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Transcript
Running head: CASE STUDY: HERPES ZOSTER IN A PATIENT WITH CLL
Case Study: Herpes Zoster in a patient with CLL
Cornelia C. Campbell
Washburn University
Specialty Practicum II
NU607
Dr. Bobbe Mansfield
March 01, 2012
1
CASE STUDY: HERPES ZOSTER IN A PATIENT WITH CLL
2
Demographic information
A Caucasian female, aged 59 years & 4 months was seen in a primary care setting (this initial encounter is
hereafter referred to as PC#1). She presented with a complaint of intractable pain and tenderness over her left
buttock, groin and labia majora.
Past Medical/Surgical History
The patient’s past surgical history includes several lymph node biopsies (needle biopsy x4, and incisionbiopsy x1) and a single bone marrow aspiration. Her past medical history is remarkable for:
Concern
Age / Timeline
Suspicious skin lesion
41 years
Intra-mammary
54 years
lymphadenopathy
(axillary tail of left breast)
Symptomatic left axiliary 56 years
lymphadenopathy
Bilateral, symptomatic
axillary & supraclavicular
lymphadenopathy
Acute thrombocytopenia
secondary to CLL
57 years
Isolated outbreaks of cold
sores (herpes simplex 1
virus)
11 months
preceding PC#1
encounter
3 months later
Outcome / Implication
Pathology = benign seborrheic keratosis
Deemed secondary to cat scratch injury.
Spontaneous resolution
Needle biopsy & pathology: atypical lymphoid
proliferation suspicious of low grade lymphoma
Oncology consult & staging work-up: Diagnosed with
malignant lymphoma, non-Hodgkin, small lymphocytic,
CD20 positive – stage 2A.
Lymph node biopsies & bone marrow aspiration.
Progression to chronic lymphocytic lymphoma (CLL) with
peripheral blood lymphocytosis
Started chemotherapy: 5 cycles of 3 days each over total of
5 months. Completed chemotherapy 6 months prior to
PC#1 encounter
Controlled with systemic Valacyclovir at earliest
presentation of symptoms
Social History (including cultural and spiritual considerations)
The patient lives on a farm in rural north-eastern Kansas, in a single family home shared with her 62 year
old husband of 40 years. The couple is happily married, has lived on the same farm for almost four decades
where they raised three children (now adults & all happily married). Their children and seven grand-children
live within the state of Kansas; one daughter lives in the same rural district. The patient also has extended
family members and many life-long friends who live in the area. She has been a regular, active member of a
local church, adheres to the Christian faith and describes her religious devotion as one of her most valued
CASE STUDY: HERPES ZOSTER IN A PATIENT WITH CLL
3
personal resources. She has established a reputation as an adherent, responsible consumer of health care
services; she exhibits an active interest and regularly participates in the design of her health care. She is able
to make informed treatment decisions and often consults published sources, internet based information sites,
and her health care providers to further expand her knowledge and understanding of health related matters.
She has established ongoing relationships with the staff and providers at the rural health clinic.
The patient’s occupational history includes being the wife of a lifelong farmer and being actively involved
in the management as well as manual labor on the farm. She also worked as an administrative assistant at the
local school and retired in 2008, ending a 20 year career. She describes her career as being fulfilling as well as
stressful at times.
The patient’s lifestyle habits include regular physical exercise and well-balanced meals which often include
produce from her own garden. She consumes small to moderate amounts of coffee and carbonated beverages,
but rarely drinks alcoholic beverages. She denies the use of tobacco products and illicit drugs. She is sexually
active in a monogamous, heterosexual relationship and does not use any birth control as she is postmenopausal. She performs regular, monthly breast self-examinations and skin checks. She feels safe at home
with no concerns of neglect or abuse and has never suffered neglect or abuse. She consistently wears a seat
belt when travelling in a vehicle and uses protective equipment as recommended when engaging in potentially
hazardous tasks or manual labor. She received vaccinations against smallpox, polio, varicella and influenza
as a child and against influenza, tetanus and hepatitis B as an adult.
Family History
The patient’s father died at age 67 years of non-Hodgkin lymphoma. He was otherwise healthy. Her
mother, who also had a history of type 2 diabetes, hypertension (HTN) and coronary artery disease (CAD),
died at age 65 years of a stroke. She has four siblings who are still alive and one brother who died at an early
age (5 years old) of a neurologic malignancy (exact nature unknown to the patient). Her two sisters both have
type 2 diabetes, and the older sister also has asthma and hay fever. Her oldest brother has CAD and the
younger brother is an alcoholic but currently sober. Her grandparents (paternal and maternal) all died of
CASE STUDY: HERPES ZOSTER IN A PATIENT WITH CLL
4
cardiac causes at an older age and to the patient’s knowledge, did not have any other major health concerns.
One maternal aunt died of breast cancer in her late middle-age.
Please refer to Appendix A (figure 1) for a Genogram.
Review of Systems and Physical Examination
During PC#1, the patient presented at the rural health clinic with a complaint of intractable pain and
increased tenderness over her left buttock, groin and labia majora.
