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Eye Pain and Visual Change

A 65-year-old woman with a history of hypertension, hyperlipidemia, presents to the emergency department (ED) complaining of blurry vision in the left eye, pain in her left eye, and a new rash to her left forehead. One week ago, she was diagnosed with left-sided parotitis by her primary care physician (PCP) and started on antibiotics. On physical examination, you notice a patch of grouped vesicles on an erythematous base located in a dermatomal distribution on her forehead that does not cross midline. There are also a few vesicles located at the tip of her nose. Her visual acuity is 20/20 OD (OD = right eye) and 20/70 OS (OS = left eye), her cornea is cloudy, and her left pupil is mid-dilated with poor reactivity to light. There is no afferent pupillary defect (APD) in either eye. Intraocular pressure (IOP) is noted to be 14 OD and 39 OS. Fluorescein stain of the left eye is normal. Funduscopic exam shows normal appearing optic disc and periphery in the left eye.

What is the likely causative organism?

a. Adenovirus

b. Pseudomonas aeruginosa

c. Varicella zoster virus (VZV)

d. Herpes simplex virus (HSV)

e. Chlamydia trachomatis

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 may complain of a prodrome of headache, fever, malaise, unilateral pain, hypesthesia of the affected eye or forehead that can precede the appearance of the rash. Ipsilateral parotitis can be seen with VZV infections.

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, but the clinical scenario described is more consistent with VZV. C. trachomatis (e) can cause conjunctivitis in neonates and sexually active adults. None of these agents are the cause of shingles.

A 65-year-old woman with a history of hypertension, hyperlipidemia, presents to the emergency department (ED) complaining of blurry vision in the left eye, pain in her left eye, and a new rash to her left forehead. One week ago, she was diagnosed with left-sided parotitis by her primary care physician (PCP) and started on antibiotics. On physical examination, you notice a patch of grouped vesicles on an erythematous base located in a ...

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