Clustered Vesicular Lesions in Middle-Aged Female

Case at a Glance

A 48-year-old female presented with acute onset of clustered, painful vesicular lesions in the inframammary region with rapid progression from erythematous patches to raised, fluid-filled bumps over 48 hours.

Patient's Story

The patient, a 48-year-old female (BMI 22.7), presented with a 2-day history of skin lesions in the left inframammary fold. She reported that the lesions initially appeared as red, flat areas but quickly progressed to become raised, clustered bumps associated with significant pain. She denied any associated pruritus. Her medical history was notable for uterine fibroids. She denied any recent illness, stress, or immunocompromising conditions.

Initial Assessment

Physical examination revealed multiple clustered vesicular lesions on an erythematous base located in the left inframammary region. The lesions appeared to follow a dermatomal distribution. The patient reported tenderness to palpation but denied pruritus. Vital signs were stable, and she appeared otherwise well.

The Diagnostic Journey

Given the characteristic presentation of clustered, painful vesicles in a dermatomal distribution with rapid onset, the differential diagnosis included herpes simplex virus (HSV) infection and herpes zoster (shingles). The unilateral distribution and dermatomal pattern were more suggestive of varicella-zoster virus reactivation. Laboratory workup was considered including viral PCR and/or viral culture of vesicular fluid to confirm the diagnosis.

Final Diagnosis

Based on the clinical presentation of unilateral, dermatomally distributed, painful vesicular lesions, the most likely diagnosis is herpes zoster (shingles) affecting the thoracic dermatome.

Treatment Plan

Antiviral therapy with acyclovir, valacyclovir, or famciclovir was recommended to reduce viral shedding and symptom duration. Pain management with appropriate analgesics and topical treatments for symptomatic relief were discussed. Patient education regarding the contagious nature of the lesions and proper wound care was provided.

Outcome and Follow-up

The patient was advised to follow up if symptoms worsened or failed to improve with treatment. Monitoring for potential complications such as post-herpetic neuralgia was recommended. The importance of seeking immediate care for any signs of secondary bacterial infection or systemic symptoms was emphasized.