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February 2015: Dermatology

62-year old male camp boss presents to you with a complaint of unexplained left sided chest/flank/back pain for four days. After a thorough H&P you can find no obvious etiology for his complaints, although he does have a low-grade fever of 99.4 and appears to be somewhat sensitive to the area of complaint. You tell him that maybe some acetaminophen or ibuprofen and possibly some warm compresses might help with his discomfort. In addition you give him reassurance and tell him to return if symptoms persist.

The following day the patient returns when he notices a rash developing after getting out of his morning shower.  He also complains that the rash is very sensitive to touch.  Upon further questioning the patient notes that he has been very tired over the last week.  He has no previous history of rashes, and had not been exposed to any new chemicals recently.   He is on day 12 of a 21-day hitch.

On review of symptoms he denies chills as well as joint or muscle pains, but has been having headaches and mild photophobia one-week prior.  The patient denies shortness of breath, dizziness or vision changes.

  • Past Medical History: Hypertension, poorly controlled diabetes
  • Past Surgical History: Cholecystectomy 1995, appendectomy 2000
  • Current Medications: HCTZ 12.5mg/d, lisinopril 40mg/d, aspirin 81mg/d, metformin 1000mg po bid, Lantus 10 units at bedtime
  • Allergies: NKDA
  • Immunization Status: Tetanus and influenza are up to date
  • Social History: Denies alcohol and illicit drugs, smokes 1½ packs a day
  • Family History: Mother with CAD, diabetes, ovarian cancer; father with CAD, stroke, died at age 45

Vitals

  • Temp 97.9
  • Pulse 88
  • Respirations 14
  • BP 145/93
  • PO 97% on room air

Physical Exam

  • General: Alert and Oriented x 4, no acute distress
  • Cardio: regular rhythm and rate, no murmurs appreciated
  • Lung: clear to auscultation except for some scattered expiratory wheezes – left greater than right
  • Abdomen: soft non-tender, non-distended, normal bowel sounds
  • Extremities: no clubbing, cyanosis or edema
  • Skin: affected area somewhat erythematous with groups of blister-like lesions of various sizes. The blisters appear to have clear fluid in them and extend around the patient’s left flank from the mid-line of the abdomen to the mid-line of the back in a dermatomal pattern.

Source: Michael D. Kotler, MD.

 

How would you approach this patient?

Diagnosis: Herpes Zoster (Shingles)

Discussion

Herpes Zoster, also known as shingles, is a viral infection of the skin usually involving a single dermatome. Shingles is a reactivation of the varicella virus (chicken pox) that has entered the cutaneous nerves.  Unlike most viral illnesses an attack of herpes zoster does not confer lasting immunity. If you suspect this diagnosis, it is important to ascertain whether the patient has had chicken pox in the past. Initial and subsequent outbreaks can be precipitated by stressful events either physical and/or psychological.

 

Tenderness or hypersensitivity throughout a dermatome can be predictive of the disease. Pain, itching, or burning can precede the rash by several days. One can also experience fever, malaise, generalized body aches, “flu-like symptoms” particularly on the initial outbreak.  Once the rash does appear, it may spread rapidly but should not cross the mid-line. Some complications may include peripheral nerve palsies, muscle inflammation, and pain (post herpatic neuralgia) that can last for months after an outbreak.

 

Generally, herpes zoster would not prevent the patient from continuing his/her job duties. However, this would need to be determined on a case-by-case basis as this illness can affect people to different degrees. There may be situations where altered job function may need to be considered depending on where the outbreak is located as it can be very painful. Should there be a large area of skin loss due to extensive blistering you would entertain the same considerations for skin loss due to second-degree burns.

 

Particular attention needs to be paid to an outbreak involving facial dermatomes due to an increased risk of eye involvement. Live virus can be found in the blisters and could be transmitted by touch to the eye. For the same reason we also have to be concerned about exposing a co-worker who could be in their first trimester of pregnancy as this virus is associated with increased risk of birth defects and complications during the first trimester of pregnancy.

Treatment

  • Symptomatic control of pain and inflammation with topical lidocaine patches, oral steroids, and/or narcotic medications depending on patient’s level of pain
  • Cool tap water can be applied for 20 minutes several times daily over the area to aid in comfort as well
  • Oral/topical antiviral drugs to be started immediately upon diagnosis or strong clinical suspicion
    • Acyclovir (Zovirax) 800mg 5x daily
    • Acyclovir (Zovirax) ointment Q3h while awake
    • Valacyclovir  (Valtrex) 1000 mg 3x daily
    • Famciclovir (Famvir) 500 mg 3x daily can decrease inflammation and reduce viral shedding
    • Cover open areas with loose gauze/dressing
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