This is an active learning exercise in which the clinical relevance of an illustrative example of a herpesvirus infection is discussed.

 

Prior to the class you should, through independent study understand the terms used in the case  study become sufficiently knowledgeable on the subject    to participate in the discussion attempt to answer the learning objective questions

 

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 in a dermatomal distribution. The eruption consists of closely grouped vesicles on a coalescent erythematous base (see photograph).

 

Learning Objectives What is your leading diagnosis, and what is its pathophysiology? Why are cardiac enzymes measured, what are they and what does the term "cycling" refer to? What are the risk factors associated with occurrence of this disease? How would you confirm the diagnosis? If this patient's disease involved the right side of his forehead, and the tip and side of his nose, what additional studies would be needed? How would you treat this "chest pain" patient? Your patient would like to know if he can safely baby-sit for his daughter, who in addition to having a four-year old son is currently in her first trimester of pregnancy. What do you tell him?

 

1. What is your leading diagnosis, and what is its pathophysiology?

 

2. Why are cardiac enzymes measured, what are they and what does the term "cycling" refer to?

 

3. What are the risk factors associated with occurrence of this disease?

 

4. How would you confirm the diagnosis?

 

5. If this patient's disease involved the right side of his forehead, and the tip and side of his nose, what additional studies would be needed?

6. How would you treat this "chest pain" patient?

 

7. Your patient would like to know if he can safely baby-sit for his daughter, who in addition to having a four-year old son is currently in her first trimester of pregnancy. What do you tell him?

 

Refer to DOIA at www.dermis.net with links and a standard, up to date medical textbook, e.g. Harrison’s Principles of Internal Medicine.

Case study compiled for CUNY Medical School Department Microbiology and Immunology by G. M. Lipper, M.D., Harvard Medical School Dept. of Dermatology.