Age: 73.0
Sex: F
Vaccine: VARZOS
Symptoms: Allergy to arthropod bite, Biopsy skin abnormal, Drug eruption, Eosinophilic cellulitis, Erythema
Clinical narrative: Information has been received from a physician concerning a 73-year-old female with an allergy to SILVADENE CREAM, hypertension and hypercholesterolemia who on 08-NOV-2007 was vaccinated with a dose of Zostavax (Oka/Merck).  Concomitant therapy included losarten and hydrochlorothiazide (MSD), losartan (MSD), omeprazole (MSD) and pravastatin.  On approximately 28-NOV-2007, 2 weeks post vaccination, the patient developed an itchy rash scattered on her trunk, extremities and scalp.  The rash was described as "vesicles, papules and crusted lesions".  On 17-DEC-2007 the patient was diagnosed with hypertrophic in situ squamous cell carcinoma.  At the time the rash began the patient had also recently started taking HYZAAR.  HYZAAR was discontinued and the rash did not improve.  Follow-up information received via medical records indicated the following: On 10-DEC-2007 that patient was seen for an evaluation of a skin rash that started two weeks ago initially on her back.  This has worsened and has spread all over the body.  She is quite uncomfortable with pruritis.  The patient was started on a new medication HYZAAR in November.  She also had shingles vaccine 08-NOV, but states "she did not develop reaction at the injection site".  She also had an injury to her right lower leg in AUGUST and had been using SILVADENE CREAM.  She developed a reaction to this and discontinued.  Physical examination revealed a wide spread dermatitis on the trunk and extremities with some excoriated papules noted.  Impression was possible dermatitis medicamentosa.  Treatment plan: patient was treated with KENALOG 40mg IM today, triamcinolone cream 1% mixed with cetaphil cream and 25% menthol to be applied twice a day to affected areas.  XYZAL 5mg every night for pruritis.  The physician reported "I am not sure which medication she is reacting to but is now off SILVADENA CREAM".  On 17-DEC-2007 the patient was seen to recheck her skin rash.  The patient stated "it is getting worse".  The patient is currently on HYZAAR for six weeks and has been altering this with COZAAR, which she had been on previously.  Physical examination revealed an increased number of lesions, which for the most part are discrete, slightly crusted papules.  These are present on the trunk and extremities.  Impression: rule out dermatitis medicamentosa versus reaction to the zoster vaccine.  Plan: a 4mm punch biopsy was done from a lesion on the left upper back.  Two sutures placed.  The patient will be placed on a MEDROL DOSEPAK because she is traveling out of town.  On 07-JAN-2008 the patient was re-examined to recheck her skin rash.  The patient stated she continues to "break out".  The biopsy done last visit revealed a hypertrophic situ squamous cell carcinoma.  This was not represented of the rest of her dermatitis.  Physical examination: there is crusting and scaling in the scalp.  There are scattered erythematous papules and papular vesicles noted on the trunk and extremities.  Lesion biopsied last visit on the upper back has healed well with erythematous scar remaining.  Impression and Plan: squamous cell carcinoma in situ of the back.  Lesion will be treated today.  Diagnosis of skin rash remains uncertain.  Another lesion will be biopsied today.  The patient points to a new lesion on the left arm, which is an erythematous, slightly eroded papule.  This was removed today by 4mm punch biopsy and sent to pathology.  The patient will continue the triamcinolone cream since this appears to help the symptoms.  The patient will also be given CLOBEX Shampoo to use for the scalp.  On 14-JAN-2008 the patient was seen for suture removal and to go over her pathology.  The lesion biopsied from her left arm revealed perivascular dermatitis with eosinophils and slight squamous atypia.  The differential diagnosis includes urticaria, papular urticaria, insect bite reaction, or other arthropod bites.  Scabies is included in the differential.  Drug reaction is also a possibility.  The patient is still itchy and continues to get new lesions, although the scalp has improved with CLOBEX shampoo.  Physical Examination: is essentially unchanged with scattered erythematous papules on the trunk and extremities.  Skin cancer treatment site on the upper back is doing well without evidence of infection.  Impression and Plan: Diagnosis remains unclear of pruritic skin rash.  Because scabies is a possibility, the patient will be treated with ELIMITE CREAM for one night from head to toes as directed.  The physician stated "if this does not relieve her symptoms and skin rash, I will consider a drug reaction".  Sutures were removed today. On 28-JAN-2008 the patient was seen for a pruritic skin rash.  The patient stated she is "quite uncomfortable with pruritis".  She states she scratches and claws at her skin and can not sleep at night.  The patient was treated with ELIMITE CREAM for scabies because of a mention of this on the pathology, but this has not helped.  She stopped HYZAAR six days ago.  This was started around the same time of the skin rash starting.  The patient had Zostavax (Oka/Merck) prior to the skin rash.  The vaccine was given on 03-NOV-2007 and the rash started two weeks later and has continued.  This has worsened.  The biopsy shows perivascular dermatitis with eosinophils.  Physical examination revealed vesicles, papules, and crusted lesions scattered on the trunk, extremities and scalp.  This is worse than at the time of her last visit.  Impression: dermatitis medicamentosa.  Plan: The patient will stay off HYZAAR and will be referred to a dermatology department.  The patient will start prednisone 20mg daily and hydroxyzine 25mg at bedtime and will continue triamcinolone cream twice a day.  Additional information has been requested.