A rash that cannot be missed : disseminated herpes zoster as a result of immunomodulation by Adalimumab
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"The patient is a 75-year-old Caucasian male who was admitted in May for management of a penile ulceration and a generalized rash. He has a medical history of Type II Diabetes Mellitus, tobacco abuse, and Rheumatoid Arthritis (RA) on adalimumab. One week prior to his presentation, the patient noted an ulcer proximal to the glans penis (Figure 1). Upon further questioning, he reported noticing a small tick attached to his thigh one week prior. He has no history of sexually transmitted illnesses, incarceration, animal exposures, or meningeal signs. Two days prior to admission, the patient developed a large, dark, vesicular lesion on the anterior scalp, followed by smaller lesions over the rest of his body including the hard palate (Figures 2-6). Laboratory studies demonstrated a mildly elevated Erythrocyte Sedimentary Rate, C-Reactive Protein, and transaminitis. The patient was started on empiric doxycycline and intravenous acyclovir. Infectious work-up was negative for gonorrhea, chlamydia, syphilis, HIV, Ehrlichia, and Rocky Mountain Spotted Fever. Shave biopsies were obtained of the penile lesion and a lesion from the patient's upper back. Dermatopathology evaluation demonstrated herpetic dermatitis in both sites, and a penile swab polymerase chain reaction for Varicella Zoster Virus was positive. Treatment for disseminated Herpes Zoster was initiated with marked improvement of the lesions noted at follow-up."
Am J Hosp Med 2019 July;3(3):2019.010 https://doi.org/10.24150/ajhm/2019.010
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