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Adolescent female presents with painful rash on neck, ear
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A 15-year-old female presented to her primary clinic complaining of recent onset of a painful rash on the right side of her neck and ear. The history of this began about 2½ weeks earlier when she was seen at another clinic with an uncomplicated urinary tract infection, for which she received an injection of ceftriaxone and a prescription for oral trimethoprim-sulfamethoxazole (Bactrim, AR Scientific).
James H. Brien
Within a couple of days, she developed a rash on the right side of her upper back and neck that was thought to be secondary to the TMP-SMX, which was stopped and no further antibiotics were given. She was then prescribed a short course of oral steroids, which reportedly helped the rash briefly resolve. However, a few days after finishing the steroids, the rash returned in the same general area with some painful itching. She was prescribed a topical steroid cream that had no effect, and the rash worsened within a couple of days, accompanied by some decreased hearing in her right ear. She then returned to her regular primary provider, who referred her for admission.
Her medical history is that of a previously healthy adolescent female. She had some recurrent otitis media requiring pressure equalization tubes with adenoidectomy as a young child, but has done well since. Her immunizations are up-to-date and she had documented varicella infection as a toddler. No records were available regarding the recent UTI, but there was no prior history of UTIs. Animal exposure is limited to family pets; two dogs and a cat. There was no recent travel or sick contacts.
Figures 1 and 2.
Examination reveals normal vital signs and the vesicular rash shown in Figures 1–4.
Image: Brien JH
Examination reveals normal vital signs and the vesicular rash shown in Figures 1–4. It is also noted that she had some mild hearing loss in the right ear, as well as some decreased sensation on the right side of her face, but no facial paralysis. The rest of her exam was normal.
Figures 3 and 4.
Lab tests sent include herpes simplex virus and varicella zoster polymerase chain reactions from an intact lesion; results are pending.
What’s Your Diagnosis?
A. Shingles
B. Atopic dermatitis
C. Cutaneous herpes simplex
D. Ramsay Hunt syndrome
Case Discussion
I hope you weren’t fooled by Ramsay Hunt syndrome because the patient had some hearing loss. The answer is (A) shingles involving C2 and C3 and possibly part of the third branch of the trigeminal nerve (V3). To fit the diagnostic criteria for Ramsay Hunt syndrome, it must result in some 7th cranial nerve impairment, which this patient did not have. James Ramsay Hunt (1872-1937) described this syndrome in 1907 while he was a neurology faculty member at Cornell Medical School, and noted that it was caused by the reactivation of herpes zoster in the geniculate ganglion. While hearing loss and/or tinnitus is also characteristic of Ramsay Hunt syndrome, the facial palsy appears to be required for the diagnosis according to his original description. Otherwise, it’s just another case of shingles of the head and neck.
The treatment of zoster in hospitalized, sick children is usually IV acyclovir. However, for older children (≥12 years), oral valacyclovir can be used at a dose of 1 g three times daily for 7 days, which was used for continuation of therapy as an outpatient in this patient soon after confirming the diagnosis. In many cases, the actual need for treatment with an antiviral agent is debatable, especially since most patients are diagnosed past the time when benefit would be expected, which should be within 48 to 72 hours; however, most will receive therapy anyway.
Atopic dermatitis would not likely include vesicles.
It’s not unusual for shingles to follow in the wake of an unrelated febrile illness. However, this patient’s initial presentation with a UTI and how the treatment may or may not have been associated with the initial rash will remain unclear. It is likely that this rash was zoster from the beginning and that it was not recognized until the appearance became more typical.
Many neurologists recommend treating with gabapentin (Neurontin, Parke-Davis) for the neuralgia associated with shingles, which was done for this patient with good results.
Unless the patient had eczema herpeticum (Figure 6), then the appearance could closely resemble shingles. Simple cutaneous hHSV infections are usually in small patches (Figure 7).
Atopic dermatitis (Figure 5) would not likely include vesicles, unless the patient had eczema herpeticum (Figure 6), then the appearance could closely resemble shingles. Simple cutaneous HSV infections are usually in small patches (Figure 7), but the overlap of appearance with shingles can be substantial, again making clinical distinction very difficult. Then, only identification of the virus will tell. Nowadays we use PCR for viral identification.
Columnist Comments
The 47th Annual Uniformed Services Pediatric Seminar (USPS) will be held March 3-6, at the Hyatt Regency on the River Walk in San Antonio. It’s an excellent general pediatric meeting that is AAP-endorsed, and you don’t have to be in the military to attend. I will be presenting some interesting cases there, and hope to see you there as well. See the following link to review the brochure: www2.aap.org/sections/uniformedservices/2013USPSBrochure.pdf.
The 25th Annual Infectious Diseases in Children Symposium was held in November in New York. As a speaker there, my sessions typically have no Q & A periods, but I received some questions cards anyway. Whether you have a question from the meeting or a question or comment about this column, please send them to my email address, jhbrien@aol.com, and I will try my best to answer quickly. If you do not hear from me in a few days, please resend.
I wish you all Happy Holidays and a healthy New Year.
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James H. Brien, DO, is a member of the Infectious Diseases in Children Editorial Board, as well as Vice Chair for Education at The Children’s Hospital at Scott and White, and is the Associate Professor of Pediatrics at Texas A&M University, College of Medicine, Temple, Texas, can be reached at jhbrien@aol.com.
Disclosure: Brien reports no relevant financial disclosures.