF the thoracic nerves T2 to 21 163 T6. Entrapment of these nerves is speculated to be causal. Typically the condition 164 occurs in older patients and there is a long history of discomfort, itch, or even hyper- 165 esthesia in the region. Skin changes can be minimal or related to chronic rubbing and 166 scratching with thickening and darkening of the skin in the affected area.