This is an interesting case and one for medical students to be used as a review. Starts with a case and followed by Dr Vivek Baliga's review on the diagnosis with references.

1. Review - Case Of A
Rash On The Hips
Dr Vivek Baliga B
Consultant Physician
Baliga Diagnostics

2. Case
● 82 year old gentleman
● History of type 2 diabetes, high blood pressure and ischemic heart
disease
● Currently taking Aspirin 75 mg OD, Ramipril 2.5 mg BD, Atorvastatin
10mg OD nocte and Metoprolol 25 mg BD.
● History of having a hotter than normal bath 1 week ago - developed a
rash over left flank
● Complains of burning sensation over the rash
● No abdominal complaints or joint pains

4. DIAGNOSIS?

5. HERPES ZOSTER
(SHINGLES)

6. Herpes Zoster
● Painful unilateral skin rash
● Higher incidence in elderly patients
● Etiology - Varicella Zoster Virus (the cause of chickenpox)
● After an attack of chicken pox, the Varicella virus remains dormant in the
dorsal root ganglia
● Certain triggers reactivate the virus, which then moves down sensory
nerve roots and affects specific dermatomes.

7. Who Is At Risk?
● Increasing age - higher in those over 75 years
● Altered cell mediated immunity
○ Lymphoproliferative disorders
○ On immunosuppressive medication
○ Organ transplant patients
○ HIV seropositive (lesser in seronegative)

8. Symptoms And Signs
● Prodromal Phase
○ Lasts 48 - 72 hours
○ Starts with pain and altered sensation (paresthesia) in the affected
area

9. Symptoms And Signs
● Rash appears
○ Erythematous maculopapular rash which progresses to a vesicular
rash affecting single dermatome
○ Never crosses the midline
○ Course - 3 -5 days
○ Pustulates, ulcerates and scabs afterwards.
○ Healing over 4 to 6 weeks

10. Common Nerves Affected
● Commonly affects
○ Thoracic nerves
○ Ophthalmic division of trigeminal nerve
○ VII and VIII nerve - Ramsay Hunt Syndrome

11. Diagnosis
● Clinical symptoms and signs are usually sufficient
● Can sometimes be confused with Herpes Simplex if it affects the sacral
and cervical areas
● Viral culture not very helpful
● Direct immunofluorescence of fluid more sensitive - helps differentiate
between simplex and zoster
● If no rash present but clinical suspicion is high, consider polymerase chain
reaction.

12. Diagnosis
● Tzanck smear of vesicular fluid - not as useful but can be done if needed.
● It could spread to liver and other organs in people with low immunity

13. Complications
● Post herpetic neuralgia - Pain that persists for months or years after
infection has cleared. Defined as pain that persists beyond 30 days of
rash or healing.
○ Patients over 50 years - greater skin surface area. Incidence
increases with advancing age.
○ Female gender
○ Severe rash on presentation
○ Presence of a prodrome
○ Severe pain on diagnosis
○ Presence of viremia on PCR

14. Complications
● Acute Retinal Necrosis
○ Seen in immunocompetent patients; greater incidence in HIV
positive patients
○ Does not necessarily follow trigeminal nerve involvement
○ Fundoscopy - Granular, yellow, hemorrhagic lesions
○ Can cause blindness in HIV positive patients
○ Antiviral therapy works in patients with good immunity only

15. Complications
● Herpes Zoster Ophthalmicus
○ Involves first branch of trigeminal nerve
○ If untreated leads to
■ Keratitis
■ Iritis
■ Episcleritis
■ Blindness

16. Complications
● Bacterial super-infection
● Myelitis
● Meningoencephalitis involvement

17. Treatment
● Various options - The sooner initiated, the better the outcome (<72
hours)
○ Aciclovir 800 mg 5 times daily for 8 to 10 days
○ Famciclovir 250 mg 3 times daily for 7 days
○ Valaciclovir 1 gram 3 times daily for 7 days
● Pain reduction
○ Prednisolone 60 mg daily - taper slowly to reduce pain and speed up
healing of lesions
○ Amitriptyline 25 mg daily for 3 to 4 months

18. Treatment of Post-Herpetic Neuralgia
● Gabapentin
● Pregabalin
● Tricyclic antidepressants
● Topical lignocaine
● Capsaicin

19. Gnann Jr, J. W., & Whitley, R. J. (2002). A 77-year-old man reports a five-day history of burning and aching pain in his right side and a two-
day history of erythema and clusters of clear vesicles, accompanied by headache and malaise. How should he be evaluated and treated?. N
Engl J Med, 347(5).

20. Closing Remarks
● Herpes zoster is a painful re-activation of chicken pox
● Clinical symptoms and signs are characteristic and sufficient for diagnosis.
● Antiviral therapy is the mainstay of treatment.
References
1. Cohen, Jeffrey I. "Herpes zoster." New England Journal of Medicine 369.3 (2013): 255-263.
2. Wareham DW, Breuer J. Herpes zoster. BMJ : British Medical Journal. 2007;334(7605):1211-1215.
doi:10.1136/bmj.39206.571042.AE.