Young Man With Facial Rash and Headache

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Are these tender, vesicular erythematous lesions symptomatic of HIV/AIDS? Of Ramsay Hunt syndrome? Of Herpes simplex or varicella-zoster virus infection?

A 31-year-old previously healthy man had presented 1 week earlier to an outside emergency department (ED) with severe ear fullness, pain, and diminished hearing on the left side that had been present for several days. He was discharged and treated for otitis media with amoxicillin, but after 72 hours his symptoms worsened. Tender, vesicular erythematous lesions developed in his mouth and on the left side of his face, including his forehead, maxilla, and mandible (Figure).

He was brought to our ED by his fiancé, with a fever (temperature to 39.3°C [102.7°F]). His main complaint was severe frontal headache, which he described as sharp and squeezing, “like my head is in a vice,” with radiation across the top and back of his head bilaterally. The pain was exacerbated with any movement of his head and neck, especially with rapid movement, and was associated with anorexia, nausea/vomiting, and photophobia.

The patient and his fiancé have 2 children and have lived together for 5 years. The patient reported having had sex with up to an additional 100 female partners, whom he would solicit during “sex binges” during the couple’s frequent break-ups. He denied having sex with men. Condom use was sporadic. The patient denied any recent travel and exposure to chemicals. He has no pets or sick contacts. He works as a pharmacy technician but has not taken any new medications.

He denied visual disturbance, confusion, cough, sore throat, chest pain, abdominal pain, dysuria, focal weakness, tingling in the arms or legs, or genital lesions.

Figure: Isolated left sided facial lesions.

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