Page 17 - Journal of Special Operations Medicine - Summer 2016

Table 1 Differential Diagnosis was also given tramadol 50mg by mouth every 6 hours
Herpes zoster (shingles) as needed for pain from his neuralgia.
Varicella zoster (chicken pox) Postherpetic neuralgia is the most common complica-
Bedbugs tion of herpes zoster, but this is uncommon in young
8
Contact dermatitis immunocompetent patients. Herpes zoster is neither
Cellulitis contagious nor debilitating, so no duty limitations were
Fungal infection placed on the patients.
Allergy Although the patients had no risk factors for contract-
ing herpes zoster infection, acute stress can weaken the
immune response and make patients more susceptible to
symptoms of burning or tingling pain along a dermato- such infections. Stress can come from multiple sources
mal distribution before manifestation of a rash in a deployed environment:

Herpes zoster is not contagious and cannot be trans- • Physical stress from physical exertion and exhaustion
mitted from person to person. Approximately 32% of • Environmental stress from living in austere environ-
the US population will experience herpes zoster in their ment with poor living conditions and few amenities
lifetime, with the rate increasing after age 50 years, and • Emotional stress from relationships
the majority of cases after age 80 years. The biggest risk • Mental stress from upcoming redeployment and un-
2
factors for herpes zoster include age, female sex, under- certainty from a flexible mission
lying malignancy, disorders for cell-mediated immunity,
and chronic lung or kidney disease. 3,4 Deployed providers should consider this herpes zoster
diagnosis in any Soldier who had varicella zoster as a
Herpes zoster can involve the nasociliary branch of the child and presents with the classic prodromal symp-
ophthalmic nerve. If vesicles are present on the eyelids toms, vesicular rash that is localized to a dermatome
and tip of the nose, the patient is at risk for herpes zoster and does not cross midline, and neuralgia.
ophthalmicus, which can lead to blindness. Examina-
5
tion of the eye with fluorescein may be helpful to iden- Disclaimer
tify involvement. In addition to antiviral therapy and
pain management, these patients require priority medi- The view(s) expressed herein are those of the author(s)
cal evacuation. and do not reflect the official policy or position of the
US Army Medical Department, the US Army Office of
Involvement of the vestibulocochlear nerve is known as the Surgeon General, the Department of the Army and
Ramsay Hunt syndrome. This manifests as ipsilateral Department of Defense, or the US Government.
facial paralysis, ear pain, vertigo, and vesicles in the au-
ditory canal and auricle. Taste perception, hearing, and Disclosures
lacrimation may also be affected. 6,7
The authors have nothing to disclose.
This case appears to be the classic case of herpes zoster
in two (and potentially four) young, healthy Soldiers. References
They were all getting ready to redeploy and to see their
families, possibly causing increased stress. 1. US Special Operations Command. Special Operations Forces
medical handbook. 2nd ed. Washington, DC: US Government
Printing Office, 2008.
Conclusion 2. Hope-Simpson RE. Postherpetic neuralgia. J R Coll Gen Pract.
1975;25:571–575.
These cases and images were presented to the dermatolo- 3. McDonald JR, Zeringue AL, Caplan L, et al. Herpes zoster
gist at the Uniformed Services University of Health Sci- risk factors in a national cohort of veterans with rheumatoid
arthritis. Clin Infect Dis. 2009;48:1364–1371.
ences in Maryland via the Telemedicine Teleconsultation 4. Thomas SL, Hall AJ. What does epidemiology tell us about risk
Program. The staff dermatologist agreed that these cases factors for herpes zoster? Lancet Infect Dis. 2004;4:26–33.
were classic for shingles, and it was most likely by chance 5. Sjaikh S, Ta CN. Evaluation and management of herpes zoster
that two healthy Soldiers contracted it at the same time. ophthalmicus. Am Fam Physician. 2002;66:1723–1730.
Both Soldiers were started on a 1-week course of antivi- 6. Adour KK. Otological complications of herpes zoster. Ann
Neurol. 1994;35(suppl): S62–64.
ral therapy to shorten the disease course. Valacyclovir 1g 7. Mishell JH, Applebaum EL. Ramsay-Hunt syndrome in a pa-
by mouth three times a day was started with progressive tient with HIV infection. Otolaryngol Head Neck Surg. 1990;
resolution of the herpetic rash and pain. The first patient 102:177–179.

Herpes Zoster Outbreak 3