A 63 y.o. male presents with headache, weakness and R eye pain
His picture is shown below
what could be wrong?
Our patient had herpes keratitis. It is the leading cause of blindness worldwide.
Varicella zoster is the causative agent of chickenpox and although it remains dormant in the sensory dorsal root ganglia following primary infection, it can reactivate and appear as herpes zoster. It can present with fever, malaise and myalgia followed by the outbreak of a vesicular rash which is often pruritic. Although it begins as macules or papules it quickly becomes vesicular.
10% of immunocompromised patient will develop a generalized eruption or disseminated zoster(not confined to one dermatome) In addition to the skin rash; visceral complications can occur(pneumonia, myocarditis, hepatitis or vasculitis) Encephalitis has been reported.
When herpes involves the first division of the fifth cranial nerve, ocular involvement is likely. The nasociliary branch of the fifth cranial nerve also supplies the tip of the nose and Hutchinson’s sign refers to vesicles on the tip of the nose. Eye involvement includes corneal involvement, uveitis and glaucoma can develop so all these patients need to be referred to ophthalmology.
herpes keratitis has a classic dendritic pattern
There are many diseases which cause skin vesicles so it is useful to divide them into three clinical categories. Single lesions or localized lesions like anthrax, herpes or poison ivy, generalized lesions mostly on the head like varicella and a third group that includes generalized lesions with greatest concentration on the extremities. This latter group includes both lesions that are predominantly on the palms and soles like Coxsackie and syphilis as well as lesions like ricketsttsialpox which are rarely found on the palms and soles.
CAUSES OF VESICULAR RASHES
Viruses-HIV, parvo, enteroviruses- Coxsackie. Coxsackie virus is associated with a common syndrome in children-“ hand, foot and mouth disease”.
coxsackie on a child'‘s hand
Dermatitis- PLEVA –pityriasis lichenoides( caused by a hypersensitivity reaction to an infection or anti –TNF agents. It is treated with doxycycline for its anti-inflammatory effects. Eczema can present as a vesicular rash. Allergic contact dermatitis is often vesicular and can be caused by poison ivy, nickel (as in jewelry), or Neosporin.
Bacterial diseases-tsutsugamushi disease, rickettsialpox. While tsutsugamushi disease, a scrub typhus disease, carried by chiggers, is found in the far East; rickettsialpox is found in urban areas of the US and the bacteria, R akari, is commonly found on the mite carried by the house mouse. It was first isolated in New York City in 1946.
rickettsial pox
Drug eruptions- vancomycin is the most common cause of drug-induced linear IgA dermatosis which is a bullous disease directed against the pemphigoid antigen. ACE inbibitors and sulfa are also common causes. .
Bullous insect bite reactions- - Body lice are found world wide and transmit epidemic typhus, trench fever and louse-borne relapsing fever.
body lice can present with a vesicular rash
Polymorphous light eruption- occurs in spring or early summer 30 minutes after exposure to the sun.
polymorphous light eruption appears within 30 minutes of sun exposure.
With so many vesicular rashes how do you make the diagnosis of herpes zoster?
Zoster has:
1. A painful or abnormal sensory prodrome
2. A dermatomal distribution of rash
3. Grouped vesicles
4. Pain or allodynia in the area of the rash.
Our patient was noted to have peripheral keratitis and treated with valcyclovir for 14 days. He improved.
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