Can You Diagnose This Condition?
March
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A 66-year-old man presents to the emergency department with a facial droop. His symptoms started last night and have worsened since then. His temperature is 99.0°F (37.2°C), blood pressure is 135/84 mm Hg, pulse is 76/min, respirations are 19/min, and oxygen saturation is 99% on room air. Physical exam reveals a right-sided facial paralysis that involves the forehead. Exam also reveals the finding shown above. Which of the following is the most appropriate treatment for this patient?
A) Acyclovir and prednisone
B) Ceftriaxone and vancomycin
C) Cephalexin
D) Prednisone
Answer: Acyclovir and prednisone
Herpes zoster oticus, also called Ramsay Hunt syndrome, is an otologic manifestation of herpes zoster. It occurs when there is a reactivation of varicella-zoster virus in the geniculate ganglion of cranial nerve VII (though other cranial nerves, including VIII and IX, may be involved). It presents with the classic triad of ipsilateral facial paralysis, pain in the ear and ear canal, and vesicles in the auditory canal and auricle. This form of Bell palsy is different from other forms as it has the characteristic skin lesions seen with herpes zoster. Contrast this to the skin lesion seen in Lyme disease (erythema migrans) or the absence of skin findings in idiopathic cases. Other common symptoms include altered taste, lesions on the tongue, and hyperacusis. The diagnosis can be made clinically with the classic presentation and rash. Treatment must include acyclovir, which improves outcomes. Steroids may be administered and might improve neurologic outcomes with mixed evidence. Complications of Ramsay Hunt syndrome include permanent neurologic dysfunction (facial weakness) and chronic neuropathic pain. Outcomes in Ramsay Hunt syndrome are generally worse when compared to other causes of Bell palsy.
Ceftriaxone and vancomycin (B) are antibiotics that can be used for more extensive skin infections, as this regimen covers for gram-negatives, gram-positives, and methicillin-resistant Staphylococcus aureus. It would be indicated if there was a superinfection in the setting of herpes zoster oticus. Cephalexin (C) is commonly prescribed for cellulitis, which presents with erythema, warmth, and tenderness over the skin. Prednisone (D), eye lubrication, and taping the eye shut at night is the appropriate management of a Bell palsy that is not clearly caused by herpes zoster. However, in the setting of an active herpes zoster infection, acyclovir should be given.
February
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A patient presents after being bitten by a rattlesnake. Which of the following findings would be consistent with this envenomation?
A) Fasciculations
B) Respiratory paralysis
C) Slurred speech
D) Thrombocytopenia
Answer: Thrombocytopenia
Crotalinae envenomations can be caused by bites from snakes such as rattlesnakes, cottonmouth snakes, copperhead snakes, sidewinders, and water moccasins. The venom of a crotalid damages local tissues and leads to tissue destruction and can activate the coagulation cascade. Initial care should be focused on evaluating and irrigating the wound as well as removing any retained foreign bodies, such as fangs. If the wound cannot be explored, then a radiograph may be needed to rule out retained bodies. Incising the wound and attempting to suck out the venom is not indicated. Further care involves laboratory studies, including a CBC, chem-10, and coagulation labs. Laboratory derangements may include thrombocytopenia, a prolonged PT and PTT, a decreased fibrinogen, and an elevated D-dimer. The constellation of all these findings would suggest disseminated intravascular coagulation (DIC). The extremity should be examined and elevated. Care should be taken to evaluate for compartment syndrome, which presents with severe pain of the affected extremity that is worsened with passive range of motion of that extremity. Further management may require crotalid monoclonal antibody administration. Patients should then be admitted for observation and further care.
Fasciculations (A), respiratory paralysis (B), and slurred speech (C) are seen with Elapidae envenomations from snakes such as the coral snake. Coral snakes release a potent neurotoxin, and often the bite is minimally painful. Life-threatening sequela includes respiratory failure requiring intubation.
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