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.

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

References

Dworkin RH, Johnson RW, Breuer J, et al. Recommendations for the management of herpes zoster. Clin Infect Dis. 2007;44 Suppl 1:S1.