Vesicular lesion at the tip of the nose

 Q; 52 years old male with history of renal insufficiency is recovering in ICU from community-acquired pneumonia. The patient develops zoster-like vesicular lesion at the tip and side of the nose. What's the underlying danger? 

Answer: Herpes zoster ophthalmicus (HZO) 

It is called Hutchinson's sign. Vesicular lesion at the tip or the side of nose highly correlates with involvement of the eye. This represents involvement of the nasociliary branch of ophthalmic division of trigeminal nerve, which innervates the globe of the eye. 

HZO is an ophthalmic emergency as it can threaten vision. It may be associated with hyperemic conjunctivitis, uveitis, episcleritis, or keratitis.

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References:

1. Tomkinson A, Roblin DG, Brown MJ. Hutchinson's sign and its importance in rhinology. Rhinology 1995; 33:180. 

2. Zaal MJ, Völker-Dieben HJ, D'Amaro J. Prognostic value of Hutchinson's sign in acute herpes zoster ophthalmicus. Graefes Arch Clin Exp Ophthalmol 2003; 241:187. 

3. Liesegang TJ. Herpes zoster ophthalmicus natural history, risk factors, clinical presentation, and morbidity. Ophthalmology 2008; 115:S3. 

4. Szeto SK, Chan TC, Wong RL, et al. Prevalence of Ocular Manifestations and Visual Outcomes in Patients With Herpes Zoster Ophthalmicus. Cornea 2017; 36:338.