A review of symptoms yielded the following information:
a. Constitutional: A good historian with written notes regarding the history of present illness (HPI).
Usually able to perform all activities of daily living (ADLs) without assistance but since onset of
current illness, has required minimal assistance. Previously able to perform instrumental activities of
daily living (IADLs) independently but at this time, is limited in some areas such as driving, shopping
and frequently leaving her home.
b. HEENT: No changes in vision, hearing, smell & taste. Wears corrective lenses for reading and
driving. No congestion, pain or discomfort of associated structures. No vertigo.
c. Respiratory: No shortness of breath, dyspnea, cough, excretions. Not aware of any abnormal breathing
sounds.
d. Cardio-vascular: No chest pain, pressure or discomfort. No palpitations. No syncope.
e. Gastro-intestinal: Slight decrease in appetite but no nausea, vomiting, constipation, diarrhea or bowel
incontinence. Unintentional weight loss of 2 lbs in past 3 months. Able to tolerate a regular diet and
maintain adequate fluid intake. No excessive thirst or hunger and no early satiety. No hematachezia or
melena.
f.
Genito-urinary: No incontinence, urge, frequency. Slight dysuria involving perineal skin but not the
internal urinary tract. No hematuria. No urinary retention or oliguria. Significant tenderness and pain
of left labia majora. No mucosal irritation or dryness.
g. Musculo-skeletal: No changes in strength, range of motion or muscle tone. No joint tenderness or
swelling. No recent falls or trauma and no amputations or contractures.
CASE STUDY: HERPES ZOSTER IN A PATIENT WITH CLL
5
h. Skin: Continued significant tenderness of skin of left buttock, left groin area and now also of her left
labia majora. Reports clusters of vesicular rash, mostly scabbed over. Concerned regarding possible
new lesions or ulceration of existing lesions.
i.
Neurologic: No changes in memory, cognition or reasoning. Occasional headaches – relieved by
acetaminophen. Neuralgia and parasthesia of left buttock, groin and labia majora.
j.
Psychological: Describes herself as emotionally drained but denies hopelessness, depression, inability
to care for self or suicidal ideation.
k. Hematology/Lymphatic: History of Chronic Lymphocytic Leukemia (CLL) with questionable
immune-competence. No recent lymphadenopathy on self-examination and no lymph-tenderness.
Most recent hematology report (2 months prior) demonstrated normal WBC but mild
thrombocytopenia.
l.
Current medications: a list of current medications can be found in Appendix B, table 1.
History of the present illness
The patient presented to the rural emergency department (RED) 10 days prior with a complaint of
intense burning pain of the left buttock area radiating into the left groin since 3 days prior. The
appearance of several small vesicles on her left buttock, had lead her to believe she might be experiencing
an episode of Shingles (Herpes zoster) instead of sciatica-like pain, which had been her first impression.
Upon noticing the rash, she self-medicated with a home supply of Valacyclovir 1000mg once on the
evening and once on the morning before presenting to the RED. At the RED, she gave a history of
previous excellent response to Valacyclovir (when used to treat Herpes simplex viral cold sores). The
diagnosis of Shingles (Herpes zoster due to reactivation of the varicella zoster virus, VZV) was clinically
confirmed and based on her previous good response to this treatment it was decided to continue with the
Valacyclovir 1000mg by mouth every 8 hours for 7 days. She was also started on Lortab 5/325mg 1-2
tablets every 4 -6 hours as needed for pain relief but has only taken limited quantities to reduce intense
pain and not to pro-actively manage her pain.
CASE STUDY: HERPES ZOSTER IN A PATIENT WITH CLL
6
During encounter PC#1, the patient reported symptom improvement (rash, burning & pain) up to 4
days prior when she completed the 7 day course of Valacyclovir. Since then she has noticed a gradual
return of the burning and pain, with an acute increase noted during the past 24 hours. Despite taking
Lortab 5/325mg 1-2 tablets every 4 hours as directed, she is experiencing inadequate pain relief at the time
of PC#1. Home remedies that were ineffective included Calmoseptine lotion, Aloe Vera gel and Balmex
ointment. Warm sitz baths, Aspercreme and Gold Bond powder aggravated the pain. Pain relief (albeit of
varying duration) was achieved through the use of ice packs or cold, moist compresses, wearing no clothes
on lower body, and applying Desitin cream and corn starch powder to the affected areas.
Physical examination findings included:
a. Vital signs: Temp = 97.2; P = 116; BP = 150/86; Sp02 = 97% on RA; Resp = 18
b. Weight = 161 lbs
c. General: alert, oriented & spontaneously interactive. Mild discomfort while standing, significant pain
when sitting down – prefers to stand. Movement guarded. Not disabled with no indication of recent
trauma. Appears fatigued at times with occasional grimacing. No fever and malaise. Excellent
personal hygiene & self-care. Appropriately dressed in loose-fitting clothes.
d. HEENT: Normocephalic; EOM intact, PERRLA bilaterally, no scleral icterus, lesions or erythema
noted. Ear canals patent, TMs non-erythematous & no effusion. Nasal passages patent & free of
erythema. Oral mucosa moist & glistening. No lesions, erythema, drainage or halitosis noted.
e. Neck: supple w/o JVD, bruits, thyromegaly, lymphadenopathy, tenderness or swelling.
f.
