Question of the Week # 176

Q176) A 48 Year old woman is evaluated in your office for a skin eruption that appeared few days ago. She has a history of Non-Hodgkin’s lymphoma that was treated 2 years ago and is in remission. A PET ( positron emission tomography) scan that was performed 3months ago did not reveal any evidence of recurrent disease. She also reports recurrent episodes of genital herpetic lesions which  resolve spontaneously. Her most recent genital herpetic eruption was 4 weeks ago and it was self-limited. At this time, she is concerned about a skin eruption that is predominantly distributed on her arms, hands and feet.  On examination, there is no peripheral lymphadenopathy. Genital examination is normal with out any vesicles or papules. Skin examination reveals the lesions as shown in the image below.

The most appropriate management option for this patient:

A)     Observation

B)      Repeat PET/CT scan

C)      Start Acyclovir

D)     Biopsy of the lesion

E)      Start antihistamine

15 Responses

  1. ccccccccc

  2. The rash is asymptomatic—It must be either skin eruption from meds or a sign of the disease process. This isnt herpes. I would either observe to see if it gets worse or biopsy to see what it is

  3. Answer please

  4. A, Just observe

  5. Erythema exsudativum multiforme minor, erythema iris.

    answer is E

  6. Again, its caused my HSV – Eryth. Multiforme… start acyclovir!

  7. Suppression of herpes simplex virus (HSV) can prevent HSV-associated erythema multiforme, but antiviral treatment started after the eruption of erythema multiforme has no effect on the course of the erythema multiform
    AnswerE

  8. Observe this patient, that’s all. The treatment of EM 80% of the time is observation!

  9. patient has no pruritus or symptoms whatsoever . Why give medication ?? Herpes has resolved. No point in giving acyclovir . I would just say observed . If symptoms worsen , consider tx.

    Just my 2 cents 🙂

  10. Mild symptom, first time, diagnosed herpes – observe (not this case)
    Severe symptom, recurrent, diagnosed herpes – acyclovir (this case)
    Compelling additional reason – this patient is on long term immunosuppressants for NHL and he needs more aggressive treatment of disease. Answer, I think should be to start acyclovir (c)

    • Wrong boss! Reason- The patient is in remission and there is no evidence of recurrent disease. Moreover, this patient currently does not have herpes, he has erythema multiforme alone and acyclovir only stops herpetic lesions at the time of presentation. There’s no point taking acyclovir when there are no herpetic lesions present!

      Answer is OBSERVATION.

      • Wrong boss – a very confusing rant; happy & gay perhaps? I wouldn’t be the judge of that. Let Archer alone blow the whistle.
        Remission – paucity of evidence that PET CONFIRMS absence of disease even though the test has high Negative predictive value in surveillance screening.(1)
        Recurrent – One uses that term specifically to imply more than 6 episodes in a year. You don’t agree with the patient’s report but do you agree that she has asymptomatic herpes? Or do you wish to culture confirm first or you wish to wait for more episodes of clinical genital herpes in her? I do not say that is wrong but observation without preventive intervention at this time is not what I will do. I accept that this patient was diagnosed with herpes and she has recurrent form of the disease. Prophylactic acyclovir against recurrent herpes and Recurrent EM has been shown by research to lower annual recurrence rate and it have no significant toxic effect in ‘normal adults’ (patient in ‘remission’)(2) (3).
        But most importantly, this is a preventive health issue. This patient is a carrier who is not on treatment. Without signs of infection, this patient can infect sexual partners 10% of the time(4). Prophylactic use of acyclovir is safe even in severely immunocompromised hosts(5). Asymptomatic viral shedding is the most common mode of transmission and did you know that this occurs through infected saliva as well?(6) Suppressive acyclovir therapy reduces these risks by 50% (6). The prolonged continous Acyclovir Study showed that suppressive therapy alone decreases the annual recurrence rate from 12 recurrences to 1 during the third year(2). The statement, ‘ there is no point starting acyclovir without clinical lesions’ is certainly undermining the use of prophylactic treatment in this patient. Like a religion, I would like to prevent recurrences, both of herpes and EM. My comrades may prefer to prevent prolonged systemic acyclovir prophylaxis. Eventually the patient decides whether to start antivirals or to live with herpes but this is still a serious public health issue down played by epidemiological data and government policy. It is a notifiable disease in Australia but not US and many countries. I rest my case.

        (1) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3227521/
        (2) http://www.ncbi.nlm.nih.gov/pubmed/1990191
        (3) http://www.ncbi.nlm.nih.gov/pubmed/7888365
        (4) http://www.webmd.com/genital-herpes/news/20110412/genital-herpes-silent-spread
        (5) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1548921/
        (6) en.wikipedia.org/wiki/Herpes_simplex

      • Correct. Recurrent EM from HSV can only be treated by treating HSV

    • Erythema multiforme is frequently self-limiting and requires no treatment.– EM is self limited, hypersensitivity reaction to infections (coccidioidomycosis, herpes simplex, histoplasmosis, leprosy, mycoplasma, typhoid), drugs (penicillin, phenylbutazone, phenytoin, salicylates, sulfa), carcinoma / lymphoma, or collagen vascular disorders–
      This Pt has several possible causes of EM not only herpes EM is a skin condition of unknown cause, usually follows an infection or drug exposure—so do not assume that the cause is Herpes and treat herpes, or provide prophylaxis to herpes which is not acyclovir as far as I know the correct prophylaxis is the Vaccine—for Test mode answer is Observation — In real life you can give whatever you want —this Question the Pt comes for skin eruptions (target lesion) not for genital herpes, Non-Hodgkin’s lymphoma – so no need to Tx with acyclovir or chemotherapy for his past lymphoma and herpes —

  11. PET scan does not rule out relapse.

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