Herpes zoster (shingles) is an acute, painful, vesicular, and cutaneous eruption caused by varicella zoster virus, the same virus which causes chicken pox. It is due to the reactivation of the virus which remains dormant in sensory ganglions following chicken pox. It is usually confined to a single dermatome but may involve 2-3 dermatomes. Typically, it is a unilateral lesion which can affect both cranial and peripheral nerves. It is usually a self-limiting disease; however, it may cause significant morbidity especially in the elderly. It is more common in older people and individuals with immunocompromised conditions. Antiviral drugs can shorten the duration and the severity of the illness and need to be started as soon as possible after the appearance of the rash. Gabapentin and tricyclic antidepressant are effective in postherpetic neuralgia. Vaccine can reduce the risk of infection and its associated pain. Typically, it occurs once in a lifetime, but some individuals may have more than one episode. 1. Introduction This case illustrates the importance of thorough clinical examination of patients presenting with rare or uncommon manifestations of common diseases. 2. Case Report A 67-year-old man was referred to the general medical clinic by his GP with a 3-week history of tiredness, dysuria, and frequent micturition that had not responded to antibiotics. He denied having haematuria, hesitancy, weak stream, or postmicturition dribbling. There was no fever, rigors, or loin pain. His urinalysis was normal. Urine culture, sent by his GP, was negative for infection. A routine battery of blood tests, including PSA, was normal. On further questioning, he described penile numbness and constipation. He denied any abdominal pain, nausea, or vomiting. He also denied any weakness or sensory changes in the limbs. He had past history of type 2 diabetes mellitus, heart failure, coronary artery bypass surgery, chronic obstructive pulmonary disease, hypothyroidism, and peripheral vascular disease. Neurological examination was unremarkable, apart from a subjective sensation of numbness of the glans penis. However, when the patient turned over to have his anal tone tested, a classic rash of herpes zoster was found on his left buttock involving S2-S3 dermatomes. The patient was totally unaware of the rash (Figure 1). Figure 1 He was treated for shingles; however, two weeks later he was readmitted with a sudden onset of deafness in his left ear and poor balance. An ENT specialist saw him, and his audiogram showed a dead left ear. CT and subsequent MRI scans of the brain
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