CITW 6: A Clumsy Foot

Welcome back to another Clinical Image of the Week from the case files of the Brown EM Residency!

HPI: 74 y/o male with multiple medical problems who presents to the ED with four days of left leg pain, left foot numbness, and a new left foot drop. Additionally, his wife points out that she has noticed a new rash extending up his left foot and leg. He denies any fevers, chills, recent infections or trauma to the leg.

Vitals: BP 157/72, HR 77, T 98.8 °F, RR 16, SpO2 97 % on RA

Notable PE: Numbness and rash (see below) noted on the dorsal aspect of the left foot, extending up the lateral aspect of the left leg to the knee. 3/5 strength with dorsiflexion of the left foot.

Rash 1
Rash 2
What’s the diagnosis?


Here are some quick facts:

  • Shingles is reactivation of latent herpes zoster within sensory ganglia resulting in painful, vesicular lesions in a specific dermatomal distribution (typically thoracic or lumbar).
  • Zoster keratitis is involvement of the opthalmic branch of the trigeminal nerve and is an opthalmologic emergency (sight threatening).
  • Ramsay Hunt Syndrome is a polycranial neuropathy: Ipsilateral facial droop, ear pain, and lesions in the auditory canal.
  • Prodromal pain the same dermatomal distribution can precede the rash by days to weeks.
  • In an immunocompetent host, lesions are typically found in just one dermatome, crust by 7-10 days (no longer contagious), and having  more than one episode is rare.
  • Complications include post-herpetic neuralgia, bacterial super infection, central spread (meningitis/encephalitis), or motor neuropathies (as this patient had).
  • Immunocompromised hosts are at risk for cutaneous dissemination (multiple dermatomes, crossing the midline) and visceral involvement.

How is this managed:

  • If presenting within 72 hours of lesion development, valacyclovir (1,000 mg) TID for seven days, which is preferred over acyclovir due to a better dosing schedule.
  • Oral analgesics for pain control.

Case Conclusion:

  • Patient was sent home on valacyclovir with neurology, infectious disease, and primary care follow up.

Shout out to Dr. Fischer for this case!

The contents of this case were deliberately altered to protect the identity of the patient. All content in this report are for educational purposes only. The patient consented to the use of these images.

See you next week!

Source: UptoDate

4 thoughts on “CITW 6: A Clumsy Foot

  1. Yes. The interesting thing about this case is the MOTOR symptoms, which you usually don’t see with zoster. It can happen, though. As you can see from the image, it’s most likely in the L5 dermatome.

  2. Great case. One thing to always remember is to “get down to the skin” when you have strange or neuropathic pain. The last Zoster case I saw with a resident was intense chest wall neuropathic-type pain in a woman. The EM resident looked at her back and side and didn’t see lesions. Alas, under her bra and hidden by overlapping breast tissue was a patch of fresh vesicular lesions on an erythematous base. Also, remember the pain can precede the lesions, so if you have mysterious intense pain, tell the patients to look for lesions in the next few days.

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