UMEM Educational Pearls

Title: What's the Diagnosis? Image and Case by Dr. Kathleen Stephanos

Posted: 10/10/2016 by Tu Carol Nguyen, DO
Click here to contact Tu Carol Nguyen, DO

Question

57 year-old female with history of bilateral lung transplants presents with fever, and 2 days of a painful, red, bumpy rash over the left labia and left buttock, but also notes a small tender area on the plantar surface of the left foot.

Below is a figure depicting the location of the rash, as well as a photo of her foot.

Answer

This is Herpes Zoster (Shingles).

Presentation:

Zoster typically appears along a single dermatome, without crossing midline in immunocompetent hosts, but may involve 2-3 adjacent dermatomes.

In immunocompromised patients, systemic involvement may occur.

Thoracic and lumbar dermatomes are the most common.

Lumbar and sacral dermatomes wrap around the lower extremity and may spare the skin between the perineum and the foot.

Treatment:

Immunocompromised patients should be treated with IV Acyclovir 10mg/kg q 8hr for 7 days (Use IBW in obese patients)

In immunocompetent individuals, if identified within 48 hours of rash onset, may receive oral therapy with famciclovir, acyclovir or valcyclovir
Herpes Zoster alone should not prompt immunosuppression work up
- However, concerns for underlying immune disorders if:
  - continued development of lesions > 1 week, or
  - involvement of more than 3 dermatomes

References

Dworkin RH, Johnson RW, Breuer J, et al. Recommendations for the management of herpes zoster. Clin Infect Dis. 2007;44 Suppl 1:S1.