The Question
A 72 year old woman with rheumatoid arthritis treated with methotrexate and prednisone 5 mg daily comes in with a three day history of a painful, burning rash on the right side of her forehead and the tip of her nose. She describes tingling in the area for two days before the rash appeared. She also notes mild right eye redness and tearing but says her vision is unchanged. Temperature is 37.1°C, blood pressure 128/76 mmHg, pulse 78/min. Examination shows grouped vesicles on an erythematous base distributed over the right forehead, upper eyelid, and the tip and side of the nose, sharply demarcated at the midline. There is mild conjunctival injection on the right without corneal haze, and extraocular movements are full. Visual acuity is 20/25 in both eyes and there is no relative afferent pupillary defect. Which of the following is the most appropriate next step in management?
See the answer and explanation below:
Post-Call Recovery Reads
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A
Explanation
Clinical Pearl:
Vesicles on the tip or side of the nose in herpes zoster ophthalmicus (Hutchinson's sign) mark nasociliary nerve involvement and predict a high risk of keratitis, uveitis, and other sight threatening complications, so these patients need same day ophthalmology evaluation plus prompt systemic antiviral therapy.
Explanation:
This woman has herpes zoster ophthalmicus, and the vesicles extending onto the tip of her nose are Hutchinson's sign, which reflects involvement of the external nasal branch of the nasociliary nerve and correlates strongly with subsequent corneal and intraocular disease even when the eye exam still looks reassuring. Standard of care is prompt initiation of an oral antiviral such as valacyclovir, ideally within 72 hours of rash onset, combined with urgent same day ophthalmology referral so that early keratitis or uveitis can be caught before permanent vision loss occurs, and this is especially urgent given her immunosuppression from methotrexate and chronic prednisone. Adding a systemic steroid taper without an antiviral, as in the second option, does nothing to control viral replication and could theoretically worsen dissemination in an immunosuppressed host, so it is not an acceptable substitute for antiviral therapy. Watching and waiting is inappropriate here: her preexisting immunosuppression and the presence of Hutchinson's sign both raise her risk of severe ocular and disseminated disease, and delaying treatment worsens outcomes. Topical corticosteroids applied directly to active vesicular lesions can promote local viral spread and are not part of standard management of cutaneous zoster. An MRI has no role in this presentation, since she has no encephalopathy, focal neurologic deficits, or other findings suggesting CNS involvement, and ordering one would only delay the antiviral therapy and ophthalmology evaluation that she actually needs.
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