Author: Harris Ahmed, MPH
Co Author #1: Morgan Long
Co Author #2: Samuel Richardson
Co Author #3: Mohammed Mortazavi, MD

Patient Presentation:
Our patient is a 16-year-old Hispanic male who initially presented to the Emergency Room one day after sustaining a right-sided head injury associated with a brief loss of consciousness during football practice.

His presenting symptoms included a severe frontal retro-orbital headache, achy and throbbing forehead pain radiating into his eyes, photophobia, hyperacusis, dizziness, neck pain, and cervical spine tenderness. He was diagnosed with a concussion.

Three days after his initial injury, the patient was re-evaluated in the emergency department due to progressive right eye pain, headache, nausea and vomiting, a new painful rash over the right face Case Photo #5 , severe right-sided facial pain, and bilateral photophobia noted to be slightly worse on the right. He was given intravenous pain medications and anti-emetics, and he was discharged with directions to follow up with Infectious Disease, Ophthalmology, and Concussion Clinic. On presentation to the Concussion Clinic six days after his injury, the patient completed a sports concussion assessment tool (SCAT), scoring 80 of 132 on the symptom severity score.

History:
There was no personal history of immunodeficiency, autoimmune disease, sexually transmitted diseases, Herpes Simplex, Varicella Zoster (Chickenpox), Herpes Zoster (Shingles), or close contact with Varicella or Herpes Simplex patients. Patient had received live Varicella vaccine in childhood.

Physical Exam:
Physical Exam within the Concussion Clinic
General: Slight distress
Skin: erythematous maculopapular rash in a dermatomal distribution on the right forehead with vesicles on an erythematous base Case Photo #5
Head, Eyes, Ears, Nose, Throat: extra-ocular movements intact, pupils equally round and reactive to light and accommodation, severe photophobia on right
Neck: non-tender over cervical spine, full range of motion, with end range stiffness
Psychiatric: within age expected normal limits
Neurologic and Muscloskeletal: Cranial nerves II through XII grossly intact, severe tenderness along the cranial nerve V1 dermatome. Motor and sensory testing intact in all four extremities. Normal muscle bulk and tone throughout. Deep tendon reflexes +2 and symmetric in all four extremities. Normal gait.
Balance Error Scoring System (BESS) testing: double leg-0 errors, tandem-2 errors, single-deferred

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