Chest, heart & lungs: Eupneic with inspiratory phase = expiratory phase. Symmetrical chest wall
expansion w/o use of accessory muscles. Clear to auscultation & percussion. Slight tachycardia with
regular rhythm. S1 & S2 appreciated. No bruits, murmurs, gallops or clicks. Small biopsy scar in left
axilla noted. No skin lesions, no lymphadenopathy. Clinical breast exam deferred as per patient’s
request.
g.
Abdomen: no visible lesions or peristalses. Bowel sounds active in 4 quadrants. No rebound, guarding
or tenderness however slight apprehension noted during palpation of lower left quadrant (approaching
CASE STUDY: HERPES ZOSTER IN A PATIENT WITH CLL
7
groin area). No hepatomegaly, no splenomegaly. No bruits, no CVA tenderness. No palpable lymph
nodes.
h. Rectal: exam deferred as not reported to be affected by current concern. No symptoms indicative of
blood loss.
i.
Extremities: no clubbing, cyanosis, edema or lesions. Skin slightly dry on lower legs. Cap refill less
than 2 seconds in all extremities. Peripheral pulses present, regular & full. Marked tenderness and
guarding in left groin upon assessment of left femoral pulse.
j.
Musculo-skeletal: Guarded transfers; slow, cautious gait due to perineal discomfort. No limitations in
ROM or muscle strength but detailed exam deferred to limit discomfort. No deformities noted. No
amputations.
k. Skin: Clean, warm and dry. Specific to affected regions: Skin over upper half of left buttock normal.
Lower medial left buttock presents with two discrete clusters of crusted-over and healing lesions noted
on an erythematous base. Confined to left S2 and S3 dermatomes. Does not cross midline. Medial
cluster measures 3cm(H) x 5cm(W) on top of 5cm x 7cm area of erythema. Lateral cluster measures
1.5cm (H) x 3.0cm (W) on top of a 3.5 cm x 5cm area of erythema. Skin of left groin area moist & free
of lesions & erythema but with marked allodynia (extreme sensitivity to touch). Perineum slightly
moist without significant erythema. Good hygiene. White powdery substance noted (corn starch
powder). Lateral aspect of left labia majora has two scattered vesicles on erythematous base – not
ulcerated, not scabbed, not weeping. Also, 2 small (less than 1cm each) areas of erythema without
vesicular rash noted. Mild, ill-defined swelling of these 2 areas, sensitive to touch.
l.
Neurological: Alert & oriented x3. Significant neuralgia of S2 and S3 dermatome-associated areas
over left lower medial buttock, left groin area and left labia majora – does not cross the midline.
m. Psychiatric: Somewhat depressed affect, occasional grimacing and occasional frowning noted. Denies
suicidal ideation / history of suicidal ideation. Appears drained and fatigued. PHQ-2 score =2.
CASE STUDY: HERPES ZOSTER IN A PATIENT WITH CLL
8
Pertinent diagnostic tests
Diagnosis of herpes zoster is based on clinical findings, supported by presence of unilateral vesicular
eruption with well-defined dermatomal distribution following a painful sensory, dermatome-limited prodrome.
Despite patient’s underlying compromised immunity, no atypical lesions or distribution were noticed at this
time and further diagnostic tests (viral culture, direct immunofluorescence & polymerase chain reaction essay)
were considered unnecessary.
In addition to the subjective and objective assessment findings, a complete
blood count with auto and manual differential (CBC w/manual diff) was ordered to evaluate constitutional
wellness. Significant results included:
Hb = 14.0 (N)
Hct = 38.9 (N)
RBC = 3.98 (N)
WBC = 3.8 (L)
MCV = 97.8 (H)
MCH = 35.1 (H)
Platelets = 152 (N)
MPV = 5.5 (L)
# Baso = 0.1(H)
%Baso = 3.6
#Lymph = 1.1 (L)
%Lymph = 29.7 (N)
(Please see Appendix B, table 2 for complete results.)
Differential Diagnosis with final diagnosis and rationale
Critical thinking pertaining to differential diagnoses can be summarized as follows:
Possible diagnoses
Herpes zoster
(resolution in progress)
Post herpetic neuralgia
(PHN)
Prodromal neuralgia
(of recurrence /
refractory flare)
Zoster sine herpete
Contact dermatitis
(allergic or irritant)
Bacterial skin
superinfection with
Bullous Impetigo
Zosteriform Herpes
simplex virus (HSV)
Molluscum
contagiosum (MC)
Reason(s) why included / excluded in final diagnosis
Likely but due to pt’s immune-compromised state (CLL) and increase in pain after
initial improvement, also at risk for subsequent complications
Likely manifestation as complication of zoster – PHN onset as resolution of VZV
rash occurs. Immune-compromised pt is at higher risk for this complication.
