PEDIATRIC ID QUIZ

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PEDIATRIC ID QUIZ 5
ENLARGE IMAGE

• CC/HPI A 15 year old male presents with
  history of a vesicular rash on his left forehead
  for 2 days. This rash is painful and does not
  cross the midline. Pain and pruritus began about
  24 hours before the development of visible skin
  lesions.
• Past medical history He had a similar
  rash in the same location two years ago which
  resolved spontaneously within 6 days. His past
  medical history is also significant for a medical
  evaluation in the same facility 13 years ago but
  neither the patient or his father remember the
  problem for which he was evaluated at that time.
• Family history His 4 year old brother had
  hand-foot-mouth disease two month ago. His mother
  and maternal grandfather were treated for
  tuberculosis 17 years ago.
• Immunizations according to his
  immunization card he has been fully immunized
  against diphtheria, pertussis, tetanus, measles,
  mumps, rubella, Haemophilus influenzae type b,
  poliomyelitis and hepatitis B.
• Social He lives with his parents and two
  younger siblings. They do not have any pets at
  home and there is no history of recent travel

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ADDITIONAL INFORMATION
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WHICH OF THE FOLLOWING INFORMATION WOULD YOU LIKE
TO KNOW?
PREVIOUS RECORD
SKIN EXAM
EYES AND EAR EXAM
ABDOMINAL EXAM
NEUROLOGIC EXAM
BLOOD CULTURE
FUNGAL SKIN CULTURE
VZV DFA
HSV CULTURE
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DIAGNOSIS
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HYPEREMIA OF THE LEFT CONJUNCTIVA
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This picture was taken during a medical
evaluation performed 13 years ago
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NO OTHER SKIN LESIONS ARE OBSERVED
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PAIN ON THE AREAS OF DISTRIBUTION OF THE
LEFT OPHTHALMIC BRANCH OF THE TRIGEMINAL NERVE
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NORMAL
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THIS TEST IS NOT NECESSARY
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THIS TEST IS NOT NECESSARY
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THIS TEST HAS BEEN PERFORMED
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(No Transcript)
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WHICH IS THE MOST LIKELY ETIOLOGY OF THIS
PATIENTS PROBLEM?
HERPES SIMPLEX VIRUS
COXSACKIEVIRUS A1
Sporothrix schenckii
VARICELLA ZOSTER VIRUS
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HERPES-ZOSTER
This patient has the classical clinical
presentation of herpes-zoster infection which
includes development of pain and vesicles in a
dermatomal distribution (in this case the ocular
branch of the trigeminal nerve). The picture
taken 13 years ago during a previous evaluation
is consistent with healing varicella lesions.
Typically 14-21 days after initial infection
with the varicella-zoster virus the patients
develop a generalized vesicular rash. The
vesicles rupture and become crusted. The
varicella-zoster virus becomes latent within the
dorsal root ganglia after initial infection.
Reactivation (herpes-zoster) occurs occasionally
with pain and vesicular lesions which develop in
a dermatomal distribution. Reactivation is more
common in elderly individuals and individuals who
are immunocompromised. Herpes zoster is less
frequent among children who are immunocompetent.
This condition can also occur after vaccination
with varicella-zoster virus live attenuated
vaccine. In addition to clinical findings the
diagnosis of herpes zoster can be confirmed by
performing a varicella-zoster direct fluorescent
antibody from the vesicular lesions. In severe
cases of herpes-zoster or if the patient is
immunocompromised antiviral therapy is indicated.
Therapeutic options include acyclovir for young
children and acyclovir or valacyclovir for older
adolescents or adults. Children and adolescents
with recurrent episodes of herpes zoster should
be evaluated to rule out a T-cell associated
immunodeficiency. A sequelae of herpes zoster is
post-herpetic neuralgia which manifests as
persistent pain in the same dermatomal
distribution where the lesions presented
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THE WEB
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REFERENCES

• Nikkels AF, Nikkels-Tassoudji N, Pierard GE.
  Revisiting childhood herpes-zoster. Pediatr
  Dermatol 2004 21 18-23 View reference
• Uebe B, Sauerbrei A, Burdach S, Horneff G. Herpes
  zoster by reactivated vaccine varicella virus in
  a healthy child. Eur J Pediatr 2002 161442-444
  View reference
• Arvin AM. Varicella-zoster virus. Clin Microbiol
  Rev 1996 9 361-381 View reference

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• Check your e-mail frequently for Pediatric ID
  QUIZ
• If you have any questions about this or any
  other cases feel free to contact me by e-mail at
  bestrada_at_usouthal.edu or you may page me at
• 582-0072
• This activity has been supported by the
  Mitchell Clinical Scholars Program
• Benjamin Estrada MD
• Associate Professor of Pediatrics
• Division of Pediatric Infectious Diseases
• University of South Alabama