Geriatric Patient with New-Onset, Painful, Vascular Rash on Face
Try this case and test your knowledge of viral infections.
On examination, you note that the rash also appears on the tip of his nose. What is the significance of this finding?
The correct answer is:
This finding doubles the patient’s risk of developing chronic ocular inflammation with possible vision loss.
Recognize the Hutchinson sign in herpes ophthalmicus.
Patients with herpes ophthalmicus and lesions on the tip of the nose have twice the incidence of ocular involvement compared with those who do not have nasal lesions.
This patient’s presentation is most consistent with herpes zoster (shingles), which is due to reactivation of latent Varicella infection.
Approximately 1 in 3 Americans will develop shingles in their lifetime.
The risk increases with age, as does the risk of postherpetic neuralgia. This risk is increased in people aged 50 years or older, and 10% to 25% of these cases specifically involve the ophthalmic division of the trigeminal nerve (herpes zoster ophthalmicus).
Despite its name, only one-third of patients with herpes zoster ophthalmicus will have ocular involvement (conjunctivitis, keratitis, uveitis), which can lead to blindness, corneal denervation, and chronic ocular inflammation.
Among patients with herpes zoster ophthalmicus, some will also have a herpes lesion on the tip of their nose. This signifies involvement of the nasociliary branch (innervates the tip of the nose) and is known as a Hutchinson sign.
Patients with herpes zoster ophthalmicus and a Hutchinson sign have twice the incidence of ocular involvement as those without a Hutchinson sign.
Ramsay-Hunt syndrome (herpes zoster oticus) occurs when shingles affects the facial nerve near the ear.
In addition to the painful rash caused by shingles, Ramsay-Hunt syndrome can cause facial paralysis and loss of hearing in the affected ear.
Herpes zoster infection does not predict underlying immunosuppression, disseminated vascular disease, or autoimmunity.
Bell A. Herpes zoster and postherpetic neuralgia: prevention and management. Am Fam Physician. 2011;83:1432-1437.
Carlisle R. Differential diagnosis of a swollen red eyelid. Am Fam Physician. 2015;92:106-112.
Johnson JL, Amzat R, Martin N. Herpes zoster ophthalmicus. Prim Care. 2015;42:285-303.
Seethala R, Takhar SS. Viruses (chapter 122). In: Wall R, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018:1598-1618
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