Likely: immune-compromised pt’s may have atypical presentation where zoster
may breech dermatomal boundaries and/or flare up after initial improvement (due to
poor cell mediated immune response)
Likely but rare: atypical presentation in severely immune-compromised host –
absence of dermatological signs with visceral involvement
Possible as patient gives history of trying several topical therapies for pain relief
and lesion resolution.
Likely as complication of VZV in immune-compromised host. Would expect pt to
present with fever and/or elevated WBC. Also no pustules, no weeping ulcerations,
no yellow, crusted lesions noted. No umbilication of vesicles.
Unlikely: HSV usually not unilateral presentation and outbreak of skin lesions not
preceded by prodromal neuralgia.
Likely as viral superinfection with higher incidence in immune-compromised hosts.
Although MC may affect crural folds & may initially be unilateral, lesions are
usually umbilicated (not found in this pt) & MC is not associated with neuralgia
(prodromal or progressive).
CASE STUDY: HERPES ZOSTER IN A PATIENT WITH CLL
9
Based upon the clinical presentation of crusted vesicular lesions on a erythematous base following a
prodrome of acute, unilateral neuritis; favorable response to initial anti-viral treatment; absence of new
vesicular lesions but continuation of neuralgia in affected dermatomal areas, the final diagnoses for the PC#1
visit were determined as: (1) ICD: 053.9: Herpes zoster virus affecting left S2 & S3 dermatomes – resolving,
and (2) ICD: 053.13 onset of post-herpetic neuralgia (PHN). An additional diagnosis of (3) ICD: 692.0
contact dermatitis (most likely irritant type) secondary to topical remedies, was made based on the patient’s
report of trying several topical treatments and relief-measures, some of which aggravated her pain and
discomfort. At the time of PC#1 no signs of bacterial superinfection of the skin manifested but this was noted
as an absolute indication for immediate follow-up.
Plan of care
Treatments
I. Herpes zoster – resolving
Treatment goals for acute VZV are: (a) to limit the length & severity of symptoms, (b) reduce pain, (c) treat
constitutional symptoms, and (d) prevent or limit complications such as super-infections and post herpetic
neuralgia (PHN). Administration of antiviral therapy (especially when started within the first 48-72 hours)
may shorten the course, limit the severity& decrease the likelihood of PHN in certain patients. In this case, the
patient had already received antiviral therapy, Valacyclovir (1,000mg po TID x 7days), appropriately
administered at the earliest signs of dermatological involvement (started 10 days prior to PC#1 encounter). A
summary of anti-viral agents for consideration can be found in Appendix C, table 1. At the time of PC#1, it
was decided not to repeat treatment with an antiviral as no new lesions were manifesting. The patient
preferred a “watchful waiting” approach and understood that she was to start a second wave of antiviral
treatment (considered appropriate for immune-compromised patients with refractory zoster) at the earliest
manifestation of any new lesions. The patient still had an adequate home supply of Valacyclovir available as a
large quantity was ordered by her oncologist when she previously presented with HSV cold sores.
Investigation of this choice of treatment (Valacyclovir in contrast to Famicyclovir) revealed that despite
warnings that Valacyclovir should not be used in immune-compromised patients, it also has an off-label use
CASE STUDY: HERPES ZOSTER IN A PATIENT WITH CLL
10
for the prevention and treatment of zoster in cancer patients. The recommended prophylactic dose is 500mg 23 times per day and treatment (for an acute episode) should be 1,000mg po 3 times/day (Turkoski, Lance, &
Tomsik, 2010, p. 1925). At doses of 8,000mg per day, it was reported to increase the risk of thrombotic
thrombocytopenic purpura and hemolytic uremic syndrome in immune-compromised patients (Turkoski et al.,
2010, p. 1924). This potential complication supported CBC as adjunctive diagnostic test to assess for any
thrombocytopenia.
Pain was treated with hydrocodone/acetaminophen (Lortab). At the time of initial diagnosis in the RED,
Lortab 5/325mg (1-2 tablets po every 4 -6 hours) was prescribed for as needed use. The current
recommendations for the treatment of acute zoster-associated pain include the use of NSAIDs and opioid
analgesics. However, with a history of thrombocytopenia linked to previous NSAID use in this patient,
NSAIDs were to be avoided. At PC#1, her prescription of Lortab was refilled and the patient received
reassurance that she could safely take up to 8 tablets of Lortab in a 24 hour period (and even up to 10 tablets
for a short period of time). She was fortunately spared most constitutional symptoms associated with acute
shingles (i.e. malaise, fever and headache) and when these occurred on two separate days, the Lortab
successfully relieved these symptoms. Additional options for pain relief are discussed in paragraph II.
II. Post-herpetic neuralgia
The recurrence/flare of pain experienced by this patient after initial symptom improvement renders this
common complication of VZV is of special concern in this case. Factors linked with increased occurrence of
PHN include old age, severity of prodromal pain, and severity of pain in the initial, acute episode.
