WELCOME BACK TO ANOTHER CLINICAL IMAGE FROM THE CASE FILES OF THE BROWN EM RESIDENCY!

Case:

HPI/ROS: 49-year-old female with a history of hypothyroidism and asthma  presents to the ED with right eye swelling and pain. She reports that four days ago she initially developed a severe right-sided headache, which progressed to right eye swelling, redness and pain with movement. She was seen at an urgent care center and diagnosed with conjunctivitis and treated with topical antibiotics [am1]  . Today, she awoke with a new rash on her scalp as well as chills, nausea, and watery discharge from the eye. She denies visual changes or fevers.  

Vital Signs: T: 98.6, HR: 91, BP: 123/73, R: 16, SpO2: 99% on room air

Visual Acuity: R 20/25 L 20/25

Physical Examination: The patient is alert and oriented. Normocephalic, atraumatic head. Tympanic membranes are clear. Oropharnyx clear and moist. Cranial nerves II-XII are intact. Pupils are 4 mm and reactive bilaterally. Extra-ocular movements are intact. Peripheral vision is intact. Patient accommodates appropriately. Neck is supple. Lungs are clear to auscultation. Heart is regular rate and rhythm without murmurs, rubs, or gallops. Abdomen is soft, non-tender, non-distended. A rash is appreciated above the right eye with some associated mild peri-orbital swelling (see image 1). There is conjunctival injection. Slit lamp examination is performed as well (see image 2). No other pertinent exam findings.

What’s the diagnosis?

Here are some quick facts:

• Herpetic Zoster Ophthalmicus (HZO) is a vision threatening condition secondary to Varicella Zoster Virus (VZV) reactivation, “shingles”, within the trigeminal ganglion, specifically the first division (V1).
• Up to one-half of all patients with VZV V1 reactivation experience direct ocular involvement.
• Typical prodromal symptoms include headache, malaise, fever, pain and photophobia in the affected eye and surrounding dermatome.
• Upon eruption of vesicular lesions within the trigeminal dermatome, patients will likely experience hyperemic conjunctivitis, blurred vision, and/or lid droop. The rash typically does not cross the midline.
• Two thirds of patients will develop corneal involvement (keratitis), which can either manifest as punctate (our patient) or dendritic lesions on slit lamp examination.
• The anterior chamber can show cells and flare if deeper structures are affected (iritis).
• Lesions on the nose are fairly specific for HZO due to involvement of the nasociliary branch of the trigmeninal nerve, which also innervates the eye.  
• Early diagnosis is critical and management involves oral anti-retrovirals and adjunctive topical steroid drops to reduce the inflammatory response. Associated conjunctivitis can be treated with topical erythromycin ointment. Pain reduction can be achieved with topical cycloplegic agents.
• If the patient is immunocompromised or systemically ill, consider admission with IV acyclovir.
• Prompt ophthalmological follow up is warranted as well.

Case Conclusion:

This patient was discharged home on oral acyclovir and topical steroid drops. She had follow up with ophthalmology the following day.

Faculty Reviewer:

Dr. Alyson McGregor

References:

Albrecht, Mary. Clinical Manifestations of Varicella-Zoster Virus Infection: Herpes Zoster. UptoDate. 2017.

Tintinalli, et. al. Emergency Medicine. 8th Edition. 2016. 1061-1062.   

The contents of this case were deliberately altered to protect the identity of the patient. All content in this report are for educational purposes only. The patient consented to the use of these images.