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A 55-year-old man with hypertension and hypercholesterolemia presented to the clinic with a 6-day history of a painful rash on the sole of his right foot. He described the pain as akin to stepping on a sharp object and characterized it as moderately intense, sharp, continuous, and without radiation. After first noticing the pain, he had examined the inside of his boot but did not identify anything that would account for the tenderness. He reported no fevers, chills, or malaise. He denied history of human immunodeficiency virus (HIV), hepatitis, chickenpox, or recurrent infections. His medications included amlodipine, hydrochlorothiazide, and ezetimibe. He worked outdoors for an oil drilling company. He denied recent travel out of the country. Physical examination revealed 2- to 3-mm grouped vesicles on an erythematous base in a discrete area of the sole of the right foot (Figure) and no additional rashes elsewhere on the body. Vesicular fluid was sent for analysis.
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Acute herpes zoster (shingles) infection
B. Initiate antiviral therapy with valacyclovir
The key to diagnosis in this case is an eruption on the sole of the foot that appeared clinically consistent with herpes zoster. He had no systemic symptoms of or risk factors for septic emboli; thus, blood cultures would not be of diagnostic utility. Occupational exposure and the sudden onset of severe pain may have been suggestive of an arthropod bite; however, the patient denied such a history. Dyshidrotic eczema often presents as a vesicular rash on the plantar surface and can be treated with topical corticosteroids or oral antihistamines; however, the painful and nonpruritic nature of the rash makes this diagnosis less likely.
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Corresponding Author: Ramya Vangipuram, MD, Center for Clinical Studies, 451 N Texas Ave, Webster, TX 77598 (email@example.com).
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Additional Contributions: We thank the patient for providing permission to share his information.
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