Prophylactic VZV vaccination, timely initiation of anti-viral therapy, and certain pharmacological agents
(supported in limited studies) have been suggested to prevent the development of PHN. Several options exist
for the treatment of PHN. Those taken into consideration for this patient are listed in Appendix C, table 2 (oral
administration) and table 3 (topical preparations). During PC#1, the patient, primary care provider and FNP
student came to the agreement that the patient would continue treatment of pain with oral Lortab but that she
would increase dosing above what she has been using in order to effectively and pro-actively manage her pain.
Additionally the patient also preferred to continue with the application of topical remedies and a variety of
CASE STUDY: HERPES ZOSTER IN A PATIENT WITH CLL
11
symptomatic measures (see Appendix C, table 4). It was also agreed upon that Gabapentin would be
considered as the next line of pharmacologic treatment to address the PHN if more conservative treatments fail
to provide adequate relief.
III. Contact Dermatitis
Reporting several trials with a variety of non-prescription topical remedies (listed in Appendix C, table 4), a
mild case of contact dermatitis (most likely, irritant dermatitis) was suspected and to avoid any further
irritation to the area, it was opted not to prescribe any pharmacological treatment. Instead, the patient received
instruction to wash the affected areas with tepid water, using either no soap or only a very mild soap (for
sensitive skin). Areas were then to be patted dry gently and if possible exposed to air (by wearing loose-fitting
or no underwear). Subsequent irritation was to be avoided by choosing the one topical remedy which proved
to be the most effective and avoiding all other products for at least 7 days. Exposure to extreme temperatures
and ultra-violet light was also discouraged.
Patient Education
In this case, the patient established a reputation as a very involved and pro-active member of her health
management team. She was very open and enthusiastic about receiving education regarding recommendations
in the management of both her VZV shingles as well as her CLL as a complicating factor. The relationship
between her CLL and VZV disease was discussed and the patient understood that her lympho-proliferative
disease (CLL) and chemotherapy treatments would continue to put her at higher risk for VZV reactivation in
the future. The normal progression of VZV shingles from papules, to vesicles-bullae, to pustules and eventual
crusts were discussed. Other aspects included in discussions during PC#1 encounter and/or subsequent followup visits and phone calls, included:
a. Factors which may trigger reactivation of VZV (including: immunosuppression, certain medications,
other infections, physical and emotional stress).
b. Actions which can be taken to prevent reactivation (including: optimizing immune-status; infection
control; avoiding, preventing or pro-actively managing stress)
CASE STUDY: HERPES ZOSTER IN A PATIENT WITH CLL
12
c. Early recognition of prodromal symptoms and timely initiation of anti-viral therapy at first signs of
VZV skin rash (patient and providers agreed that patient is to maintain a home-supply of valacyclovir
and although prophylactic continuation of the valacyclovir was not deemed appropriate at this time,
she would initiate treatment at the earliest manifestation of VZV rash, or similar prodromal neuralgia).
d. Pain control and management (especially how effective pain control could reduce the risk for PHN).
e. Early recognition of serious complications such as (i) involvement of nasociliary branch of ophthalmic
nerve with subsequent acute retinal necrosis, (ii) disseminated zoster (which may occur 5 – 10 days
after onset of dermatomal disease), (iii) bacterial superinfections (especially skin infections), (iv)
peripheral motor neuropathy, (v) meningitis/encephalitis, and (vi) Ramsay Hunt syndrome (herpes
zoster oticus), and (vii) signs of visceral involvement (fever & lymphadenopathy).
f.
In this case, with know immune-compromise and the location of the patient’s skin rash (perineal area)
special attention was given to discuss the prevention, early recognition and treatment of bacterial skin
infection as a complication. It was decided that no prophylactic antibiotics (topical or systemic) were
needed and she received praise for her existing vigilance in this area.
g. Prevention/pro-active management of opioid-induced constipation
h. Pro-active management of long term implications involving physical functioning (fatigue, activity and
rest, weight loss), psychological functioning (anxiety, depression), social functioning (changes in
intimacy & social attendance) & functional areas (ability to continue/resume IADLs & ADLs).
Regarding immunization against VZV shingles (recommended for people 60 years of age and older
since 2006), it was discussed with the patient that despite the FDA’s 2011 approval for persons aged 50 to
59 years, the Advisory Committee in Immunization Practices declined recommendation of this vaccine for
this age group (50-59 year olds). Additionally, despite the higher risk for immune-compromised patients
to present with VZV reactivation, vaccine administration for its prevention is not advised in patients with
primary or acquired immune-deficiencies (including leukemia, lymphoma or other malignancies of bone
marrow or lymphatic system). For some patients, VZV vaccination is indicated prior to the start of
CASE STUDY: HERPES ZOSTER IN A PATIENT WITH CLL
13
immunosuppressive therapy, but since this patient is already challenged with immune-compromise,
vaccination would not be indicated for her at this time.
As already discussed under the treatment for Contact Dermatitis, the patient was cautioned against the
use of too many topical remedies to avoid irritation of or further damage to the skin.
Follow-up
The plan for follow-up included the following:
a. Re-visit the primary care provider in no more than 4 weeks for routine follow-up. Return at an earlier
stage would be indicated if:
i.
