eMedicine Specialties > Ophthalmology > Infectious Disease

Herpes Zoster: Differential Diagnoses & Workup

Author: Manolette R Roque, MD, MBA, President and CEO, Service Chief of Ocular Immunology and Uveitis, Refractive Surgery, EYE REPUBLIC Ophthalmology Clinic; General Manager, Ophthalmic Consultants Philippines; Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, Asian Hospital and Medical Center; Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, St. Luke's Medical Center Global City; Senior Eye Surgeon, The LASIK Surgery Clinic; Senior Eye Surgeon, Precise Eye Laser Center
Coauthor(s): Barbara L Roque, MD, Full Partner, Ophthalmic Consultants Philippines Co, Chief of Service, Pediatric Ophthalmology and Strabismus, Consulting Staff, Orbit and Eye Plastics, Eye Republic Ophthalmology Clinic; C Stephen Foster, MD, FACS, FACR, FAAO, Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Founder and President, Ocular Immunology and Uveitis Foundation, Massachusetts Eye Research and Surgery Institution
Contributor Information and Disclosures

Updated: Dec 17, 2009

Differential Diagnoses

Bell Palsy
Horner Syndrome
Burns, Chemical
Keratitis, Herpes Simplex
Conjunctivitis, Viral
Keratopathy, Neurotrophic
Corneal Erosion, Recurrent
Molluscum Contagiosum
Entropion
Ocular Manifestations of HIV
Episcleritis
Scleritis
Exophthalmos
Trigeminal Neuralgia
Glaucoma, Uveitic
Uveitis, Evaluation and Treatment
Headache, Migraine
Herpes Simplex
HIV

Other Problems to Be Considered

Traumatic abrasions
Paralytic ptosis
Cicatricial lid retraction or loss
Iridocyclitis
Cataract
Postherpetic neuralgia
Orbital apex syndrome
Inflammatory syndromes
Argyll Robertson pupil
Retinitis
Choroiditis
Optic neuritis
Extraocular muscle palsies
Cluster headache
Tension headache
Otitis externa
Otitis media
Hemorrhagic stroke
Ischemic stroke
Isolated facial nerve trauma

Workup

Laboratory Studies

  • Herpes zoster is diagnosed mostly on the basis of the characteristic pain and appearance of the dermatomal rashes. More often than not, laboratory tests are unnecessary. Empiric treatment, when indicated, should not be delayed pending the results of diagnostic tests.
  • On rare occasion that a differential diagnosis of several skin lesions must be made, confirmatory laboratory examinations may be undertaken. These tests include morphologic, immunomorphologic, viral isolation, serologic, and cellular immunity tests.
  • Morphologic tests may involve the Tzanck staining techniques (eg, Giemsa, Wright, and/or Papanicolaou staining and light and/or electron microscopy).
    • Tzanck smears are regarded as simple procedures for the rapid presumptive diagnosis of VZV.
    • Typical findings are multinucleated giant syncytial cells, homogenization of nuclear chromatin, and acidophilic intranuclear antibodies with faceted contours. These results may help in identifying the herpes virus, but they cannot be used to distinguish VZV.
  • Scrapings for smears and cultures are usually negative, and biopsy is required for definitive diagnosis. Biopsy typically includes culture and histopathologic examination with special stains and/or polymerase chain reaction of extracted DNA.64,65
  • Immunologic tests for viral antigen
    • Direct immunofluorescence or immunoperoxidase stains
    • Radioimmunoassay
    • Enzyme-linked immunosorbent assay
    • Agar gel immunodiffusion
    • Immunoelectrophoresis
  • Molecular biology of VZV DNA66,67,68
    • In situ hybridization
    • Polymerase chain reaction

Other Tests

  • Cell-mediated immunity testing
    • VZV antigen skin test
    • VZV lymphocyte proliferation
  • Serology for VZV antibodies
    • Neutralizing or complement-fixing antibody tests
    • Enzyme-linked immunosorbent assay
    • Radioimmunoassay
    • Membrane antigen immunofluorescence
    • Immune adherence hemagglutination

Procedures

  • Biopsy for direct immunofluorescence testing (see Lab Studies)

Histologic Findings

Histopathologic findings result from viral replication, secondary inflammation, and vascular occlusion. The pathologic hallmark of reactivating herpes zoster is ganglionic inflammation and hemorrhagic necrosis of the ganglion and corresponding sensory nerve.

