Chang S., a student at Yale School of Medicine, shares how he uses the VisualDx image library to identify likely concurrent diagnoses:
“A middle-aged gentleman without significant past medical history was sent to the ER by his primary dermatologist for concern for zoster. He was evaluated by dermatology in the ED and admitted for systemic antiviral for presumed disseminated zoster. Besides his primary distribution on the face, he only had vesicles on the back. His back was swabbed 3x and remained positive for VZV. The presentation was interesting, and we used VisualDx to see if any other diagnosis was more likely. We went through the differentials listed under disseminated zoster, and came up with 2 other diagnoses, including miliaria and eczema herpeticum, that are likely concurrent based on clinical photos provided in VisualDx.”
What is disseminated zoster?
Herpes zoster (shingles) is a reactivation of latent infection of varicella-zoster virus (VZV). Disseminated zoster most commonly affects immunocompromised patients and only rarely the immunocompetent population. Dissemination typically occurs 4-11 days after the onset of localized cutaneous disease. Dissemination may be confined to the skin or it may affect the viscera as well. It is estimated that cutaneous dissemination occurs in 10%-40% of immunocompromised patients affected by zoster.
What should we be aware of when making a diagnosis?
- Consider disseminated zoster in any immunocompromised individual presenting with multiple skin lesions outside the primary dermatome.
- Patients with systemic dissemination should be treated in an intensive care unit.
- Consultations that may be required include dermatology, infectious diseases, neurology, and gastroenterology depending on involvement of visceral organs.
How can we treat this?
Acyclovir given intravenously is the first-line therapy for disseminated disease. Treatment halts disease progression and reduces the duration of viral replication.
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