What is the next best step (NBS) for a patient presenting with vesicles on the index finger and thumb, a pink tint to the body, and perioral vesicles?

From the Guidelines

The next best step for a patient presenting with vesicles on the index finger and thumb, a pink tint to the body, and perioral vesicles is to initiate antiviral therapy, likely with acyclovir, famciclovir, or valacyclovir, as these symptoms suggest a herpesvirus infection, such as varicella zoster virus (VZV) or herpes simplex virus (HSV). The clinical presentation of vesicles on the index finger and thumb, along with perioral vesicles, is highly suggestive of a herpesvirus infection, which can be severe in immunocompromised hosts 1. The presence of a pink tint to the body may indicate a disseminated infection, which requires prompt antiviral treatment to prevent complications such as chronic ulcerations, secondary bacterial and fungal superinfections, and potentially life-threatening outcomes 1. Key considerations in managing this patient include:

• The patient's immune status, as immunosuppressed hosts are at higher risk for severe and disseminated infections 1
• The need for early initiation of antiviral therapy to reduce the risk of complications and improve outcomes 1
• The potential for herpesvirus infections to be transmitted through direct contact with active lesions, which may have implications for contact tracing and prevention of further transmission 1 Given the potential severity of herpesvirus infections, particularly in immunocompromised hosts, initiating antiviral therapy with acyclovir, famciclovir, or valacyclovir is the most appropriate next step, as these medications have been shown to be effective in reducing the severity and duration of infection, as well as preventing complications 1.

From the Research

Presentation and Diagnosis

• The patient's symptoms, including vesicles on the index finger and thumb, a pink tint to the body, and perioral vesicles, are consistent with Hand, Foot, and Mouth Disease (HFMD) 2, 3, 4, 5, 6.
• HFMD is a contagious viral disease that mainly affects infants and young children, characterized by fever, vesicular rashes on hands, feet, and buttocks, and ulcers in the oral mucosa 2.

Treatment and Management

• Currently, there is no pharmacological intervention or vaccine available for all types of HFMD, although a formalin-inactivated EV-A71 vaccine has completed clinical trials in several Asian countries 2.
• Treatment is typically symptomatic, and children are particularly infectious until the blisters have disappeared 5.
• Supportive treatments, such as the administration of intravenous immunoglobulin and glucocorticoid therapies, may be used to manage severe neurological complications 3.

Next Best Step

• The next best step for the patient would be to monitor their symptoms and provide supportive care, such as hydration and pain management, to alleviate discomfort and prevent complications 3, 5.
• It is essential to be aware of the potential for severe neurological complications, such as meningoencephalitis and brainstem encephalitis, and to seek medical attention immediately if the patient's condition worsens 3, 4.