MTC 6/10: Got shingles in the eye?

During our Hillcrest morning conference today, we learned about the unfortunate case of an otherwise healthy young man who developed herpes zoster ophthalmicus. He presented with severe right-sided eye pain that began a few days after the appearance of confluent vesicles in the CN V1 and V2 distributions (i.e., ophthalmic and maxillary divisions of the trigeminal nerve). He also had an intense, burning pain in the area of the rash. We reviewed important differential considerations, including orbital cellulitis, keratitis, conjunctivitis, anterior uveitis, optic neuritis, dry eye syndrome, acute angle-closure glaucoma, and cluster headache. Ultimately, an ophthalmologic exam revealed pseudodendrites consistent with VZV keratitis. A search for provoking factors for VZV reactivation, including an HIV test, was unrevealing. His symptoms improved after treatment with IV acyclovir, hydration, IV analgesics, and antimicrobial eyedrops.

Our ID fellow extraordinaire, Dr. Rehan Syed, guided us through a whirlwind tour of the potential ocular and neurologic complications of herpes zoster, including herpes zoster ophthalmicus and acute retinal necrosis, and their initial management. Because some of these conditions can be sight- or life-threatening, early recognition is critical. Special thanks to Dr. Syed for sharing his insights on these important conditions!

Key Learning Points:

  1. Uncomplicated herpes zoster infection is treated with a 7-day course of an oral antiviral such valacyclovir.
  2. If there is any concern for CN V1 involvement or visual disturbances, call ophthalmology for an urgent evaluation!
  3. If there is ocular or CNS involvement, a more prolonged treatment course with IV acyclovir is recommended.

Medical Spanish Word of the Day: la culebrilla (lah koo-leh-BREE-yah) = shingles

Ophthalmology/ID Summit!

We had our very first Ophthalmology/Infectious Disease “summit” yesterday at Morning Report at the VA! It was a fascinating case of endogenous endophthalmitis presented by one of our prior preliminary medicine interns turned Ophthalmologist Dr. Sally Baxter! Briefly, a 35 year old man with history of heroin abuse presented with a painful red right eye that developed over 3 days, associated with reduced vision. The Ophthalmology team described their sophisticated exam findings examining all portions of the eye. The patient was noted to have signs of panuveitis and likely endophthalmitis. Vitreous tap was performed for culture and patient was started on broad spectrum antibiotics. CT head and MRI orbits obtained to r/o invasive disease Blood cultures yielded polymicrobial growth. TTE/TEE performed without any signs of vegetations. Ultimately patient left AMA and was lost to follow-up. Exogenous endophthalmitis can be caused by trauma or after surgical manipulation. However, the DDx for endogenous endophthalmitis is broad and includes multiple infectious etiologies (fungal, viral,

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