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A 55-Year-Old Man With a Painful Rash on the Sole of His Foot

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

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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Article Information

Corresponding Author: Ramya Vangipuram, MD, Center for Clinical Studies, 451 N Texas Ave, Webster, TX 77598 (rvangip@gmail.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.

References
1.
Creed  R, Satyaprakash  A, Tyring  SK. Varicella-zoster virus. In: Tyring  SK, Yen Moore  A, Lupi  O, eds.  Mucocutaneous Manifestations of Viral Diseases. Cornwall, UK: Informa Healthcare; 2010:98-122.
2.
Schmader  K.  Herpes zoster.  Clin Geriatr Med. 2016;32(3):539-553.PubMedGoogle ScholarCrossref
3.
Hernandez  PO, Javed  S, Mendoza  N, Lapolla  W, Hicks  LD, Tyring  SK.  Family history and herpes zoster risk in the era of shingles vaccination.  J Clin Virol. 2011;52(4):344-348.PubMedGoogle ScholarCrossref
4.
Whitley  RJA.  A 70-year-old woman with shingles: review of herpes zoster.  JAMA. 2009;302(1):73-80.PubMedGoogle ScholarCrossref
5.
Hernandez  PO, Javed  S, Mendoza  N, Lapolla  W, Hicks  LD, Tyring  SK.  Family history and herpes zoster risk in the era of shingles vaccination.  J Clin Virol. 2011;52(4):344-348.PubMedGoogle ScholarCrossref
6.
Decroix  J, Partsch  H, Gonzalez  R,  et al; Valaciclovir International Zoster Assessment Group (VIZA).  Factors influencing pain outcome in herpes zoster: an observational study with valaciclovir.  J Eur Acad Dermatol Venereol. 2000;14(1):23-33.PubMedGoogle ScholarCrossref
7.
Wood  MJ, Johnson  RW, McKendrick  MW, Taylor  J, Mandal  BK, Crooks  J.  A randomized trial of acyclovir for 7 days or 21 days with and without prednisolone for treatment of acute herpes zoster.  N Engl J Med. 1994;330(13):896-900.PubMedGoogle ScholarCrossref
8.
Whitley  RJ, Weiss  H, Gnann  JW  Jr,  et al; The National Institute of Allergy and Infectious Diseases Collaborative Antiviral Study Group.  Acyclovir with and without prednisone for the treatment of herpes zoster: a randomized, placebo-controlled trial.  Ann Intern Med. 1996;125(5):376-383.PubMedGoogle ScholarCrossref
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