Prepared by Janet G. Hickman, MD, Private Practice, Dermatology Consultants, Medical Consultant and Investigator, The Education & Research Foundation, Lynchburg, Va
A 59-year-old man presents with a rash of 1-week duration on his face, neck (Figure 1), chest, and legs. He also complains of a headache and myalgia. His wife is receiving chemotherapy for cancer.
Which of the following statements is true?
- Viral culture is the most rapid method to confirm the diagnosis
- He does not require treatment with antiviral agents, because more than 3 days have passed since the onset of his rash
- He will not develop postherpetic neuralgia, because he is younger than 60 years old
- He should have a thorough evaluation for causes of immunosuppression
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- Figure 1
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D.— Grouped vesicles with erythema and necrosis in a dermatomal pattern are strongly suggestive of herpes zoster. The rash outside the dermatome suggests disseminated zoster, raising concern for an underlying cause of immunosuppression that needs to be evaluated. Disseminated herpes zoster or zoster in the immunocompromised patient is an indication for IV treatment with acyclovir (Zovirax). Although the incidence of postherpetic neuralgia is lower in people younger than 60, it can still be a significant problem. Viral culture
can take up to 2 weeks to identify varicella zoster virus (VZV) infection. More rapid tests include a Tzanck smear (Figure 2) to confirm that it is herpetic (zoster or simplex) and a polymerase chain reaction test to confirm that it is VZV. Zoster is not as contagious as varicella, but since the patient's wife is receiving chemotherapy, she is at risk if she has direct contact with his rash.
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- Figure 2
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