Case Of The Week – Ear Rash

This 80 year old gentleman renal transplant patient presented with confusion, hallucinations, rash and ear pain.

Describe and diagnose the rash.

There is a vesicular crusted rash to the ear lobe and canal consistent with shingles.
We can see a similar vesicular eruption over the whole left side of his face.
This suggests varicella zoster (shingles) virus infection of his left facial (VII) and vestibulocochlear (VIII) cranial nerves.
We might expect to find facial weakness (like Bell’s Palsy), hearing loss, tinnitus and vertigo on the affected side.

The confusion and hallucinations with this rash is concerning for herpes encephalitis (a complication of herpes virus infection), more common in immunocompromised patients such as this gentleman.

How should this patient be managed?

Investigations – MRI brain prefered. CT +/- contrast if MRI unavailable

LP unless contraindicated (concern for raised ICP/coagulopathy)

Bloods, BSL, BC as appropriate to rule out other conditions

Treatment

Resuscitation – no acute airway or haemodynamic concerns so resuscitation not required

Supportive treatment – Analgesia, monitoring, treat seizures/agitation

Targeted treatment – Aciclovir 10mg/kg tds
Antibiotics if meningitis a possibility

Disposition – This patient will need goals of care discussion and transfer to a centre with ICU and Neurosurgery available. His Transplant Team should be closely involved in decision making.

Untreated the mortality of herpes encephalitis is up to 70% (more so in the frail), and even treated 20% of patients die, and 25% are left with neurological morbidity such as seizures or neuropsychiatric symptoms.