49 year old woman with a red, patchy rash

1
49 year old woman with a red, patchy rash

• Outpatient Case Presentation
• Family Medicine Rotation
• Imtiaz Ather, OMS-III
• July 19th, 2007

2
Subjective

• A 49 yo F presented to the office with a history
  of a red, patchy rash located on her left chest
  and extending to the middle of her back. The
  rash began one week prior.
• Pt complained of severe constant pain (9/10)
  along rash site, causing much discomfort and
  inability to lie on left side, leading to
  problems with sleep.
• Pt denies itchiness or tingling.
• Pt has history of sacroiliitis, osteoarthritis of
  lumbar spine, and posterior bulging of L2-L4
  intervertebral discs.

3
PMSX

• Chicken pox at age 5
• Pt denies past surgical history or
  hospitalizations
• NKA
• Immunizations up to date
• Medications
• 6/30/07 Prednisone 10 mg po tid x 3days
  prescribed for exacerbation of sacroiliitis.

4
Social History

• Pt works as an office secretary, and admits that
  work has been stressful recently
• Pt is married with 2 children
• No recent travel outside US, no tobacco, alcohol,
  or recreational drug use.
• Pt eats 3 balanced meals daily, but does not
  exercise due to low back pain.
• Pt is unable to get adequate sleep due to low
  back pain and stress from work.

5
Family History

• Mother deceased, had type II DM
• Father deceased, had epilepsy
• 3 brothers and 3 sisters, alive and well
• 2 daughters, alive and well

6
ROS

• General () fatigue, () loss of appetite
• Skin () painful rashes along left side
• H (-) headache, (-) dizziness, (-) rashes
• E (-) changes in vision, (-) dry eyes
• E (-) tinnitus, (-) pain, (-) vertigo
• N (-) bleeding, (-) rashes, (-) itching
• T (-) sore throat, (-) gum bleeding

7
ROS (contd)

• Breast Pt does self-breast exams. (-) lumps,
  (-) pain
• Resp (-) SOB, (-) cough, (-) wheezing
• Cardiac (-) chest pain, (-) palpitations, (-)
  htn
• GI (-) abdominal pain, (-) changes in bowel
  movements, (-) hemorrhoids
• Urinary (-) dysuria, (-) hematuria
• Gynecological Pt receives yearly exams. Gr2,
  para2. LMP 6/2007
• Musculoskeletal (-) swelling, (-) weakness
• Neuro (-) memory loss, (-) gait changes
• Endo (-) polydipsia, (-) polyphagia, (-) ?
  sweating
• Extremities (-) numbness, (-) bruising

8
Objective

• Well-nourished, well-groomed female patient,
  AOx3, in mild discomfort, leaning onto right side
• Vital signs
• Temp 97.6
• P 70
• BP 120/70
• Resp 16

9
Objective (cont.)

• Skin Erythematous, patchy, uniformly-sized
  macules located anteriorly at the left 6th
  sternocostal joint and extending posteriorly to
  the T6 spinous process, along the left T6
  dermatome.
• Unilateral (does not cross midline)
• () tenderness upon palpation
• (-) vesicles, (-) blisters, (-) bleeding
• (-) pus
• (-) lymphadenopathy

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Objective (cont.)

• HEENT (-) Lesions on face, lips, or oral mucous
  membranes.
• PERRLA. (-) conjunctivitis, (-) eyelid
  swelling
• (-) vesicles on nose, (-) lymphadenopathy
• Neck supple, FROM, (-) carotid bruits, (-) JVD.
• Chest Normal AP diameter. CTA. See skin for
  info on lesions.
• Cardiac RRR. S1 and S2 of normal intensity.
• Abdomen Normal BS, (-) organomegaly, (-)
  bruits.
• Extremities Pulses 2. FROM. (-) swelling.
• Osteopathic ? AROM of lower back due to pain.
• Neuro CN II-XII intact, (-) deficits, reflexes
  ()2, Strength 5/5

11
Assessment

• Middle age woman with sudden onset of painful,
  bullous dermatitis.
• Differential diagnosis
• Autoimmune bullous disorder
• Contact dermatitis
• Disseminated Coxsackie Virus Infection
• Impetigo
• Varicella zoster

