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Dr Vivek Baliga Review - Case Of A Rash On The Hips

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This is an interesting case and one for medical students to be used as a review. Starts with a case and followed by Dr Vivek Baliga's review on the diagnosis with references.

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Dr Vivek Baliga Review - Case Of A Rash On The Hips

  1. 1. Review - Case Of A Rash On The Hips Dr Vivek Baliga B Consultant Physician Baliga Diagnostics
  2. 2. Case ● 82 year old gentleman ● History of type 2 diabetes, high blood pressure and ischemic heart disease ● Currently taking Aspirin 75 mg OD, Ramipril 2.5 mg BD, Atorvastatin 10mg OD nocte and Metoprolol 25 mg BD. ● History of having a hotter than normal bath 1 week ago - developed a rash over left flank ● Complains of burning sensation over the rash ● No abdominal complaints or joint pains
  3. 3. DIAGNOSIS?
  4. 4. HERPES ZOSTER (SHINGLES)
  5. 5. Herpes Zoster ● Painful unilateral skin rash ● Higher incidence in elderly patients ● Etiology - Varicella Zoster Virus (the cause of chickenpox) ● After an attack of chicken pox, the Varicella virus remains dormant in the dorsal root ganglia ● Certain triggers reactivate the virus, which then moves down sensory nerve roots and affects specific dermatomes.
  6. 6. Who Is At Risk? ● Increasing age - higher in those over 75 years ● Altered cell mediated immunity ○ Lymphoproliferative disorders ○ On immunosuppressive medication ○ Organ transplant patients ○ HIV seropositive (lesser in seronegative)
  7. 7. Symptoms And Signs ● Prodromal Phase ○ Lasts 48 - 72 hours ○ Starts with pain and altered sensation (paresthesia) in the affected area
  8. 8. Symptoms And Signs ● Rash appears ○ Erythematous maculopapular rash which progresses to a vesicular rash affecting single dermatome ○ Never crosses the midline ○ Course - 3 -5 days ○ Pustulates, ulcerates and scabs afterwards. ○ Healing over 4 to 6 weeks
  9. 9. Common Nerves Affected ● Commonly affects ○ Thoracic nerves ○ Ophthalmic division of trigeminal nerve ○ VII and VIII nerve - Ramsay Hunt Syndrome
  10. 10. Diagnosis ● Clinical symptoms and signs are usually sufficient ● Can sometimes be confused with Herpes Simplex if it affects the sacral and cervical areas ● Viral culture not very helpful ● Direct immunofluorescence of fluid more sensitive - helps differentiate between simplex and zoster ● If no rash present but clinical suspicion is high, consider polymerase chain reaction.
  11. 11. Diagnosis ● Tzanck smear of vesicular fluid - not as useful but can be done if needed. ● It could spread to liver and other organs in people with low immunity
  12. 12. Complications ● Post herpetic neuralgia - Pain that persists for months or years after infection has cleared. Defined as pain that persists beyond 30 days of rash or healing. ○ Patients over 50 years - greater skin surface area. Incidence increases with advancing age. ○ Female gender ○ Severe rash on presentation ○ Presence of a prodrome ○ Severe pain on diagnosis ○ Presence of viremia on PCR
  13. 13. Complications ● Acute Retinal Necrosis ○ Seen in immunocompetent patients; greater incidence in HIV positive patients ○ Does not necessarily follow trigeminal nerve involvement ○ Fundoscopy - Granular, yellow, hemorrhagic lesions ○ Can cause blindness in HIV positive patients ○ Antiviral therapy works in patients with good immunity only
  14. 14. Complications ● Herpes Zoster Ophthalmicus ○ Involves first branch of trigeminal nerve ○ If untreated leads to ■ Keratitis ■ Iritis ■ Episcleritis ■ Blindness
  15. 15. Complications ● Bacterial super-infection ● Myelitis ● Meningoencephalitis involvement
  16. 16. Treatment ● Various options - The sooner initiated, the better the outcome (<72 hours) ○ Aciclovir 800 mg 5 times daily for 8 to 10 days ○ Famciclovir 250 mg 3 times daily for 7 days ○ Valaciclovir 1 gram 3 times daily for 7 days ● Pain reduction ○ Prednisolone 60 mg daily - taper slowly to reduce pain and speed up healing of lesions ○ Amitriptyline 25 mg daily for 3 to 4 months
  17. 17. Treatment of Post-Herpetic Neuralgia ● Gabapentin ● Pregabalin ● Tricyclic antidepressants ● Topical lignocaine ● Capsaicin
  18. 18. Gnann Jr, J. W., & Whitley, R. J. (2002). A 77-year-old man reports a five-day history of burning and aching pain in his right side and a two- day history of erythema and clusters of clear vesicles, accompanied by headache and malaise. How should he be evaluated and treated?. N Engl J Med, 347(5).
  19. 19. Closing Remarks ● Herpes zoster is a painful re-activation of chicken pox ● Clinical symptoms and signs are characteristic and sufficient for diagnosis. ● Antiviral therapy is the mainstay of treatment. References 1. Cohen, Jeffrey I. "Herpes zoster." New England Journal of Medicine 369.3 (2013): 255-263. 2. Wareham DW, Breuer J. Herpes zoster. BMJ : British Medical Journal. 2007;334(7605):1211-1215. doi:10.1136/bmj.39206.571042.AE.

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