Case (38)

[Yaxya]

A 54 years old WM presents at your office complaining of 48 hrs. intermittent left-sided chest pain. When asked to describe his symptoms, he reports intermittent episodes of deep, burning, lancinating pain localized to his left substernal region and radiating in a band-like fashion to his back. The pain has been non-responsive to sublingual nitroglycerin. Pertinent past history reveals a recent CABG.

Review of systems reveals fatigue, malaise and a mild headache. He denies cough, palpitations, shortness of breath, nausea, diaphoresis, lightheadedness or radiation of the pain to his left arm.

On examination, temperature and vital signs are normal. Systems exam is normal, notably, cardiac and pulmonary systems are unremarkable. His left ribs are slightly tender to palpation. An EKG shows nonspecific ST-T wave changes.

You admit him to the hospital for observation and investigation, including cycling of his cardiac enzymes. He is discharged the next day with a diagnosis of musculoskeletal pain and a prescription for Motrin.

He calls your office 24 hrs. later, complaining of a "new drug rash" which he attributes to the motrin. You tell him to stop the medication and see him that same day. On exam, he now has a cutaneous eruption, which is limited to the left side of his chest and extends in a narrow band of erythema from his xiphoid process to the midline of his back . The eruption consists of closely grouped vesicles on a coalescent erythematous base .
1-what is the most probale diagnosis?
2-what's the differntial diagnosis?
3-how to manage?

[Doctoor]

Yaxye, I think your patient has Herpes Zoster (shingles) because of:
-Burning, lancinating pain often is neurogenic in origin
-Radiating pain in a brand-like fashion to the back, also goes with pancreatitis but no other symptoms to suport this option
-Unilateral cutaneous eruption, which consists of closely grouped vesicles on a coalescent erythematous base is pathognomonic in our case

Angina/MI or Other dermatological conditions like herpes simplex and molluscum contagiosum may be differential diagnosis

Herpes zoster usually disappears on its own, and may not require treatment except for symptom relief, such as pain medication.
Acyclovir is an antiviral medication that may be prescribed to shorten the course, reduce pain, reduce complications, or protect an immunocompromised individual.
Hope this is the answer

[Yaxya]

thanks doctoor ur answer is correct