12
Shingles

• Due to reactivation of Varicella Zoster Virus
  (aka Herpes Zoster)

13
Etiology

• Causes of VZV reactivation
• Pt must have hx of chickenpox infxn
• Greater risk if lt2 months old when infected
• ?age (more common if over 50 yo)
• Immunocompromise (AIDS or immunnosuppresant
  therapy)
• Stress, trauma, bereavement
• Spinal cord surgery or spinal irradiation

14
Epidemiology

• Incidence 200 per 100,000 ppl per year
• Freq 10-20 of population at some point in life
• Not uncommon in immunocompromised pts (50 of
  Hodgkins lymphoma pts develop shingles)
• MF

15
Common Symptoms

• Malaise, HA, Fever
• Acute, knife-like pain with tingling and itching,
  occurring 3-5 days before rash presents
• It can affect cranial nerves
• facial nerve, peripheral hemiparesis of the
  face.
• acute loss of hearing, vertigo (Ramsay Hunt
  Syndrome).

16
Signs

• Closely grouped red papules, which rapidly become
  vesicular, appearing in a continuous band,
  generally in a single dermatome
• Occasional, some vesicles may be outside
  dermatome
• Usually u/l
• Lymphadenopathy of draining area

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Acute
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Signs (cont.)

• Vesicle characteristics
• Become papular and/or hemorrhagic in 1-4 days
• Cloudy, with red base
• Varying sizes
• Become umbilicated briefly, then form crusts and
  fall off in 3 weeks. May leave scarring.

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2 weeks
20
Diagnostic tests

• Usually based on clinical findings, but in case
  of doubt
• Direct Antigen staining
• Tzanck test (shows multinucleated giant cells)
• Serology testing (shows ? VZV Ab)
• Viral culture from swab
• PCR (to detect VZV DNA)

21
Complications

• Disseminated VZV infxn
• Occurs in immunocompromised pts
• Severe skin eruption, with spread to organs
  causing pneumonitis, pancreatitis, encephalitis.
• Requires hospitalization, close monitoring.

22
Complications (cont.)

• Herpes Zoster Ophthalmicus
• Reactivation at nasociliary branch of ophthalmic
  division of CN V
• Leads to involvement of cornea, iridocyclitis,
  and secondary glaucoma, which can lead to vision
  loss
• Vesicles will first be seen on tip and side of
  nose, with eyelid swelling and conjunctivitis
• Refer to dermatologist or ophthalmologist

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Complications (cont.)

• Postherpetic neuralgia
• Constant or intermittent intense stabbing pain
  along dermatome
• Worse at night or with temperature changes
• May last for months (rarely, years)

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Treatment

• Begin herpes antiretroviral therapy w/in 72 hrs
  of onset of rash to speed resolution and ? risk
  of postherpetic neuralgia
• Acyclovir, Valacyclovir, or Famcyclovir
• 7-10 days, or until all lesions are crusted

Combine with Prednisone for 2 weeks to relieve
pain. Especially useful for Ramsay Hunt Syndrome
NSAIDs Wet compress
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Treatment (cont.)

• For postherpetic neuralgia
• Gabapentin (Neurontin)
• Similar structure to GABA, binds Ca channels,
  exact mechanism unknown
• Side fx Dizziness, drowsiness, peripheral edema

• Pregabalin (Lyrica)
• Similar to Gabapentin, but more potent for
  neuropathic pain and less side fx

• TCAs, Anticonvulsants, Topical Lidocaine

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Plan

• Pregabalin 75mg po bid x 30 days
• Course of acyclovir treatment
• Follow up in 1 week

27
References
www.firstconsult.com http//www.ninds.nih.gov/diso
rders/shingles/shingles.htm http//www.emedicinehe
alth.com/shingles/article_em.htm Images www.nlm.ni
h.gov/.../ency/fullsize/19687.jpg
www.healthline.com/.../139_3925-778811.JPG
www.fda.gov/.../2001graphics/shingles.gif
tray.dermatology.uiowa.edu/.../HerpZosDis-01.jpg