MKSAP: 65-year-old woman with prodrome of pain on the tip of the nose

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 65-year-old woman is evaluated for a prodrome of pain on tip of the nose followed by a painful eruption involving the right periorbital tissue.

On physical examination, all vital signs are normal. There are grouped vesicles on an erythematous base on the tip of the nose and about the right eye.

Which of the following is the most appropriate first step in management of this patient?

A) Apply warm compresses
B) Begin ophthalmic corticosteroids
C) Begin valacyclovir and obtain urgent ophthalmology consultation
D) Obtain bacterial culture and start cephalexin

MKSAP Answer and Critique

The correct answer is C: Begin valacyclovir and obtain urgent ophthalmology consultation.

This patient has herpes zoster ophthalmicus (shingles), and referral to an ophthalmologist and empiric treatment with an antiviral agent (acyclovir, valacyclovir, or famciclovir) are imperative. Ophthalmic zoster, if not treated promptly, can lead to blindness. Shingles, which is reactivation of varicella-zoster virus, can occur anytime after the primary varicella infection. It often begins with a prodrome of intense pain, and in more than 90% of patients, it is associated with pruritus, tingling, tenderness, or hyperesthesia. The cutaneous eruption typically involves a single dermatome and rarely crosses the midline. In a recent, prospective multicenter study, eye redness and rash in the supratrochlear nerve distribution had a statistically significant association with clinically relevant eye disease. One hundred percent of patients who developed moderate to severe eye disease presented with a red eye. Hutchinson sign (zoster eruption on the tip of the nose) was not predictive of clinically relevant eye disease. Clinical diagnosis is based on both history and physical examination. Testing by direct fluorescent-antibody testing or by polymerase chain reaction can confirm the diagnosis; however, decisions regarding antiviral therapy are often based on history and physical examination rather than reliance on laboratory testing.

Applying warm compresses or obtaining bacterial culture and starting antibiotics would not be appropriate treatment for a viral infection, and delaying treatment could result in blindness. Ophthalmic corticosteroids are frequently administered as an adjunctive agent to antiviral therapy in the treatment of ophthalmic zoster but are never used as a single agent and should be administered by a specialist.

Key Point

  • Ophthalmic herpes zoster infection should be considered a medical emergency that requires prompt referral to an ophthalmologist and initiation of an antiviral agent.

This content is excerpted from MKSAP 16 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 16 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

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