UMEM Educational Pearls


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.


This is Herpes Zoster (Shingles).


  • 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.


  • 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


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