Snapshot A 45-year-old woman presents to the emergency room for a rash on her face. She reports that this rash started as a small flat red rash yesterday but progressed to a very painful rash. She also reports some blurry vision in her right eye. She has a past medical history of lupus and is on long-term steroids. On physical exam, she has an extensive vesicular rash on the right side of her face involving her nose and eyes. She is admitted into the hospital for antiviral therapy, and ophthalmology is consulted. Introduction Classification varicella-zoster virus (VZV) an enveloped, linear double-stranded DNA virus also known as human herpesvirus-3 transmitted via respiratory secretions direct contact with skin lesions causes chickenpox, herpes zoster (shingles), encephalitis, meningitis, and pneumonia Epidemiology demographics herpes zoster in elderly population encephalitis and pneumonia in the immunocompromised men > women risk factors immunosuppression advanced age previous infection with VZV Pathogenesis the virus infects T-cells the virus is often latent in the dorsal root ganglia or trigeminal ganglia reactivation of the latent virus causes herpes zoster often precipitated by immunocompromise or stress Prevention herpes zoster recombinant vaccine adults > 50 years of age live vaccine adults > 60 years of age Prognosis complete healing may take more > 1 month Presentation Symptoms preceded by prodrome of itchiness or tingling painful rash Physical exam painful unilateral vesicular/pustular skin eruption along a single dermatome does not cross midline may involve the eye herpes zoster opthalmicus distribution of cranial nerve V may involve the ear Ramsay-Hunt syndrome or herpes zoster oticus distribution of cranial nerve VII Studies Labs Tzanck smear multinucleated giant cells polymerase chain reaction direct fluorescent antibody staining Making the diagnosis most cases are clinically diagnosed in atypical cases, laboratory examination may be useful Differential Herpes simplex virus distinguishing factor typically does not present in a dermatomal fashion Contact dermatitis distinguishing factor typically is more itchy than painful Treatment Management approach for herpes zoster, antivirals are first-line therapy Medical oral antivirals indications all patients with shingles drugs valacyclovir famciclovir acyclovir intravenous antivirals indication patients with visceral or central nervous system disease drugs acyclovir analgesics indication all patients drugs do not give aspirin for risk of Reye syndrome Complications Disseminated disease in immunocompromised patients often involves the viscera Post-herpetic neuralgia incidence very common Fetal complications blindness scarring limb hypoplasia Vision loss, corneal anesthesia, and keratitis from herpes zoster opthalmicus
QUESTIONS 1 of 7 1 2 3 4 5 6 7 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M2.ID.15.75) A 65-year-old male is evaluated in clinic approximately six months after resolution of a herpes zoster outbreak on his left flank. He states that despite the lesions having resolved, he is still experiencing constant burning and hypersensitivity to touch in the distribution of the old rash. You explain to him that this complication can occur in 20-30% of patients after having herpes zoster. You also explain that vaccination with the shingles vaccine in individuals 60-70 years of age can reduce the incidence of this complication. What is the complication? QID: 106722 Type & Select Correct Answer 1 Ramsay-Hunt syndrome 4% (1/28) 2 Acute herpetic neuralgia 0% (0/28) 3 Post-herpetic neuralgia 86% (24/28) 4 Secondary bacterial infection 0% (0/28) 5 Recurrent zoster 4% (1/28) M 6 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (M2.ID.14.20) A 75-year-old man presents to his primary care physician with a painful rash. He notes his side began to hurt several days prior without any visible skin changes; however, over the past 2 days a rash has developed. The patient's past medical history is only notable for diabetes mellitus type II. He was recently started on an antibiotic for sinusitis as well. In his spare time, he goes hiking and recently returned from a hiking trip 2 days ago. He is currently sexually active with both men and women. His temperature is 99.0°F (37.2°C), blood pressure is 154/88 mmHg, pulse is 83/min, respirations are 12/min, and oxygen saturation is 98% on room air. Physical exam is notable for the finding in Figure A. Which of the following is the most likely diagnosis? QID: 104231 FIGURES: A Type & Select Correct Answer 1 Contact dermatitis 26% (9/34) 2 Erythema multiforme 9% (3/34) 3 Human herpes virus 1 0% (0/34) 4 Human herpes virus 3 62% (21/34) 5 Human herpes virus 6 0% (0/34) M 6 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic