Herpes Zoster Clinical Presentation

  • Author: James E Moon, MD; Chief Editor: Steven C Dronen, MD, FAAEM   more...
 
Updated: May 11, 2011
 

History

Prodromal pain precedes the rash in approximately 70-80% of patients; it is typically confined to the same dermatomal distribution as the rash. In immunocompetent patients, herpes zoster is generally restricted to one dermatome, with possible limited involvement of adjacent dermatomes due to normal variations in innervation. Many patients describe the pain as "burning," "throbbing," or "stabbing." It may be severe, mild, constant, rare, or felt as another sensation such as pruritus. The involved area may be tender to palpation.[16]

After 48-72 hours, or longer in some cases, the rash develops. Initially, and briefly, maculopapular lesions rapidly transition to vesicles in 1-2 days. New vesicles tend to form over 3-5 days, sometimes coalescing to form bullae. The lesions then rupture and release their contents, ulcerate, crust over, and dry, over 7-10 days. As with chickenpox, once crusting occurs, the lesions are no longer infectious.

Depending on the dermatome involved, additional physical examination findings may include the following:

  • Corneal ulcers, conjunctivitis
  • Regional lymphadenopathy
  • Cranial nerve palsies
  • Peripheral facial nerve palsy
  • Delirium, confusion, coma (in patients with meningoencephalitis)
  • Loss of taste in the anterior tongue (in Ramsay Hunt Syndrome)

Symptomatic involvement of multiple dermatomes or bilateral aspects of the same dermatome (ie, crossing the midline) may indicate disseminated disease or another etiology such as herpes simplex virus (HSV) infection.

Symptoms and lesions tend to resolve over 10-15 days. However, lesions may require up to 1 month to completely heal. Scarring and hyperpigmentation or hypopigmentation at lesion sites may persist for a long period or may be permanent. Pain duration is variable but is usually less than 1 month. Pain lasting longer than 1 month is referred to, by definition, as postherpetic neuralgia.

Less than 20% of patients have systemic symptoms, such as headache, fever, malaise, or fatigue, at any point during a case of herpes zoster.[16]

Herpes zoster may develop without the typical rash, as aseptic meningitis or zoster sine herpete, which is a condition defined as pain and paresthesias along a dermatome without the development of visible cutaneous involvement.

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Physical Examination

The primary physical finding is a rash in a unilateral dermatomal distribution. The rash may be erythematous, maculopapular, vesicular, pustular, or crusting, depending on the stage of disease. Note the images below.

Herpes zoster on the neck. Herpes zoster on the neck. Suspected Zoster of the Hand Suspected Zoster of the Hand

Lesions on the tip of the nose signify involvement of the nasociliary nerve. This finding mandates slit-lamp examination with fluorescein stain to look for the dendritic corneal lesions of herpetic keratitis.

As previously mentioned, in an uncertain number of cases, zoster may manifest without rash or vesicles, with only pain in a dermatomal distribution (ie, zoster sine herpete).

Herpes zoster ophthalmicus

Presentations of HZO are diverse. In addition to the classic symptoms and lesions of herpes zoster, other common manifestations include conjunctivitis, scleritis, episcleritis, keratitis iridocyclitis, Argyll-Robertson pupil, glaucoma, retinitis, choroiditis, optic neuritis, optic atrophy, retrobulbar neuritis, exophthalmos, lid retraction, ptosis, and extraocular muscle palsies.

HZO may appear weeks to months after the resolution of other symptoms.

Postherpetic neuralgia and long-term sequelae may result.

When the nasociliary branch is involved, vesicles may appear on the tip or side of the nose (Hutchinson sign). Such a presentation is a predictor for possible serious complications, such as ocular inflammation and corneal denervation.

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Contributor Information and Disclosures
Author

James E Moon, MD  Clinical Investigator, Department of Clinical Trials, Walter Reed Army Institute of Research and Assistant Professor, Department of Medicine, Uniformed Service University of Health Sciences

Disclosure: Nothing to disclose.

Coauthor(s)

Duane R Hospenthal, MD, PhD  Chief, Infectious Disease Service, San Antonio Military Medical Center, Brooke Army Medical Center; Professor of Medicine, Uniformed Services University of the Health Sciences

Duane R Hospenthal, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Armed Forces Infectious Diseases Society, Association of Military Surgeons of the US, Infectious Diseases Society of America, International Society for Infectious Diseases, International Society of Travel Medicine, and Medical Mycology Society of the Americas

Disclosure: Nothing to disclose.

Richard S Krause, MD  Senior Clinical Faculty/Clinical Assistant Professor, Department of Emergency Medicine, University of Buffalo State University of New York School of Medicine and Biomedical Sciences

Richard S Krause, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Mark R Wallace, MD, FACP, FIDSA  Clinical Professor of Medicine, Florida State University College of Medicine; Head of Infectious Disease Fellowship Program, Orlando Regional Medical Center

Mark R Wallace, MD, FACP, FIDSA is a member of the following medical societies: American College of Physicians, American Medical Association, American Society of Tropical Medicine and Hygiene, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Specialty Editor Board

Jeffrey Glenn Bowman, MD, MS  Consulting Staff, Highfield MRI

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Eric L Weiss, MD, DTM&H  Director of Stanford Travel Medicine, Medical Director of Stanford Lifeflight, Assistant Professor, Departments of Emergency Medicine and Infectious Diseases, Stanford University School of Medicine

Eric L Weiss, MD, DTM&H is a member of the following medical societies: American College of Emergency Physicians, American College of Occupational and Environmental Medicine, American Medical Association, American Society of Tropical Medicine and Hygiene, Physicians for Social Responsibility, Southeastern Surgical Congress, Southern Association for Oncology, Southern Clinical Neurological Society, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Burke A Cunha, MD  Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM  Chair, Department of Emergency Medicine, LeConte Medical Center

Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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Herpes zoster on the neck.
Herpes zoster on the lateral part of the abdomen.
Suspected Zoster of the Hand
Maculopapular rash due to herpes zoster in a child with a history of leukemia. Courtesy of the CDC.
 
 
 
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