Any signs or symptoms of complications (as discussed under Patient Education paragraphs e –
g) manifest.
ii.
Any new lesions occur (and patient understood that she could immediately start a second
course of anti-viral therapy with home-supply of Valacyclovir).
iii.
Any increase in pain (especially visceral pain), or constitutional symptoms (such as fever,
malaise, petechiae or lymphadenopathy) manifest.
b. Assessment at subsequent visits would specifically address skin integrity, pain control, resolution of
skin rash, psychological wellness and restoration of optimal immune-status.
c. Patient is also to maintain her follow-up schedule with her oncologist which, at the time of PC#1 was
stipulated at quarterly visits with the oncology team and monthly CBC and basic panel labs checked at
the primary care clinic and faxed to her oncologist.
d. Specific to pain management it was decided that if patient’s pain is not significantly controlled in 14
days, the patient would return to the clinic for assessment and most likely started on Gabapentin for
increased pain control.
Referrals
At the time of PC#1, no new referrals to specialty care were initiated but her plan of care and follow-up
included referrals to:
CASE STUDY: HERPES ZOSTER IN A PATIENT WITH CLL
14
a. Pain management specialist – if treatment with opioid and adding Gabapentin failed to provide
adequate pain relief OR if pain would become severe or refractory to treatment at any time.
b. Opthalmology – if any ophthalmic nerve involvement manifested or were suspected
c. Hospitalization – if any signs of disseminated herpes would appear
d. Oncology – to maintain her current follow-up schedule (quarterly visits)
Patient and family involvement in treatment decisions
The patient maintained absolute involvement in her treatment decisions. As already mentioned she had a
very pro-active attitude and spent many hours researching conventional and less conventional treatment
options using different sources. In general she was able to make sound, informed decisions and where needed,
received guidance from her primary health care team (example: not to overuse topical remedies) and from her
specialty care provider (oncology) regarding the preference of Valacyclovir (above Famciclovir) in this case.
Although the patient’s husband always accompanied her to the clinic, he opted not to be present in the
examination room but accepted the invitation to ask questions in a way and at a time suitable for him. The
patient reported that he did take an active interest in her condition but that he preferred discussing it with her.
She also shared findings and treatment decisions with her daughter (according to the patient) who supported
her in her treatment decisions and usually accompanied the patient and her husband to oncology visits. The
patient introduced the primary care provider and FNP student to the concept of EFT (Emotional Freedom
Techniques). In this self-taught treatment, the patient was able to combine principles of bio-feedback,
acupuncture, acupressure and thought field therapy into a meditative session while tapping on so-called "end
points of the body's energy meridians". She found this to be very helpful in pain relief but also to replenish her
emotional energy. As this appeared to be beneficial to the patient, she was encouraged to continue with this
type of therapy.
Reflection on Care Provided
Care provided by the FNP student included a single primary care visit (PC#1) at which time an acute
concern which manifested 10 days prior was being re-addressed. The visit was prompted by the concern of
either disease regression or a second exacerbation of the same symptoms. Inadequate pain management and
CASE STUDY: HERPES ZOSTER IN A PATIENT WITH CLL
15
the development of complications were also a concern. The PC#1 encounter afforded time for a thorough
review of symptoms, physical exam, review of past medical history and family as well as social history. Due
to the remote geographical location of the clinic, the patient was co-managed by a physician assistant whom
conducted the follow-up visit. In order to overcome this challenge, the FNP student was able to meet with the
patient for a follow-up discussion and to discuss additional patient education topics. Additionally, the
preceptor also followed the patient’s progress (as collaborating physician to the PA) and engaged in several
discussions of this case with the FNP student.
Reflecting on the lessons learned it really struck me how disease conditions which may not receive highprofile attention, may still manifest as complex conditions with profound implications for my patients.
Diseases which may, by some, are described as simple and easy to manage, may in fact, produce serious health
detriments when combined with the unique, individual features of our patients, which may truly determine the
severity and impact of the disease in that individual case. Co-morbid conditions must always be considered
and co-managed with integration of knowledge on how two distinctly separate pathological processes may
intertwine.
Further I’ve realized that the phenomenon of compromised immunity, either primary or acquired, can
drastically change the face of many familiar diseases and challenge both patients and providers with unusual
presentations, precocious manifestations, slower resolve and increased risk of complications (some of them
equally unusual). Additionally, co-morbidities such as immune-compromise may limit our treatment options
and methods of prevention and force us to think outside the box.
The age of accessible information and technology offers our patients the opportunity to investigate their
symptoms, often present us with a prepared list of differential diagnoses and challenge the treatment options
we consider and recommend. This necessitates providers to constantly expand their knowledge and
understanding of disease processes and treatment modalities and through the use of evidence based practice,
recommend the most beneficial treatments to our patients. Finally, the biggest challenge lies in fusing clinical
knowledge, social skills and due diligence into an individualized plan of care which would optimally benefit
the patient as primary participant in his/her healthcare.
CASE STUDY: HERPES ZOSTER IN A PATIENT WITH CLL
16
References
Albrecht, M. A. (2011, February). Clinical manifestations of varicella-zoster virus infection: Herpes zoster.
