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Look at this lady and proceed! ( Station 5)

Discussion:

     It is a popular case in MRCP PACES station 5, no candidate will miss the lesion because it is obvious. You notice this lady has an obvious scar over the left ophthalmic branch of trigeminal nerve. It is obvious that the scar is caused by previous Herpes Zoster syndrome ( Shingles). You must proceed to do the following,

Check the lady's visual acuity as you know Shingles can cause corneal ulceration and reduced visual acuity,

Ask some relevant questions about predisposing factors to this condition such as immunosuppression secondary to long term steroid ingestion, HIV etc.

Suggest to examiners that you would like to check at other parts of body to look for previous shingles infection as well because it is not uncommon for patients to get recurrent Shingles infections.

    Although I show you a patient with scarring due to shingles, it is quite common as well in MRCP PACES for you to get a case with active shingles infection. The lesion is always described as vesicular rash along a dermatome and you may find elymph nodes enlargement along the lymphatic drainage.

Remember that HIV patients may have multidermatomal, disseminated and recurrent shingles infection.

Common questions examiners would ask you,

1) How do you confirm the diagnosis?

( It is mainly a clinical diagnosis in everyday practice, however, in your MRCP PACES exam, remember that this can be confirmed by viral titers and isolation of the virus from the blister using Tzanck smear).

2) What is the commonest complication after shingles infection?

( Neuropathic pain! Remember how to manage neuropathic pain as well!)

Conclusion:

This young lady has previous shingles infection secondary to longterm steroid ingestion before. ( She has SLE).

Extra points:

Examine this lady's face and proceed. ( Station 5)

Discussion:

     As I mentioned before, this case is popular in MRCP PACES station 5 if you are sitting the exam in Asia especially in Singapore, Malaysia and Hong Kong. You notice this lady has butterfly rash on the face ( sun-exposed area), you should proceed to do the following,

    Conjunctiva and eye -Look for anemia because patient may have haemolysis or gastritis due to steroid ingestion.Look for jaundice as well because patient may have autoimmune hepatitis
    Mouth- Look hard for mouth ulcer.
    Scalp-Look for alopecia and discoid rash.
    Hand-Look for vasculitis rash , Raynaud's phenomenon, arthritis, palmar erythema.Observe for any weakness as well because patient may have previous stroke due to vasculitis.
    Leg-Look for vasculitis rash and livedo reticularis.Look for oedema as well because lupus nephritis causes proteinuria and nephrotic syndrome.
    Cushing's features- Have a general look at the patient and look for features of Cushing's syndrome because patients are usually on long term steroid.

Suggest to examiners that you would like to do the following,
    Fundoscopy-Look for presence of cytoid body.   
    Blood pressure-Examine the patient's blood pressure, patients tend to have high BP due to SLE itself or due to side effect of steroid.
    Urine for protein and sugar-Patient may have proteinuria and glycouria due to steroid ingestion.    
    History of drug ingestion-Drug-induced lupus may give you the same features. Classical drugs to be associated with SLE are isoniazid, procainamide and hydralazine.

Common questions examiners would ask you,

1) How do you diagnose SLE?

( Any four of the 11 criteria set by American Rheumatic Association)

2) Which two organs are usually not involved in drug-induced lupus?

( Brain and kidney!!)

Conclusion:

This young lady has active SLE and was just started on steroid.

Extra points:

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