72 Year Old Man with 3 Day History of Right-Sided Chest Pain

A 72-year-old man comes to the physician because of a 3-day history of right-sided chest pain. He denies any shortness of breath, nausea or vomiting. Physical examination shows a unilateral, erythematous, maculopapular rash extending from the anterior chest wall around to the back in a dermatomal pattern. The remainder of the examination is normal. In conversation, he states that is he is going to visit his grandchildren next week and that their mother “doesn’t believe in immunizations”. His grandchildren are at increased risk for which of the following rashes?

A. Discrete maculopapular lesions that become confluent as they spread from “head to toe”
B. Dome-shaped papules with central umbilication
C. Expanding annular lesion with central clearing
D. “Slapped-cheek” appearance and a lacy reticular rash
E. Vesicles at various stages of evolution

The Correct Answer is E. Vesicles at various stages of evolution.

This patient has herpes zoster, which is a reactivation of the varicella-zoster virus (VZV) that was dormant in the dorsal root ganglion. Zoster (shingles) affects individuals in the 6th to 8th decades. It is characterized by pain, fever, and a dermatomal erythematous → vesicular rash. Treatment includes antiviral therapy. Individuals with herpes zoster are contagious and can spread the VZV virus. Chickenpox (varicella) is characterized by a vesicular rash at various stages of evolution. The varicella vaccination is recommended at 12 months, however if the grandchildren have not been immunized, they may develop chickenpox.

Discrete maculopapular lesions that become confluent as they spread from “head to toe” (choice A) is the typical presentation of measles, which is caused by a paramyxovirus. It is associated with cough, conjunctivitis, coryza, and Koplik’s spots.

Dome-shaped papules with central umbilication (choice B) is the description of molluscum contagiosum, caused by a poxvirus.

An expanding annular lesion with central clearing (choice C), also known as erythema chronicum migrans, is the rash of Lyme disease, caused by Borrelia burgdorferi (after a tick bite). The rash begins as an erythematous macule that expands with central clearing, leading to the typical “bull’s eye” lesion

A “slapped-cheek” appearance and a lacy reticular rash (choice E) is the description of the rash of erythema infectiosum (Fifth disease), which is caused by parvovirus B16.