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An 82 year old woman with seronegative rheumatoid arthritis was admitted during a flare in her disease. Since diagnosis five years previously her arthritis had been managed with low dose oral corticosteroids at a dose of 10 mg daily.
Shortly after admission she complained of severe pain on the sole of the left foot. Examination at the time showed a discrete area of vesicular eruption (fig 1). Oral antiviral treatment (acyclovir) was started for herpes zoster. Within 24 hours she had developed a more extensive zoster rash distributed over the posterior aspect of the left leg from ankle to buttock in the S1/S2 dermatome (fig 2). Symptomatically the neuralgic pain completely settled within two days while the rash persisted for a further few weeks.
Herpes zoster infection is well documented in patients with rheumatoid arthritis, particularly those receiving oral corticosteroids and methotrexate.1–4 Although most cases are limited to the typical cutaneous zoster eruption, more complicated infections can occur such as disseminated cutaneous herpes zoster complicated by necrotising fasciitis,5,6 herpes zoster encephalomyelitis,7 and lower motor neurone paresis.8 Sciatic nerve involvement is unusual in herpes zoster reactivation.
Series editor: Gary D Wright
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