Question of the Week # 249

249 )  A 64 year old  man is evaluated in your office for a left sided headache that started 24 hours ago. He describes the headache as a burning sensation over his left temple and the forehead. He also reports fatigue and malaise for the past one day. He has no significant past medical history.   On examination, he has a low grade fever at 100.4F, Blood pressure is 120/70 mm Hg. Physical examination reveals hyperesthesia on his left forehead and skin findings as shown in the picture below:

Which of the following is the most appropriate immediate next step in management ?

A) Mupirocin cream

B) Start Oral Cephalexin

C) Refer to Ophthalmology

D) Refer to Dermatology

E) Topical Acyclovir

11 Responses

  1. refer to ophthalmologist is the answer

  2. i think this is singles – herpes zoster so answer E topical acyclovir

  3. I meant Shingles

  4. Answer: C
    The clinical presentation is suggestive of Herpes Zoster Ophtlamicus (HZO). Herpes Zoster Ophtlamicus is an ophthalmologic emergency and needs urgent referral to Ophthalmologist. The patient in the question presents with burning sensation on one side of his forehead and also with vesicular, crusting lesions at the tip of his nose. This vesicular lesion at the tip of his nose is referred to as “Hutchinson’s Sign”. Clinicians should be aware of the importance of this sign because presence of lesions on the tip of the nose is associated with very high risk of Ophthlamic Involvement. The tip of the nose is supplied by the naso-ciliary branch of Trigeminal nerve which also supplies the cornea. Such patients with lesions in the area innervated by the naso-ciliary branch of the fifth nerve must be urgently referred to Ophthlamology. Even when the disease appears to be just involving the skin, a complete and thorough eye examination must be performed to exclude eye involvement. Treatment is Oral acyclovir and ophtlamology consult. Topical acyclovir may be appropriate in Herpes Zoster but not effective in reducing ophthalmic complications in HZO.

    This is not “impetigo” . Choices A and B are treatment for impetigo and are incorrect. Impetigo is not associated with vesicular lesions and also does not explain the hyperesthesia on his forehead.

  5. ccc

  6. Answer is E

  7. topical acyclovir….

  8. e

  9. CC

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