Characteristic findings in involved areas include the following: multinucleated giant cells, intranuclear inclusion bodies, ballooning and reticular degeneration, acantholytic keratinocytes, and perivascular infiltrate (polymorphonuclear neutrophils [PMNs] and mononuclear cells).

In chronic herpes zoster infections, a granulomatous reaction (epithelioid and multinucleated giant cells) may be found intraocularly (eg, ciliary body, choroid, retina).

More on Herpes Zoster

Overview: Herpes Zoster
Differential Diagnoses & Workup: Herpes Zoster
Treatment & Medication: Herpes Zoster
Follow-up: Herpes Zoster
Multimedia: Herpes Zoster
References
Further Reading
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Further Reading

Guidelines

Recommendations for the management of herpes zoster.

Prevention of herpes zoster. Recommendations of the Advisory Committee on Immunization Practices (ACIP).

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Keywords

herpes zoster, herpes zoster ophthalmicus, varicella-zoster virus, chickenpox, shingles, varicella, postherpetic neuralgia, herpes zoster oticus, Ramsay Hunt Syndrome, dermatomal zoster, zona, Hutchinson sign, VZV, HZO

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Contributor Information and Disclosures

Author

Manolette R Roque, MD, MBA, President and CEO, Service Chief of Ocular Immunology and Uveitis, Refractive Surgery, EYE REPUBLIC Ophthalmology Clinic; General Manager, Ophthalmic Consultants Philippines; Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, Asian Hospital and Medical Center; Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, St. Luke's Medical Center Global City; Senior Eye Surgeon, The LASIK Surgery Clinic; Senior Eye Surgeon, Precise Eye Laser Center
Manolette R Roque, MD, MBA is a member of the following medical societies: American Academy of Ophthalmic Executives, American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, American Society of Ophthalmic Administrators, American Uveitis Society, International Ocular Inflammation Society, Philippine Medical Association, Philippine Ocular Inflammation Society, and Philippine Society of Cataract and Refractive Surgery
Disclosure: Nothing to disclose.

Coauthor(s)

Barbara L Roque, MD, Full Partner, Ophthalmic Consultants Philippines Co, Chief of Service, Pediatric Ophthalmology and Strabismus, Consulting Staff, Orbit and Eye Plastics, Eye Republic Ophthalmology Clinic
Disclosure: Nothing to disclose.

C Stephen Foster, MD, FACS, FACR, FAAO, Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Founder and President, Ocular Immunology and Uveitis Foundation, Massachusetts Eye Research and Surgery Institution
C Stephen Foster, MD, FACS, FACR, FAAO is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Association of Immunologists, American College of Rheumatology, American College of Surgeons, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, American Uveitis Society, Association for Research in Vision and Ophthalmology, Massachusetts Medical Society, Royal Society of Medicine, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Kilbourn Gordon III, MD, FACEP, Urgent Care Physician
Kilbourn Gordon III, MD, FACEP is a member of the following medical societies: American Academy of Ophthalmology and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

R Christopher Walton, MD, Professor, Director of Uveitis and Ocular Inflammatory Disease Service, Department of Ophthalmology, Assistant Dean for Graduate Medical Education, University of Tennessee College of Medicine; Consulting Staff, Regional Medical Center, Memphis Veterans Affairs Medical Center, St Jude Children's Research Hospital
R Christopher Walton, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Healthcare Executives, American Uveitis Society, Association for Research in Vision and Ophthalmology, and Retina Society
Disclosure: Nothing to disclose.

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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