A 15-year-old previously healthy boy presents to the emergency department (ED) with painful vesicular rash, fever, frontal headache, neck pain and stiffness, right-sided abdominal pain, nausea, and nonbilious, nonbloody vomiting. He was seen 2 days ago in the ED for painful vesicular rash on his left arm 3 days after a camping trip. He was diagnosed with shingles and discharged with oral acyclovir as well as acetaminophen and hydrocodone for pain management. He is fully immunized and has no known history of varicella. He has no known poison ivy or poison oak exposure.

On physical examination, the ill-appearing adolescent has multiple clusters of vesicles along the C6 distribution of his left arm, extending from his upper arm down to his hand. The vesicles are in different stages of healing, with newer clusters of clear vesicles that have erythematous bases on his left thumb and older lesions near his left shoulder...

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