Rash Decision

Herpes Zoster of the Ophthalmic division of th...

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“Didn’t it hurt?” That’s the first thing I asked the 81 year-old female patient of mine, as she was trying to look up at me through a swollen eyelid.

“I noticed tingling on my forehead,” she explained, “But I wasn’t aware there was a rash until someone pointed it out to me. It never was painful.”

Only one week before she developed the tingling sensation, she also noticed difficulty in forming her words. She knew what she wanted to say, but when she spoke nothing seemed to come out quite right. It was only when the tingling and rash started to involve her eye that she became concerned.

That morning she went to her eye doctor. One look by him and the diagnosis was almost made—herpes zoster ophthalmicus—or shingles, as it is better known. Shingles is a recurrence of a virus that most of us had at one time or another. Getting chickenpox as a child meant we broke out in itching blisters, or vesicles, seemingly covering our entire bodies. Typically, we recovered without much trouble but the zoster virus that caused the rash would live to fight another day. Lying dormant in our nerve roots, the zoster virus springs to life when our immune defenses become low typically causing rash and pain anywhere in the body.

In my patient, the virus reemerged along a facial nerve and involved the eye. This manifestation of shingles becomes serious due to the potential damage to the cornea, or lens of the eye. When her eye became painful, she did the next most logical thing and went to her eye doctor. He immediately recognized the characteristic rash of herpes zoster, but became concerned with something the patient hadn’t noticed. When she smiled or tried to talk, the left side of her face didn’t move at all. In fact, that side of her face seemed destined to droop over her chin. That’s when he instructed his nurse to place the call to 911.

What my patient hadn’t noticed, but was picked up by her eye doctor, was her drooping face and trouble with speech was an impending sign of stroke. Recent studies show that the risk of stroke may be 30 percent higher in patients with shingles. When it involves the facial nerve, as in my patient, the stroke risk goes up even four times greater. Placing the patient on antiviral medications and scheduling her back for follow-up might have ended up costing her the independence she craved.

Fortunately, the ambulance whisked her quickly to the emergency room where physicians assessed and began treatment for her risk factors for stroke: high blood pressure, elevated cholesterol, and elevated blood sugars. With treatment there is a good chance she’ll recover and we’ll make sure she receives the shingles vaccine. It’s easy to make a rash decision, but by looking not just at her eye but the whole patient, her doctor made the right decision.

About Steve P. Sanders

A general internist writing and sharing ideas and art.

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