Case 4: Unexpected Rash in a 12-year-old Girl

A 12-year-old white girl presents to the emergency department with a 1-day history of fever, severe headache, photophobia, nuchal rigidity, and mydriasis. She was evaluated at urgent care 1 day before presentation due to 4 days of acute onset of sharp right upper extremity pain and 1 day of rash over the right upper extremity and shoulder. There, she was diagnosed as having shingles and was sent home with a prescription for acyclovir, of which she was able to tolerate 1 dose. Emergency department physical examination reveals an afebrile, tired-appearing girl in mild distress with cranial nerves II-XII grossly intact, photophobia, nuchal rigidity, and a nonpruritic, erythematous, blanching maculopapular and vesicular rash in the C5-C6 dermatome distribution of the right upper extremity (Figs 1 and 2). She denies nausea, vomiting, abdominal pain, or any new medications, recent stressful events, trauma, infections, or illnesses. Immunizations are up to date,...