A 68-year-old woman comes to the office for evaluation of a skin rash. The patient says that red, painful papules erupted on her right chest 5 days ago and quickly turned into vesicles containing clear fluid. The lesions are now beginning to crust and are less painful. She has never had similar lesions and does not recall coming into contact with a person having a similar illness. Medical history is significant only for well-controlled hypertension. Physical examination shows a grouped vesicular rash involving the right T4 dermatome that is beginning to heal with crusting. The rash does not cross the midline. Lightly touching the skin elicits sharp pain. The remainder of the examination shows no abnormalities. This patient is at greatest risk of developing which of the following complications as a result of her current condition?

Question

A 68-year-old woman comes to the office for evaluation of a skin rash.  The patient says that red, painful papules erupted on her right chest 5 days ago and quickly turned into vesicles containing clear fluid.  The lesions are now beginning to crust and are less painful.  She has never had similar lesions and does not recall coming into contact with a person having a similar illness.  Medical history is significant only for well-controlled hypertension.  Physical examination shows a grouped vesicular rash involving the right T4 dermatome that is beginning to heal with crusting.  The rash does not cross the midline.  Lightly touching the skin elicits sharp pain.  The remainder of the examination shows no abnormalities.  This patient is at greatest risk of developing which of the following complications as a result of her current condition?

Quizplus · Accepted Answer

This patient has a vesicular rash consistent with herpes zoster (shingles), which is caused by reactivation of latent varicella-zoster virus (VZV) infection. Following the primary infection (chickenpox), VZV remains dormant in the dorsal root ganglia until emerging decades later. Decreased cell-mediated immunity (eg, older age, immunosuppressive medications, HIV infection) increases the risk of reactivation. Reactivation of VZV causes hemorrhagic inflammation of the dorsal root ganglion and peripheral nerve. The resulting hypersensitive nerve function presents with neuropathic pain in the affected region (herpetic neuralgia), typically described as stabbing, tingling, or burning. Herpetic neuralgia can begin even before the appearance of skin lesions and may persist for up to several months. A minority of patients experience long-term residual pain, termed postherpetic neuralgia; the risk is greater in older patients (age >70) and those with more severe shingles. (Choice A) Primary VZV infection is characterized by a diffuse vesicular rash (chickenpox), but reactivation is dermatomal. Generalized reactivation or spread to other body areas can occur in immune-compromised patients but is extremely rare in healthy individuals. (Choice B) Reactive arthritis presents with an asymmetric peripheral oligoarthritis, often with extraarticular symptoms (eg, uveitis, conjunctivitis, urethritis). It typically follows bacterial gastrointestinal (eg, Salmonella, Shigella, Campylobacter) or genitourinary (eg, Chlamydia) infection. (Choice D) IgA nephropathy produces recurrent glomerulonephritis and typically presents with episodic hematuria. Common triggers include upper respiratory illness, but shingles does not typically exacerbate the condition. (Choice E) Toxic or metabolic nerve injury (eg, diabetic peripheral neuropathy) is typically proportionate to the length of the sensory nerve fibers. Symptoms appear first in the longest nerves, such as those to the feet and hands, causing a "glove and stocking" distribution. However, because reactivation of VZV occurs only in specific sensory ganglia, symptoms have a dermatomal distribution. Educational objective: A unilateral vesicular rash localized on a single dermatome in an older patient is most likely herpes zoster. Postherpetic neuralgia is the most common neurologic complication of varicella zoster virus infection.

A 68-Year-Old Woman Comes to the Office for Evaluation of a Skin