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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.
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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
- However, concerns for underlying immune disorders if:
References
Dworkin RH, Johnson RW, Breuer J, et al. Recommendations for the management of herpes zoster. Clin Infect Dis. 2007;44 Suppl 1:S1.