UpToDate. Retrieved from http://0-www.uptodate.com.topekalibraries.info/contents/clinicalmanifestations-of-varicella-zoster-virus-infection
Albrecht, M. A. (2011, October). Treatment of herpes zoster. UpToDate. Retrieved from http://0www.uptodate.com.topekalibraries.info/contents/treatment-of-herpes-zoster
Albrecht, M. A. (2012, January). Prevention of varicella-zoster infection: Herpes zoster. UpToDate. Retrieved
from http://0-www.uptodate.com.topekalibraries.info/contents/prevention-of-varicella-zoster-virusinfection-herpes-zoster
Bajwa, Z. H., Warfield, C. A., & Crovo, D. G. (2012, February). Postherpetic neuralgia. UpToDate. Retrieved
from http://0-www.uptodate.com.topekalibraries.info/contents/postherpetic-neuralgia
Centers for Disease Control and Prevention. (2008, June 6). Prevention of herpes zoster: Recommendations of
the Advisory Committee on Immunization Practices. Morbidity and Mortality Weekly Report, 57(RR5). Retrieved from www.cdc.gov/mmwr
Centers for Disease Control and Prevention. (2011, November 11). Update on herpes zoster vaccine: Licensure
for persons aged 50 through 59 years. Morbidity and Mortality Weekly Report, 60, 1528. Retrieved
from www.cdc.gov/mmwr
Craft, N., Fox, L. P., Goldsmith, L. A., & Tharp, M. D. (2011). VisualDx - Adult Rash: Herpes Zoster [Visual
diagnostic decision support]. Retrieved from http://0-www.visualdx.com
Emotional Freedom Techniques website. (2012). http://www.123eft.com
Ferri, F. F. (2012). Contact dermatitis. In F. F. Ferri (Ed.), 2012 Ferri’s clinical advisor (p. 258). Philadelphia,
PA: Elsevier.
Ferri, F. F. (2012). Herpes zoster. In F. F. Ferri (Ed.), Ferri’s clinical advisor 2012 (p. 472). Philadelphia, PA:
Elsevier.
Ferri, F. F. (2012). Lymphoma: Non-Hodgkin. In F. F. Ferri (Ed.), Ferri’s clinical advisor 2012 (pp. 607-609).
Philadelphia, PA: Elsevier.
CASE STUDY: HERPES ZOSTER IN A PATIENT WITH CLL
17
McPhee, S. J., & Papadakis, M. A. (2011). Current medical diagnosis and treatment (50th ed.). New York,
NY: McGraw-Hill Medical.
Rai, K. R., & Keating, M. J. (2012, January). Epidemiology and clinical manifestations of chronic lymphocytic
leukemia. UpToDate. Retrieved from http://0www.uptodate.com.topekalibraries.info/contents/epidemiology-and-clinical-manifestations-ofchronic-lymphocytic-leukemia
Turkoski, B. B., Lance, B. R., & Tomsik, E. A. (Eds.). (2010). Drug information handbook for advanced
practice nursing (11th ed.). Hudson, OH: Lexicomp.
Wolff, K., & Johnson, R. A. (2009). Fitzpatrick’s color atlas & synopsis of clinical dermatology (6th ed.).
New York, NY: McGraw-Hill Medical.
CASE STUDY: HERPES ZOSTER IN A PATIENT WITH CLL
Appendix A
Figure1: Genogram
*** Please see separate word document for Genogram ***
18
CASE STUDY: HERPES ZOSTER IN A PATIENT WITH CLL
19
Appendix B
Table 1: List of current medications
Drug
Hydrocodone/Acetaminophen
Docusate Sodium
Dosage
5mg/325mg tablets
100mg Gelcaps
Vitamin D3 (Cholecalciferol)
Valacyclovir
5,000 unit gelcaps
500mg tablets
Prochlorperazine maleate
10mg tablets
Desitin Cream (40% zinc oxide)
cream
Indications/Directions
1 -2 tablets every 4 – 6 hours po prn for pain
1 – 2 gelcaps at bedtime po prn for
constipation (prevention)
1 gelcap daily po
2 tablets, 3 times/day po for 7 days starting at
first manifestation of herpetic rash
1 tablet po every 6 hours as needed for
nausea
Apply to affected skin areas after gentle
washing as needed for relief of discomfort.
