Zoster Sine Herpete: 7 Warning Signs of a Misdiagnosed Condition

  • Posted on: Jun 2 2025
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At our interventional pain clinic, diagnostic clarity is more than a goal—it is a responsibility. Chronic pain without a clear source challenges even seasoned clinicians, especially when standard imaging and therapies fall short. One such case—complex, elusive, and ultimately enlightening—underscores why a methodical, anatomy-based approach can unravel the most perplexing syndromes. This is the story of how Zoster Sine Herpete, a rare reactivation of varicella-zoster virus (VZV) without rash, was identified and effectively treated.

This clinical case underscores why conditions like Zoster Sine Herpete should remain on the differential when common imaging is negative and symptoms follow a dermatomal pattern.

Patient Presentation: The Journey Before Diagnosis

A 58-year-old gentleman was referred to our clinic with a chief complaint of persistent, severe left-sided pain. The discomfort began in the paraspinal region and radiated along the flank, eventually wrapping around to the lower abdominal quadrant and groin. He described it as sharp, stabbing, and burning—with significant allodynia but no visible rash. The pain had persisted for over seven months, dramatically impairing his ability to perform daily activities.

Initial evaluations focused on common visceral and spinal causes:

  • Renal colic was ruled out with a negative urinalysis and renal ultrasound.
  • Neurologists suspected thoracic or lumbar disc herniation, but both MRIs were unremarkable.
  • Conservative treatments—physical therapy, chiropractic care, and neuropathic medications including gabapentin and lidocaine patches—offered minimal relief.
  • Interventional procedures such as trigger point injections and transforaminal epidural steroid injections were also ineffective.

The absence of structural abnormalities on imaging and the failure of multi-modal interventions left his providers without a working diagnosis. The patient was understandably frustrated. It was at this point that he was referred to our center for further evaluation.

Step-by-Step Workup at Our Center

We began by reconstructing the entire timeline of his symptoms and response to treatment.

The dermatomal spread of pain, its sharp neuropathic quality, and the extreme sensitivity to touch in the absence of rash were red flags. These clues pointed us away from spine pathology and toward a less common culprit: cutaneous nerve entrapment or viral reactivation neuropathy.

To rule out retroperitoneal or intra-abdominal etiologies, a CT scan of the abdomen, pelvis, and chest was ordered—results were negative. There were no masses, no lymphadenopathy, and no skeletal abnormalities. Laboratory workup showed no signs of active infection or systemic inflammation.

We performed a focused neurologic and sensory exam, mapping the affected dermatome to the left T11–T12 intercostal nerve distribution. Pain was localized, reproducible on palpation, and displayed a positive Carnett’s sign, indicating a likely neuropathic source.

We considered Zoster Sine Herpete because the pain followed a distinct thoracoabdominal dermatome, despite the absence of visible rash or spinal abnormalities.

Zoster Sine Herpete: The Hidden Presentation of Shingles

Zoster Sine Herpete (ZSH) refers to reactivation of the varicella-zoster virus without any associated rash. This rare presentation is often overlooked due to its silent dermatologic profile. However, it can cause significant neuropathic pain along a dermatomal pattern, much like classic shingles. The underlying pathophysiology involves viral reactivation within the dorsal root ganglia, leading to inflammation and dysfunction of the sensory nerve fibers.

According to a 2020 clinical review published in Cureus, ZSH is frequently mistaken for musculoskeletal, visceral, or radicular pain syndromes, and patients often undergo months of misdirected workups before arriving at the correct diagnosis. The lack of skin lesions makes serological and PCR-based tests helpful but not always practical in outpatient settings.

The diagnosis in our case was therefore made via exclusion, symptom mapping, and positive response to a diagnostic nerve block. The unique pain distribution and failure of spine-based therapies supported this diagnosis over other possibilities like ACNES, LACNES, or herpetic neuralgia from other sources.

ain physicians must be vigilant about Zoster Sine Herpete when evaluating patients with allodynia, dermatomal pain, and no radiologic findings.

Definitive Relief: The Role of Intercostal Nerve Block

To test our hypothesis, we performed an fluoroscopic-guided diagnostic intercostal nerve block at the T11 and T12 levels using a small volume of local anesthetic. The patient reported complete pain relief within minutes. This not only confirmed the diagnosis of intercostal neuralgia (likely viral in origin), but also allowed us to proceed confidently with a therapeutic intercostal nerve block using a combination of local anesthetic and corticosteroid.

At his two-week follow-up, the patient reported near-complete resolution of symptoms. His functionality and quality of life had dramatically improved for the first time in seven months.

The resolution of symptoms after nerve block further supported the working diagnosis of Zoster Sine Herpete-induced neuralgia.

Our Philosophy: Relentless Pursuit of Diagnostic Clarity

At our center, we do not accept “negative imaging” as a diagnosis. We understand that many pain syndromes arise from sources that elude traditional radiologic methods. Whether it is Zoster Sine Herpete, anterior cutaneous nerve entrapment, or thoracic radiculopathy without frank disc herniation, each case demands attention to dermatomal patterns, symptom timing, and clinical nuance.

This case reinforces a core principle in interventional pain medicine: Diagnostic blocks are not just therapeutic—they are critical tools in uncovering hidden pathologies. Our team is committed to investigating each case with rigor, compassion, and anatomical precision.

Our center specializes in rare and often missed conditions like Zoster Sine Herpete, which masquerade as visceral or musculoskeletal pain.

Conclusion

Zoster Sine Herpete is an underdiagnosed and underappreciated cause of chronic neuropathic pain.

Through methodical evaluation, exclusion of common causes, and strategic use of nerve blocks, we were able to restore this patient’s quality of life.

If you or someone you know is struggling with chronic pain that remains unexplained, our clinic is here to help navigate the complex diagnostic journey—because every symptom has a source.

While rare, Zoster Sine Herpete can be life-altering if not identified. A thoughtful diagnostic approach can prevent unnecessary medications and procedures.

Still Searching for a Diagnosis?

If you or a loved one is suffering from unexplained pain, our clinic specializes in uncovering elusive causes like Zoster Sine Herpete and intercostal neuralgia. Schedule a diagnostic consultation today with Dr. Amit Sharma and take the first step toward real answers.

Disclaimer: Some therapies discussed on this page, including certain nerve blocks and regenerative approaches, may be considered investigational and are not guaranteed to provide relief in all cases. Individual patient results vary. Always consult your physician.

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