A 72-year-old woman comes to the emergency department for a rash on her forehead. The rash has been present for 3 days and is getting worse. She also complains of moderate frontal headache, malaise, and fever. The patient has no neck pain, nausea, or vomiting. She has not had similar symptoms before. She is otherwise healthy and takes no medications.
Her temperature is 38.5 C (101.3 F). Her forehead is shown in the photograph below.

In addition to admission to the hospital and intravenous acyclovir, which of the following is the best next step in management of this patient?

Question

A 72-year-old woman comes to the emergency department for a rash on her forehead.  The rash has been present for 3 days and is getting worse.  She also complains of moderate frontal headache, malaise, and fever.  The patient has no neck pain, nausea, or vomiting.  She has not had similar symptoms before.  She is otherwise healthy and takes no medications.
Her temperature is 38.5 C (101.3 F).  Her forehead is shown in the photograph below.

In addition to admission to the hospital and intravenous acyclovir, which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

This patient presents with headache, malaise, fever, and a skin rash, all highly suggestive of herpes zoster. The vesicular, crusty skin eruption on her forehead also involves the eyelids, with evidence of edema and drooping. She is at risk of developing herpes zoster ophthalmicus (HZO). HZO is a serious, vision-threatening complication of reactivation of varicella zoster virus in the trigeminal nerve root ganglion. Some patients present with headache, malaise, eye pain, and fever before developing a rash on the face. Once the rash develops, patients can also have conjunctivitis, keratitis, or episcleritis. Vesicles near the nose are also associated with a high risk of HZO. Patients at risk for herpes zoster ophthalmicus require an urgent ophthalmology consultation. Immunocompromised patients with sight-threatening ophthalmicus should receive intravenous acyclovir. When urgent evaluation by an ophthalmologist is not available, topical steroid eye drops can be used to decrease the inflammatory response. (Choices A & E) Gabapentin and topical capsaicin can provide relief from pain of post-herpetic neuralgia, defined as persistent pain after resolution of the initial rash. However, these agents are not helpful for pain from acute neuritis. (Choice B) The risk of aseptic meningitis is higher in immunocompromised than immunocompetent (0.5%) individuals. This patient has no meningeal signs or risk factors for immunosuppression; hence, a lumbar puncture is not needed at this time. (Choice D) Systemic glucocorticoids, when used in combination with antiviral therapy for treatment of herpes zoster, can increase the risk of secondary bacterial skin infections. They are not recommended in this patient. Educational objective: Herpes zoster ophthalmicus is a serious, vision-threatening complication of latent varicella zoster virus infection. Treatment consists of intravenous acyclovir and urgent ophthalmologic evaluation. __________ References: Herpes zoster ophthalmicus complicated by ipsilateral isolated Bell's palsy: a case report and review of the literature. (http://www.ncbi.nlm.nih.gov/pubmed/22883841)

A 72-Year-Old Woman Comes to the Emergency Department for a Rash