Table 2: Laboratory report of hematology on PC#1 encounter
CBC with Manual Differential
Test
Result
Flag
Range
WBC
*3.8
L
4.5 – 10.5
RBC
3.98
3.69 – 5.13
Hemoglobin
14.0
11.7 – 14.5
Hematocrit
38.9
34.1 – 44.3
MCV
*97.8
H
80.6 – 95.8
MCH
*35.1
H
27.1 – 33.1
MCHC
35.9
32.2 – 36.7
RDW
12.1
10.3 – 12.9
Platelets
152
143 – 314
MPV
*5.5
L
6.0 – 9.0
Lymph: %
29.7
19.4 – 42.9
#
*1.1
L
1.2 – 3.0
Gran: %
54.2
39.3 – 73.7
#
2.0
1.2 – 7.0
Mono: %
10.9
4.4 – 12.7
#
0.4
0.2 – 0.8
Eos: %
1.6
0.6 – 7.3
#
0.1
0.0 – 0.4
Baso: %
*3.6
H
0.0 – 1.7
#
*0.1
H
0.0 – 0.1
Reflex
YES
204.10
Manual Differential
SEG manual
60
40-70
Lymph manual
32
20-45
Mono manual
8
2-10
ANISO
1+
MACRO
1+
POIK
1+
Units
/mm3
/mm3
g/dL
%
U3
pg
%
%
/mm3
U3
%
/mm3
%
/mm3
%
%
%
%
%
%
CASE STUDY: HERPES ZOSTER IN A PATIENT WITH CLL
20
Appendix C: Treatment Modalities/Considerations
Table 1: Anti-viral agents considered to decrease length and severity of acute episode
Agent:
Dose:
Notes:
Acyclovir
800mg po
4 hourly (mostly
given 5 x/day)
7-10 days
Primary drug
Inconvenience of
frequent dosing
requirement (56x/day)
Famicyclovir
500mg po
8 hourly
Valacyclovir
1,000mg po
8 hourly
7 days
Pro-drug
Considered more
helpful (than acyclovir)
in prevention of PHN
Convenient dosing
7 days
Pro-drug
Contra-indicated for
some immunecompromised patients
Convenient dosing
Foscarnet
40mg/kg IV
8 hourly over 1 hour
infusion
10 days
Pro-drug
Only available for IV
administration
Reserved for cases
resistant to acyclovir
Table 2: Treatment options for PHN – Oral administration
Pharmacological
category
Drug
Dose
Start:
(Maximum)
Reason why
considered
Warnings /
Reason(s) why
not selected
Other
considerations
Final decision
for this patient
Tricyclic
Antidepressants
Nortriptyline
10-20mg QD
Limited support for
use in conjunction
with anti-virals
during acute phase
to prevent PHN
Anti-convulsants (with analgesic properties)
Gabapentin
(Neurontin)
100mg TID po
(600mg TID)
Anti-neuralgic
action
Highly
recommended for
treatment of PHN
Increased risk for
eosinophilia,
purpura and
thrombocytopenia
May also aggravate
peripheral
neuropathy
May increase risk
for leucopenia
May take 2 -3
weeks to achieve
optimal
effectiveness.
Interacts with many
other drugs
Generic available
Very few drug-drug
interactions
Most favored
option – fewest
interactions &
EBP supported
Not selected based
on limited support
and side-effect
profile
Pregabalin
(Lyrica)
Carbamazepine
(Tegretol)
75mg QHS
(300mg BID)
Anti-neuralgic
action
Highly
recommended for
treatment of PHN
100mg BID
(600mg BID)
Anti-neuralgic
action
Often used for
treatment of PHN
& Trigeminal
neuralgia
May increase risk
Contra-indicated for
for
patients with bone
thrombocytopenia
marrow suppression.
Warning:
hypersensitivity
may mimic signs &
symptoms of
lymphoma
No generic available Interacts with many
Expensive
other drugs
Not selected - too
expensive
Not selected based
on side-effect
profile
CASE STUDY: HERPES ZOSTER IN A PATIENT WITH CLL
21
Table 3: Topical preparations / options for treatment of PHN
Treatment
How used /
applied
Reason why
considered
Warnings /
Reason(s) why
not selected
Final decision
for this patient
Lidocaine 5%
Topical Aspirin
Patch applied to intact skin
after resolution of blisters
and crusts
May be useful on buttock
once all lesions are
completely healed.
Patient still has blisters &
crusted lesions. Patch not
recommended for
application on
perineum/groin area
May be useful at later time
(after lesions are healed –
use on buttock only)
Aspirin tablets crushed &
mixed into Vaseline /
Eucerin cream
Used in many compounded
topical treatments
Topical Capsaicin
0.075% cream
Applied to intact skin after
crusted lesions are healed
Not considered
Not considered for use in
perineal / groin area
Used with success & will
continue to use
Not considered at all
Table 4: Symptomatic measures utilized by the patient
Measures utilized with success
Unsuccessful measures (ineffective/aggravating)
(Is going to continue with these)
(Tried but discontinued)
Desitin ointment (with 4% zinc oxide)
Applying heat to area / taking warm bath/shower
Cold, moist compresses (chilled, moist washcloths)
Aloe Vera Gel, Calamine lotion
Ice packs
Balmex ointment (with 11% zinc oxide)
Cornstarch powder
Gold Bond powder
Limiting mechanical irritation from clothes
Benadryl cream, Aspercreme, Cortaid lotion,
(wears loose-fitting clothes as tolerated)
Vitamin E oil
Aspirin tablets crushed & mixed into
Applying sun lamp (ultra-violet light) for 5 minutes
Vaseline/Eucerin
per day (aggravated symptoms)
EFT (Emotionally Focused Therapy)
Dimethyl sulfoxide (DMSO) 50% cream