An 85-year-old man comes to the office due to a rash over his forehead, tip of nose, and left eye. He also complains of pain and decreased vision. He has had fever, malaise, and a burning sensation around his left eye for the past 5 days. Temperature is 38.1 C (101 F), blood pressure is 140/90 mm Hg, pulse is 92/min, and respirations are 14/min. Physical examination reveals a vesicular rash on the periorbital region and lid margins. The left eye is red, with chemosis of the conjunctiva. Dendriform ulcers are seen on the cornea. What is the most likely diagnosis?

Question

An 85-year-old man comes to the office due to a rash over his forehead, tip of nose, and left eye.  He also complains of pain and decreased vision.  He has had fever, malaise, and a burning sensation around his left eye for the past 5 days.  Temperature is 38.1 C (101 F), blood pressure is 140/90 mm Hg, pulse is 92/min, and respirations are 14/min.  Physical examination reveals a vesicular rash on the periorbital region and lid margins.  The left eye is red, with chemosis of the conjunctiva.  Dendriform ulcers are seen on the cornea.  What is the most likely diagnosis?

Quizplus · Accepted Answer

Herpes zoster ophthalmicus is an infection caused by varicella-zoster virus (VZV). Most episodes occur in the elderly or immunosuppressed. VZV remains latent in the trigeminal ganglion. During periods of immunosuppression, the virus travels via the ophthalmic branch to the forehead and the eye. Symptoms manifest thereafter with fever, malaise, and a burning, itching sensation in the periorbital region. Examination reveals a vesicular rash in the distribution of the cutaneous branch of the first division of the trigeminal nerve. Conjunctivitis and corneal ulcers characterize the eye involvement. Involvement of the tip of the nose (Hutchinson sign) is associated with eye involvement. Treatment started within 72 hrs after eruption with high dose acyclovir reduces the development of complications. (Choice A) Herpes simplex keratitis, which most commonly presents as a dendritic corneal ulcer, presents with pain, photophobia, and decreased vision. There may also be minute clear vesicles in the corneal epithelium. However, herpes simplex keratitis does not cause the typical vesicular rash (eg, forehead, nose) or systemic symptoms seen with herpes zoster ophthalmicus. (Choice B) Dacryocystitis is an infection of the lacrimal sac due to obstruction of the nasolacrimal duct. It is characterized by pain, swelling, tenderness, and redness in the tear sac area. Mucus or pus can be expressed. (Choice C) Bacterial keratitis is usually seen in contact lens wearers, and following corneal trauma. The cornea appears hazy with a central ulcer and adjacent stromal abscess. Hypopyon may be present. (Choice D) The diagnosis of trigeminal neuralgia is made clinically based on history. It is characterized by a stabbing or shock-like pain over the distribution of the maxillary or mandibular division of the trigeminal nerve. The pain may be triggered by light touch or vibration. It does not cause a rash. Educational objective: Herpes zoster ophthalmicus is characterized by dendriform corneal ulcers and a vesicular rash in the trigeminal distribution.

An 85-Year-Old Man Comes to the Office Due to a Rash