Photo Rounds Friday Archive
Rash on chest
Post Date: 09/04/09
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A 29-year-old woman came in with a rash that she’d had for 2 days. She felt a bit feverish; her temperature was 99.9º F. Her husband--a physician--did not have a rash or fever. On close inspection of the rash, there were a few vesicles and papules. Her lungs were clear and there were no other signs of infection.
What's your diagnosis?
We suspected that this was a mild case of varicella. The patient’s previous history of varicella in childhood was uncertain, so we did a direct scraping of a lesion. A direct fluorescent antibody test confirmed our suspicions.
Unvaccinated adults who never had a childhood varicella infection are at risk for chicken pox and the complication of varicella pneumonia. Pneumonia is rare in otherwise healthy children with varicella, but accounts for the majority of hospitalizations in adults with chicken pox. Varicella pneumonia has up to a 30% mortality rate. It usually develops insidiously, within a few days of the rash. Signs and symptoms include progressive tachypnea, dyspnea, and dry cough. Chest x-rays reveal diffuse bilateral infiltrates. Prompt treatment with intravenous acyclovir is key.
While antiviral medications are not needed for all cases of chickenpox, it may be worthwhile to offer antiviral medications to all adults with varicella. This patient was offered antiviral medications and she chose to start a course of oral acyclovir. She did well and had no complications from the disease or the medication.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ. Chicken pox. In: Usatine R, Smith M, Mayeaux EJ, Chumley H, Tysinger J, eds. The Color Atlas of Family Medicine. New York, NY: McGraw-Hill; 2009: 489-492.
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