Skill Checkup: A 40-Year-Old Woman With Rheumatoid Arthritis Has Fever, Headache, Photophobia and Painful, Burning Rash

Heidi Moawad, MD


May 08, 2023

The Skill Checkup series provides a quick, case-style interactive quiz, highlighting key guideline- and evidence-based information to inform clinical practice.

A 40-year-old White woman who lives in Niagara-on-the-Lake, Ontario, Canada, presents to her general practitioner with fever, headache, photophobia and a painful, burning rash on her right flank; symptoms have persisted for 2 days.

The patient is 1.52 m (5 ft) and weighs 74.84 kg (165 lb). Her vitals in clinic are a temperature of 38.1°C (100.5°F), pulse of 55 beats/min, respiratory rate of 21 breaths/min and blood pressure of 117/77 mmHg.

Of note, last year the patient was referred by her general practitioner to a rheumatologist for joint pain, at which time she was diagnosed with rheumatoid arthritis (RA) and prescribed a corticosteroid. Six months later, the rheumatologist switched her RA treatment to anti-tumor necrosis factor-α (anti-TNF-α) therapy owing to inadequate response to the corticosteroid. She has been on anti-TNF-α treatment for about 6 months.

At the current visit, the general practitioner diagnoses the patient with herpes zoster (HZ), given the burning pain, characteristic morphology and typical distribution. She has not been vaccinated for HZ previously.


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