CASE 75
A 55-year-old woman presented to her family physician with a 3-day history of burning and pain over her left forearm. The symptoms were rather abrupt in onset, and she had not experienced anything like this before. Over the previous 2 days, several vesicles had developed in a band-like distribution on her arm, and new ones were erupting daily. On the day she went to see her family doctor, the lesions had started turning purplish. At no time did she have any fever, but her appetite was markedly reduced.
PHYSICAL EXAMINATION
LABORATORY STUDIES
Diagnostic Work-Up
Table 75-1 lists the likely causes of illness (differential diagnosis). A clinical diagnosis was considered based on the distinctive crops of rashes. HSV infection may, in rare cases, interfere with the diagnosis of zoster.
TABLE 75-1 Differential Diagnosis and Rationale for Inclusion (consideration)
Rationale: The presence of a rash with systemic symptoms often means a viral illness. However, contact dermatitis can also cause severe reactions. In children, common viruses are usually responsible (see above). However, localized lesions are not commonly seen with systemic viral infections and should prompt search for an allergic or local reaction. Herpes zoster should always be considered in localized rashes, particularly if the rash occurs in an adult and has a vesicular component.
In difficulty with clinical diagnosis, investigational approach may include
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