111111 - showman

[ArchivalUser]

A 46-year-old man comes to see you because of a recurrent skin infection. He regularly sees a different doctor, but has recently become dissatisfied with that physician™s care. He states that the doctor told him he had herpes zoster and treated him with valacyclovir. The infection recurred a couple of months later, however, and this time involved his entire back, whereas previously it occupied only one small sliver of his right lumbar area. Again he took valacyclovir and the rash resolved, though the pain continued for a month after the resolution of the rash. He once again has a recurrent rash and pain, this time from his nipples to his belly button. He additionally wishes to be treated for a rash on his face that he has had for the last few months. His past medical history is unremarkable for any major illnesses. He reports, however, that he has recently had some lingering œcolds, and in the early 1980s had an episode of gonorrhea. He smokes one pack of cigarettes per day, drinks 5 to 6 beers per weekend, and used cocaine and heroin in the 1970s. His temperature is 37.0 C (98.6 F), blood pressure is 135/72 mm Hg, pulse is 79/min, and respirations are 20/min. He has a diffuse erythematous rash involving most of the face. Yellow-orange, scale-forming plaques are evident on the upper lip, cheeks, nasolabial fold, and eyebrows. His eyebrows and scalp display a moderate amount of flaking and seborrhea. Oral examination reveals a small amount of grayish-white material on the lateral aspects of the tongue, which are easily removed with a tongue blade. Examination of the patient™s chest reveals multiple vesicles on erythematous bases that extend from his nipples to slightly past the umbilicus. Both flanks and part of the back are also involved. The rest of the examination is normal. Which of the following is the most likely underlying cause of this patient™s problems?

A. Complement deficiency
B. Deficiency in B cells
C. Deficiency in T cells
D. Granulocyte deficiency
E. Valacyclovir-resistant zoster

[ArchivalUser]

ccc

[ArchivalUser]

C.

[ArchivalUser]

C..

[ArchivalUser]

The correct answer is C. This patient is likely to be HIV-positive. Multidermal zoster is extremely uncommon in immunocompetent persons. Severe seborrheic dermatitis and thrush, both present in this patient, are also more common in patients with HIV. This patient has multiple risk factors, including intravenous drug use and a history of a sexually transmitted disease. He should be tested for HIV.

Complement deficiency (choice A) is rare. It often manifests as recurrent Neisseria infections. The Neisseria capsule requires complement-mediated lysis.

B-cell deficiencies (choice B) often present at a young age. Specific immunoglobulin deficiencies, however, are not as rare in adult patients, most commonly IgA deficiency. IgA deficiency presents as recurrent respiratory and gastrointestinal infections.

Granulocyte deficiency (choice D) in adult patients is most often related to malignancy, either the cancer or its treatment. Functional deficiencies of granulocyte activity, such as chronic granulomatous disease and Chediak-Higashi syndrome, are rare new diagnoses in adult populations.

Valacyclovir resistance (choice E) is rare. It is not uncommon for zoster to recur after treatment, as the organism is rarely eradicated. Multidermal zoster, however, should prompt one to think of immunodeficient states, particularly HIV.