A 65-year-old woman is brought to the emergency department by paramedics after falling on a snow-covered sidewalk. The patient fell backward onto her hands while trying to maintain her balance and immediately felt a sharp, excruciating pain in her right arm. She also notes mild tenderness and bruising on the right flank and right buttock. The patient has a history of osteoporosis and hypertension and takes valsartan, alendronate, and a vitamin D supplement. She does not use tobacco, alcohol, or illicit drugs. In the emergency department, radiograph reveals a displaced fracture of the right distal radius. The patient is admitted to the hospital and undergoes open reduction and internal fixation of the radius fracture. On postoperative day 2, she reports severe, constant, burning pain over her right flank. The postsurgical pain in the right arm is mild and well controlled with low-dose morphine as needed. Temperature is 37.8 C (100 F), blood pressure is 145/84 mm Hg, pulse is 97/min, and respirations are 16/min. Mucous membranes are moist and the oropharynx is without lesions. Cardiopulmonary auscultation reveals clear lungs and normal heart sounds. The abdomen is soft, nontender, and nondistended. The right flank is tender to light touch with a rash over the area, as shown in the exhibit. The surgical wound is healing normally without signs of infection. The patient has an otherwise uncomplicated postoperative course and is ready for discharge. Her skin lesions are partially crusted, and she will continue oral valacyclovir as an outpatient. The patient plans to host a small family dinner tonight and is concerned about the risk of disease transmission. There will be no infants, pregnant women, or immunocompromised individuals at this gathering. Which of the following is the most appropriate recommendation for this patient?

Question

A 65-year-old woman is brought to the emergency department by paramedics after falling on a snow-covered sidewalk.  The patient fell backward onto her hands while trying to maintain her balance and immediately felt a sharp, excruciating pain in her right arm.  She also notes mild tenderness and bruising on the right flank and right buttock.  The patient has a history of osteoporosis and hypertension and takes valsartan, alendronate, and a vitamin D supplement.  She does not use tobacco, alcohol, or illicit drugs.  In the emergency department, radiograph reveals a displaced fracture of the right distal radius.  The patient is admitted to the hospital and undergoes open reduction and internal fixation of the radius fracture.  On postoperative day 2, she reports severe, constant, burning pain over her right flank.  The postsurgical pain in the right arm is mild and well controlled with low-dose morphine as needed.  Temperature is 37.8 C (100 F), blood pressure is 145/84 mm Hg, pulse is 97/min, and respirations are 16/min.  Mucous membranes are moist and the oropharynx is without lesions.  Cardiopulmonary auscultation reveals clear lungs and normal heart sounds.  The abdomen is soft, nontender, and nondistended.  The right flank is tender to light touch with a rash over the area, as shown in the exhibit.  The surgical wound is healing normally without signs of infection. The patient has an otherwise uncomplicated postoperative course and is ready for discharge.  Her skin lesions are partially crusted, and she will continue oral valacyclovir as an outpatient.  The patient plans to host a small family dinner tonight and is concerned about the risk of disease transmission.  There will be no infants, pregnant women, or immunocompromised individuals at this gathering.  Which of the following is the most appropriate recommendation for this patient?

Quizplus · Accepted Answer

Explanation: This patient is being treated with oral antiviral medication for a localized herpes zoster infection. Although her rash has improved, lesions that are not completely crusted over may still transmit varicella-zoster virus (VZV) to other individuals via direct contact (primarily) or aerosolization (rare). As such, patients treated in the outpatient setting for active herpes zoster lesions should be advised to cover the rash to prevent direct contact and to avoid patients who are highly susceptible to illness, such as pregnant women who have never had varicella or the varicella vaccine, low-birth-weight infants, and immunocompromised individuals. Patients may otherwise go about their normal activities without restriction. (Choice A) A mask and gloves are required for visitors of patients hospitalized with disseminated zoster due to increased risk of transmission from widespread lesions. Localized zoster is typically treated on an outpatient basis; lesions should be covered but no mask or gloves are required. (Choices C, D, and E) Patients with herpes zoster may transmit VZV to other individuals from the onset of the rash until lesions are completely crusted over. While antivirals may expedite this process, patients remain infectious while on treatment until the rash is dry. This patient can attend her family activity but is still infectious (due to partially crusted lesions); she must cover the lesions to prevent direct contact with other individuals. Educational objective: Patients with herpes zoster may transmit varicella-zoster virus to other individuals from the onset of the lesion until it is completely crusted over. Most transmissions occur via direct contact, but aerosolized virus from active lesions has occasionally caused infections. Patients treated on an outpatient basis for herpes zoster should be advised to keep a lesion covered until it is completely crusted over. References: Herpes zoster: diagnostic, therapeutic, and preventive approaches. (http://www.ncbi.nlm.nih.gov/pubmed/24113666)

A 65-Year-Old Woman Is Brought to the Emergency Department by Paramedics