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Eye Pain and Visual Change

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A 60-year-old woman presents to the emergency department (ED) complaining of pain in her right eye and burning sensation over the right side of her forehead. On physical examination, you notice a patch of grouped vesicles on an erythematous base located in a dermatomal distribution on her forehead. There are also a few vesicles located at the tip of her nose. Her visual acuity is 20/20 bilaterally, heart is without murmurs, lungs are clear, abdomen is soft, and there are no abnormal findings on neurologic examination.

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Which of the following is the most likely pathogen?

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a. Adenovirus

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b. Pseudomonas aeruginosa

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c. Varicella zoster virus (VZV)

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d. Herpes simplex virus (HSV)

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e. Chlamydia trachomatis

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The answer is c. At a minimum the patient has herpes zoster (shingles) and may potentially have herpes zoster ophthalmicus, an infection caused by the VZV. The shingles in this case involves the ophthalmic division (V1) of the trigeminal nerve. Shingles is diagnosed clinically by visualizing a patch of grouped vesicles on an erythematous base located in a dermatomal distribution. Patients often complain of associated burning pain that precedes the appearance of the rash.

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Adenovirus (a) is the most common cause of viral conjunctivitis. P aeruginosa (b) is associated with contact lens use, corneal abrasion, and corneal ulceration. HSV (d) can cause keratitis and severe ocular infections. C trachomatis (e) can cause conjunctivitis in neonates and sexually active adults. None of these agents are the cause of shingles.

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A 60-year-old woman presents to the emergency department (ED) complaining of pain in her right eye and burning sensation over the right side of her forehead. On physical examination, you notice a patch of grouped vesicles on an erythematous base located in a dermatomal distribution on her forehead. There are also a few vesicles located at the tip of her nose. Her visual acuity is 20/20 bilaterally, heart is without murmurs, lungs are clear, abdomen is soft, and there are no abnormal findings on neurologic examination.

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Which of the following is the most concerning complication at this time?

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a. Central nervous system involvement causing meningitis

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b. Ophthalmic involvement causing anterior uveitis or corneal scarring

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c. Cardiac involvement causing endocarditis

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d. Dermatologic involvement causing permanent scarring of her face

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e. Nasopalatine involvement causing epistaxis

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The answer is b. Hutchinson sign describes vesicles on ...

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