An 82-year-old woman comes to the office due to a day of low-grade fever and rash. Two days ago, the patient began having stabbing pain in her left flank. Over the following day, this area became itchy and red. The patient tried over-the-counter topical hydrocortisone and lidocaine but had no relief. She has a history of hypothyroidism, type 2 diabetes mellitus, rheumatoid arthritis, and osteoporosis. She was recently hospitalized for sepsis secondary to a urinary tract infection and discharged on oral ciprofloxacin that she completed yesterday. The patient has no history of drug allergy but noticed a "strange taste in my mouth" after taking ciprofloxacin. Her other medications include low-dose aspirin, alendronate, levothyroxine, glipizide, low-dose prednisone, calcium, and vitamin D supplementation. She does not smoke, consume alcohol, or use illicit drugs. Temperature is 37.8 C (100 F), blood pressure is 124/72 mm Hg, pulse is 92/min, and respirations are 14/min. Examination of her left flank shows bright patchy erythema, excoriations, and several fluid-filled blisters.
Which of the following is the most appropriate next step in management of this patient?

Question

An 82-year-old woman comes to the office due to a day of low-grade fever and rash.  Two days ago, the patient began having stabbing pain in her left flank.  Over the following day, this area became itchy and red.  The patient tried over-the-counter topical hydrocortisone and lidocaine but had no relief.  She has a history of hypothyroidism, type 2 diabetes mellitus, rheumatoid arthritis, and osteoporosis.  She was recently hospitalized for sepsis secondary to a urinary tract infection and discharged on oral ciprofloxacin that she completed yesterday.  The patient has no history of drug allergy but noticed a "strange taste in my mouth" after taking ciprofloxacin.  Her other medications include low-dose aspirin, alendronate, levothyroxine, glipizide, low-dose prednisone, calcium, and vitamin D supplementation.  She does not smoke, consume alcohol, or use illicit drugs.  Temperature is 37.8 C (100 F), blood pressure is 124/72 mm Hg, pulse is 92/min, and respirations are 14/min.  Examination of her left flank shows bright patchy erythema, excoriations, and several fluid-filled blisters. 
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This elderly woman has a painful, unilateral, localized rash with fluid-filled blisters, suggesting localized herpes zoster (shingles). Herpes zoster is due to the reactivation of varicella-zoster virus (VZV) from the dorsal root ganglia of a sensory nerve following initial infection with varicella (chickenpox) during childhood or early adulthood. Risk of reactivation is greatest in those of advancing age due to waning VZV-specific cell-mediated immunity. Malignancy, liver or kidney disease, and immunocompromise (eg, chronic glucocorticoids) also increase risk. The rash of herpes zoster evolves quickly from erythematous papules into grouped vesicles. The thoracic and lumbar regions are most commonly affected, and most rashes involve a single dermatome but may extend to immediately adjacent dermatomes. Dermatomal pain (burning, throbbing, stabbing, pruritic) occurs in the majority of patients and often precedes the rash by days or weeks. grouped vesicles Diagnosis is typically made on clinical presentation alone. Patients with localized herpes zoster who have had lesions <72 hours typically receive antiviral treatment with oral valacyclovir to reduce transmission risk, new lesion formation, and (possibly) risk of postherpetic neuralgia. Analgesics for acute neuritis are also typically required. (Choices A and E) VZV polymerase chain reaction assay and viral culture are useful diagnostic tools for VZV but are typically reserved for patients with suspected infections who have atypical skin lesions (often seen in patients with immunocompromise). Patients with unilateral, dermatomal, vesicular skin eruptions are usually diagnosed without testing. (Choice B) Topical acyclovir is occasionally used for oral or genital herpes simplex virus outbreaks but is not an effective treatment for VZV. (Choice C) Topical corticosteroids (eg, clobetasol) are often used for psoriasis and steroid-responsive dermatoses; these medications are not useful for herpes zoster as they may increase the risk of secondary bacterial infection and do not treat VZV. Educational objective: Herpes zoster is due to the reactivation of varicella-zoster virus and is most commonly seen in elderly patients. Manifestations typically include a unilateral, dermatomal, vesicular rash and pain. Patients with typical lesions are usually diagnosed clinically (without testing) and treated with oral antiviral medication (eg, valacyclovir).

An 82-Year-Old Woman Comes to the Office Due to a Day