An Unusual Presentation to the Burns Unit—A Cautionary Tale

We report a case of a 34-year old female with systemic lupus erythematosus (SLE) and lupus nephritis who was referred to the regional burns service with a suspected contact burn to the left flank and hypogastrium from a hot water bottle. The patient had been applying a hot-water bottle to the area at night for pain relief and after 3-days she noticed a localised area of erythema which became larger and began to blister over a period of 5-days. The blistered areas were erythematous and wet, however the capillary refill time was sluggish. The lesion was initially diagnosed and treated as a superficial partial thickness burn that had developed secondary to prolonged contact with a hot water bottle. However, due to the history of immunosuppression as well as elements of the lesion being unusual for a burn, we consequently diagnosed this as herpes zoster infection. This case highlights the importance of always thinking of alternative diagnoses. There are several cases in the literature where shingles has been dangerously misdiagnosed, furthermore leading to patients being mistakenly treated and even operated on. In the early stages, abdominal shingles may present very similarly to superficial partial thickness burns, both with neuropathic pain, erythema and blistering. It is important for the burns surgeon to be aware of this diagnosis as a differential in atypical presentations, and to pay particular attention to the timeline of events is the key to diagnosis.