Periorbital lesion (12/1700)

An 18yo female has periorbital blisters. Some of them are crusted, others secreting
pinkish fluid. What is the most likely dx?

a. Shingles
b. Chicken pox
c. Varicella
d. Rubella
e. Measles












answer A



shingles/herpes zoster:

Clinical Presentation
• unilateral dermatomal eruption occurring 3-5 d after pain and paresthesia of that dermatome;
may be disseminated in Immunosuppressed (eg HIV, organ transplant)
• vesicles, bullae, and pustules on an erythematous, edematous base
• lesions may become eroded/ulcerated and last days to weeks
• pain is can be pre-herpetic, synchronous with rash, or post-herpetic
• severe post-herpetic neuralgia often occurs in elderly and may be permanent
• Hutchinson’s sign: involvement of tip of nose suggests eye involvement
• distribution: thoracic (50%), trigeminal (10-20%), cervical (10-20%); disseminated in HIV

 Later the rash becomes vesicular, forming small blisters filled with a serous exudate, as the fever and general malaise continue. The painful vesicles eventually become cloudy or darkened as they fill with blood, and crust over within seven to ten days; usually the crusts fall off and the skin heals, but sometimes, after severe blistering, scarring and discolored skin remain.^[13]
Shingles may have additional symptoms, depending on the dermatome involved. The trigeminal nerve is the most commonly involved nerve.^[17]
The ophthalmic division of the trigeminal nerve is most commonly involved branch.^[18] When the virus is reactivated in this nerve branch it is termed zoster ophthalmicus. The skin of the forehead, upper eyelid and orbit of the eye may be involved. Zoster ophthalmicus occurs in approximately 10% to 25% of cases. In some people, symptoms may include conjunctivitis, keratitis, uveitis, and optic nerve palsies that can sometimes cause chronic ocular inflammation, loss of vision, and debilitating pain.^[19]

chicken pox/varicella:

 Appearance: groups of skin lesions, polymorphic, from macules to papules to vesicles to crusts
Timing: 1-3 d after start of symptoms
Distribution: generalized

rubella :

Appearance: pink, maculopapular, Timing: 1-5 d after start of symptoms
Distribution: starts on face and spreads to neck and trunk

measles:

Appearance: erythematous maculopapular
Timing: 3 d after start of symptoms
Distribution: starts at hairline and spreads downwards with sparing of palms and soles