Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 52-year-old woman had a burning sensation involving the right side of her forehead and the tip of her nose for 2 days, followed by increased redness and the development of lesions involving the tip of her nose. Medical history is significant for hypertension, and her only medication is ramipril.
On physical examination, vital signs are normal. Skin examination shows an erythematous patch on the right side of the forehead with scattered overlying grouped vesicles and a vesicle on the tip of the nose with background erythema. Mild conjunctival erythema is noted. The remainder of the physical examination is unremarkable.
In addition to starting antiviral medications, which of the following is the most appropriate next step in management?
A: Administer herpes zoster vaccine
B: Start mupirocin
C: Urgent ophthalmologic evaluation
D: Urgent otolaryngology evaluation
MKSAP Answer and Critique
The correct answer is C: Urgent ophthalmologic evaluation.
This patient has herpes zoster infection involving the forehead and has a vesicular lesion on the tip of the nose (Hutchinson sign) suggesting the possibility of ocular involvement, and she should be referred for urgent ophthalmologic evaluation. This clinical scenario is consistent with herpes zoster infection involving the V1 distribution of the trigeminal nerve, which can result in eye involvement (herpes zoster ophthalmicus) and ophthalmologic complications including keratitis, scleritis, uveitis, and acute retinal necrosis. When grouped vesicles on an erythematous base involve the V1 distribution or extend to the tip of the nose, concurrent management with an ophthalmologist is indicated to help treat and prevent any of these complications. Management of these patients usually involves antiviral therapy and topical glucocorticoid eye drops to reduce inflammation.
The herpes zoster vaccine is recommended for persons 60 years or older to prevent herpes zoster and its complications. The administration of the vaccine after an episode of zoster is debated. The Centers for Disease Control and Prevention recommend providing the vaccine even after an initial herpes zoster infection. However, a recent article states that the cellular immune response to varicella zoster virus (VZV) during the first 3 years after vaccination is similar to that after an episode of herpes zoster. As a result, deferring vaccination for up to 3 years in patients who are immunocompetent, such as this patient, is recommended, as vaccination during the episode will not be as effective.
Mupirocin is an antibiotic used for the treatment of bacterial skin infections such as impetigo, furuncles, or methicillin-resistant Staphylococcus aureus. Herpes zoster is a viral infection, and mupirocin would not be appropriate.
Otolaryngology consultation is not necessary. The distribution of the vesicles in the central face is not concerning for underlying hearing or other otolaryngologic involvement. Herpes virus infection may involve the ear canal and hearing may be affected and a facial nerve palsy or vertigo also can result. This complex of findings is known as Ramsay Hunt syndrome, and systemic glucocorticoids and antiviral agents may be necessary to treat this complication, usually with co-management with an otolaryngologist.
Key Point
- Herpes zoster infection involving the V1 distribution of the trigeminal nerve can result in ophthalmologic complications including keratitis, scleritis, uveitis, and acute retinal necrosis.
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