1. Case Study #6
A.Q., a 82 year old nursing home resident, is brought to your office by staff. She tells you that she has a rash that runs from her back across part of her stomach. She also tells you that 2-3 weeks prior to the rash breaking out, she felt sharp, shooting pains in the same area where the rash is now.

3. So What is your Differential Diagnosis?

4. DIFFERENTIAL DIAGNOSIS
Prodomal stage- migraine, cardiac or pleural disease, acure abdomen or vertebral disease.
Eruption- zosteriform herpes simplex virus, herpes zoster, phytoallergic contact dermatitis (i.e., poison ivy), erysipelas bullous impetigo, necrotizing fasciitis.

5. Diagnosis
Diagnosis of herpes zoster is usually made by clinical findings but can be confirmed with a Tzanck test.
Complications can be severe.
Usually resolves within 2-3 weeks in immunocompetent individuals but pain can last for > 6 months in 1-2% of patients.

6. Tzanck Smear for Herpes Viruses

7. Signs and Symptoms
Epidemiology- vast majority of cases involve patients over the age of 50 but 5% of cases occur in children under 15.
Classic locations- unilateral, dermatomal distribution most common in thoracic (50%) and trigeminal regions (10-20%). Contiguous dermatomes may be involved but multiple non-contiguous dermatome involvement is rare.
Papules during first 24 hours followed by round/oval vesicles/bullae (around 48 hours), followed by pustules (96 hours) and then crusting at 7-10 days.
Tingling, burning and pain in dermatome preceds eruption. During eruption, patient may experience malaise, headache, fever and flu-like symptoms.
Lymphadenopathy, sensory defects and may have mild paralysis (facial paralysis if trigeminal distribution)