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Herpes Zoster: Pain Now, Rash Later

Herpes Zoster: Pain Now, Rash Later


Figure 1 – This erythematous papulovesicular rash, consistent with herpes zoster, developed on the medial aspect of the left thigh, leg, and foot of a 5-year-old boy the day after he presented with leg pain.

A 5-year-old boy was brought for evaluation of left leg pain. He had awoken with the pain 2 days earlier. He identified an area just above the medial malleolus as most painful. The pain worsened with movement (eg, walking) and was alleviated minimally with acetaminophen and ibuprofen. There was no history of trauma. By age 4, the child had received all appropriate immunizations except for the second dose of varicella vaccine; he had received the first dose at the age of 1 year.

The boy was crying and would not bear weight on the left leg. His weight was 16.8 kg (37.0 lb; 25th percentile); temperature, 36.5°C (97.6°F); blood pressure, 88/63 mm Hg; respiration rate, 24 breaths per minute; and heart rate, 114 beats per minute. He had a 5-mm lesion that looked like a scab on the medial aspect of the left leg. The hip and knee joints were slightly flexed. There was no swelling or erythema and no limitation of joint movement.

The clinical impression was that of leg pain of unknown etiology. Radiographs of the hip, knee, and ankle were normal. Complete blood cell count revealed a total white blood cell (WBC) count of 9600/μL, with 66.5% neutrophils and 26.8% lymphocytes. The platelet count was 529,000/μL, and erythrocyte sedimentation rate was 4 mm/h. An oral analgesic was prescribed, and follow-up was scheduled in 2 days.


Figure 2 – A similar rash was noted on the left side of the lower back at the level of L3 to L4. Polymerase chain reaction analysis of fluid from one of the vesicles was positive for herpes zoster.

At follow-up, it was noted that the pain had continued and that an erythematous papulovesicular rash had developed on the medial aspect of the left thigh, leg, and foot (Figure 1). There was a similar rash on the left side of the lower back at the level of L3 to L4 (Figure 2). Polymerase chain reaction (PCR) analysis of fluid from one of the vesicles was positive for herpes zoster.

Further questioning revealed that the child had had no previous illness suggestive of chickenpox and had no contact with anyone with chickenpox or shingles. He was treated with oral acyclovir (30 mg/kg/d) in addition to an oral analgesic. Within 3 days, he was pain-free. One week later, the lesions had scabbed over; serum immunoglobulin levels were within normal limits.

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