Herpes zoster infection (shingles): Clinical sciences

00:00 / 00:00

Decision-Making Tree

Questions

USMLE® Step 2 style questions USMLE

of complete

A 67-year-old woman presents to her primary care physician for follow-up of persistent pain following herpes zoster. The patient noticed a painful, erythematous, vesicular rash on her back that began over three months ago. The rash crusted over and improved, but she continues to have persistent, sharp, burning pain over the site of the rash. She has been applying the prescribed topical capsaicin and lidocaine without relief. She completed a full course of acyclovir. She is otherwise healthy and does not take any medications daily. Temperature is 36°C (96.8°F), blood pressure is 130/70 mmHg, pulse is 72/min, respiratory rate is 12/min, and oxygen saturation is 100% on room air. On physical examination, the patient appears uncomfortable. There is evidence of a well-healed rash over the left lower back that is tender to touch. The patient demonstrates hyperesthesia with light touch over this area. Which of the following is the most appropriate medication to prescribe?  

Transcript

Watch video only

Herpes Zoster infection, also known as shingles, occurs in individuals who have had a primary infection called varicella, or chickenpox, which is caused by the Varicella Zoster Virus. Following the primary infection, the virus remains dormant in the dorsal root ganglia of spinal nerves or the trigeminal ganglion. In times of stress or immunosuppression, the virus can reactivate and travel down the sensory neurons, causing herpes zoster.

Now, if your patient presents with a chief concern suggesting herpes zoster infection, first you should perform an ABCDE assessment to determine if your patient is unstable or stable. If the patient is unstable, stabilize their airway, breathing, and circulation. Next, obtain IV access and put your patient on continuous vital sign monitoring including heart rate, blood pressure, and pulse oximetry. Finally, If needed, provide supplemental oxygen.

Now, here’s a high-yield fact to keep in mind! If your patient is unstable, they may have disseminated herpes zoster, which can present with associated hepatitis, encephalitis, or meningitis. This can happen because of compromised cell-mediated immunity, or following hematopoietic stem cell transplant, in which case high viremia causes an atypical presentation. These patients can also be unstable on presentation because of the high viral load.

Okay, now let’s go back to the ABCDE assessment and take a look at stable patients. If your patient is stable, obtain a focused history and physical exam. History typically reveals a prior history of varicella infection, as well as a painful, itchy, or tingly rash that may have been preceded by a prodromal illness of malaise, headache, fatigue, and a low-grade fever.

Sources

  1. "Centers for Disease Control and Prevention" ACIP Vaccine Recommendations and Guidelines (2019)
  2. "Varicella zoster virus in solid organ transplantation: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice" Clinical Transplantation (2019)
  3. "Varicella-Zoster Virus (Chickenpox, Shingles)" Clinical Transplantation (2020)
  4. "Herpes Zoster and Postherpetic Neuralgia: Prevention and Management." Am Fam Physician (2017)
  5. "Evaluation and management of herpes zoster ophthalmicus." Am Fam Physician (2002)
  6. "ClinicalKey" Clinicalkey.com (2020)
Elsevier

Copyright © 2024 Elsevier, its licensors, and contributors. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

Cookies are used by this site.

USMLE® is a joint program of the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME). COMLEX-USA® is a registered trademark of The National Board of Osteopathic Medical Examiners, Inc. NCLEX-RN® is a registered trademark of the National Council of State Boards of Nursing, Inc. Test names and other trademarks are the property of the respective trademark holders. None of the trademark holders are endorsed by nor affiliated with Osmosis or this website.

RELX