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Crystal-induced nephropathy
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Hepatotoxicity
Long-term pain
Nausea
Stevens-Johnson syndrome
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This patient who presents with a localized vesicular rash in a dermatomal distribution has herpes zoster. The most common complication of herpes zoster is postherpetic neuralgia; or long-term nerve pain. Herpes zoster, or shingles, is caused by the reactivation of the varicella-zoster virus (VZV) in the dorsal root ganglia. Herpes zoster first presents with nonspecific symptoms, after which a characteristic vesicular rash appears in a dermatomal distribution. Eventually, the vesicles crust over, and the rash resolves after several weeks. The treatment for herpes zoster includes a guanosine analogue such as acyclovir, valacyclovir, or famciclovir. The most common complication of herpes zoster is postherpetic neuralgia, which is persistent pain after resolution of the rash. Postherpetic neuralgia is due to nerve damage, which can produce burning or electric pain. Postherpetic neuralgia can be symptomatically managed with topical capsaicin or lidocaine, or oral amitriptyline, gabapentin, or pregabalin. Both herpes zoster and postherpetic neuralgia can be prevented with the adjuvant recombinant VZV vaccine, which is recommended for individuals 50 years of age and older. Saguil et al. provide a review of herpes zoster and postherpetic neuralgia, including the oral and topical options for managing postherpetic neuralgia. The authors note that the VZV vaccine can decrease the incidence of herpes zoster. The authors recommend the live attenuated vaccine be avoided in immunocompromised patients. However, the recombinant zoster vaccine is recommended to be given to immunocompromised patients 19 years of age or older. Figure/Illustration A demonstrates a localized maculopapular rash with scattered vesicle formation (yellow circle). The rash follows a dermatomal distribution (black lines) and does not cross the midline. Incorrect Answers: Answer 1: Crystal-induced nephropathy is a possible adverse event of acyclovir use. Acyclovir is excreted in the urine but has low urine solubility. Therefore, acyclovir use, especially in the setting of volume depletion or concurrent use of other nephrotoxic drugs, can result in crystal accumulation causing obstructive nephropathy. Answer 2: Hepatotoxicity is a possible adverse effect of acetaminophen use. Acetaminophen is an adjunctive treatment used for the symptomatic management of pain associated with herpes zoster. Answer 4: Nausea is a possible adverse effect associated with treatment, including with oral guanosine analogues, acetaminophen, or corticosteroids. Corticosteroids can be used as adjunctive therapy to decrease the healing time of the lesions in herpes zoster. Answer 5: Stevens-Johnson syndrome (SJS) can be associated with oral guanosine analogues; however, it is not the most common complication of herpes zoster. SJS presents with blistering and peeling of the skin and mucus membranes. Bullet Summary: Herpes zoster is caused by reactivation of the varicella-zoster virus, and the most common complication of this disease is postherpetic neuralgia due to nerve damage.
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