Cases From AHRQ WebM&M: Hiding in Plain Sight: The Commentary

Cases From AHRQ WebM&M: Hiding in Plain Sight: The Commentary

A 10-year-old, previously healthy girl was referred to the pediatric ophthalmology service after being seen in the emergency department for blisters and swelling to the left eye, forehead, and scalp. What might influence their driving under the influence? VZV was detected by polymerase chain reaction (PCR) in the skin and blood, and no herpes simplex virus was detected by PCR or direct fluorescent antibody. These complications have an impact on healthcare costs, productivity, and quality of life for those afflicted. The child was otherwise healthy with no significant medical history and no history of recurrent infections. What accounts for the change? Vancomycin, cefotaxime, and clindamycin were added for a bacterial superinfection.

In a randomized, double-blind, placebo-controlled trial of 38,546 adults 60 years of age or older, the use of the VZV vaccine reduced the burden of illness from HZ by 61.1% (P < .001), reduced the incidence of postherpetic neuralgia by 66.5% (P < .001), and reduced the incidence of HZ by 51.3% (P < .001).[3] Presently, the VZV vaccine is recommended for the prevention of HZ in individuals 60 years of age and older. Her intraocular pressure was 24 mm Hg in the left eye and 17 mm Hg in the right eye. In this review, the authors examine the latest evidence on the roles of gland atrophy and ductal hyperkeratinization in the development of meibomian gland dysfunction. She will be monitored and followed for a more complete immunologic workup to evaluate the IgA deficiency. A second scenario might be a patient who suffers from an extensive or painful outbreak but is unable to access medical attention before the eruption resolves. Examination of the anterior segment revealed left upper lid edema with an open vesicle on the upper lid and multiple vesicles on the lid margin (Figure). How does it compare with the near vision card? Cases From AHRQ WebM&M: Hiding in Plain Sight: The Commentary

For example, a thoracic dermatomal rash may not be continuous, so it may be necessary to examine the front and back of the patient and “connect the dots.” Or, when HZ occurs fully or partially under the scalp, it can also lead to a missed diagnosis. Therefore, it is important to carefully examine patients with facial crusts and/or pain, particularly since such patients may go on to develop HZ ophthalmicus. Except for such cases with ocular involvement, delays in diagnosis generally carry little overall risk. As previously noted, acute treatment with antivirals is of minimal benefit and will not prevent postherpetic neuralgia. Corticosteroids may help reduce acute pain, but they will also not reduce the incidence of postherpetic neuralgia. All of these treatment limitations argue for increased utilization of the VZV vaccine. Finally, it is important to acknowledge the few conditions that can often be mistaken for HZ.

Sacral herpes simplex virus infections, caused by HSV-2, are often confused with HZ. These can be differentiated by a history of recurrence in the case of sacral HSV, and by viral culture or direct fluorescent antibody testing. Unilateral allergic contact dermatitis, as often occurs with cases of poison ivy, is also in the differential diagnosis, but would be associated with pruritus rather than pain. Perhaps the greatest risk to patients from a missed diagnosis of HZ is from an aggressive approach to the wrong diagnosis. More than one patient has been taken to the cardiac catheterization laboratory because of an “acute MI” after he presented with left sided chest pain, tachycardia, and nonspecific electrocardiogram changes. Other unfortunate patients have had their appendices or gall bladders removed. Some diagnostic confusion is inevitable because the pain of HZ can emerge well before the rash (and there is no accurate diagnostic test during this prodrome), but in some of the cases, subtle clues of early skin involvement were missed.

The key is to maintain a high index of suspicion for HZ — particularly when a patient’s new pain is in a dermatomal distribution, when the pain is “zoster-like,” and when the evidence for other diseases is less compelling — and to do a thorough skin examination. Perform a full history and physical examination in any patient where HZ is a consideration, such as patients presenting with a unilateral skin eruption or localized pain and paresthesias. Always consider HZ in the differential diagnosis of any patient presenting with facial pain and/or evidence of vesicles and scabbing. Refer patients with suspected HZ ophthalmicus to an ophthalmologist emergently. Consider administering the VZV vaccine to eligible patients, as it is the only intervention shown to reduce the incidence of HZ and postherpetic neuralgia. AHRQ WebM&M is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco. The AHRQ WebM&M site was designed and implemented by Silverchair.

You may also like