eMedicine Specialties > Infectious Diseases > Viral Infections

Varicella-Zoster Virus: Differential Diagnoses & Workup

Author: Wayne E Anderson, DO, Assistant Professor of Internal Medicine/Neurology, Western University of Health Sciences; Assistant Professor of Family Medicine, Touro University College of Osteopathic Medicine; Consulting Staff in Pain Management, Department of Neurology, California Pacific Medical Center
Contributor Information and Disclosures

Updated: Aug 19, 2009

Differential Diagnoses

Acute Nerve Injury
Meningitis
Cauda Equina
Meningococcal Infections
Chronic Fatigue Syndrome
Meningococcemia
Electrical Injuries
Poxviruses
Eosinophilic Fasciitis
Spinal Cord Abscess
Fibromyalgia
Spinal Hematoma
Herpangina
Spinal Stenosis
Herpes Simplex
Streptococcus Group A Infections
Impetigo
Lumbar Disc Disease
Lumbar Spondylosis

Other Problems to Be Considered

Lumbar muscle strain
Sciatica
Cervical spinal cord transection

Workup

Laboratory Studies

  • When the presentation includes the typical dermatomal rash, additional studies are not required.
  • If the diagnosis is in doubt, a Tzanck smear can be performed and has a sensitivity of about 60%. To obtain a Tzanck smear, remove the crust from a vesicle and scrape the underlying moist skin with a No. 15 surgical blade. Smear the cells from the vesicle base onto a slide, fix for 1 minute with absolute alcohol, and stain with Wright stain (other staining methods can also be used).
  • The diagnosis can also be confirmed with a culture of vesicular fluid that is positive for varicella-zoster virus (VZV).
  • In cases of zoster sine herpete, DNA analysis via polymerase chain reaction (PCR) can be used for early diagnosis if laboratory turnaround time is reasonably short. If not, the decision of whether to start empiric acyclovir must be based on clinical grounds alone.

Imaging Studies

  • MRI may be useful if myelitis or encephalitis is suspected.

Procedures

  • Lumbar puncture may be helpful if signs suggest myelitis or encephalitis. The cerebrospinal fluid (CSF) shows increased levels of protein and pleocytosis because the inflammatory response involves the leptomeninges. CSF PCR can be used to detect VZV DNA.
  • Although seldom necessary, biopsy results provide a definitive diagnosis.

Histologic Findings

  • The varicella zoster virus is a DNA virus with a genome that encodes 70 proteins.
  • The Tzanck preparation shows characteristic findings of giant cells with 2-15 nuclei. Recently infected epithelial cells contain a single enlarged nucleus with a thick nuclear membrane.
  • After reactivation, meningeal biopsy samples show a local inflammatory response, consisting of plasma cells and lymphocytes, that encompasses the leptomeninges.
  • Evidence has shown that motor neuron involvement is demyelinating rather than axonal.

More on Varicella-Zoster Virus

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

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  2. Kubeyinje EP. Cost-benefit of oral acyclovir in the treatment of herpes zoster. Int J Dermatol. Jun 1997;36(6):457-9. [Medline].

  3. [Best Evidence] Dworkin RH, Barbano RL, Tyring SK, Betts RF, McDermott MP, Pennella-Vaughan J, et al. A randomized, placebo-controlled trial of oxycodone and of gabapentin for acute pain in herpes zoster. Pain. Apr 2009;142(3):209-17. [Medline].

  4. Galil K, Choo PW, Donahue JG, Platt R. The sequelae of herpes zoster. Arch Intern Med. Jun 9 1997;157(11):1209-13. [Medline].

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Keywords

varicella-zoster virus, VZV, VZV infection, varicella-zoster virus infection, herpes zoster, shingles, zoster, postherpetic neuralgia, PHN, disseminated VZV infection, VZV encephalitis, varicella-zoster virus encephalitis, chickenpox, disseminated varicella-zoster virus infection, keratitis, herpes ophthalmicus, myelitis, impetiginization, zoster multiplex, zoster duplex unilateralis, zoster sine herpete, Ramsay-Hunt syndrome

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Contributor Information and Disclosures

Author

Wayne E Anderson, DO, Assistant Professor of Internal Medicine/Neurology, Western University of Health Sciences; Assistant Professor of Family Medicine, Touro University College of Osteopathic Medicine; Consulting Staff in Pain Management, Department of Neurology, California Pacific Medical Center
Wayne E Anderson, DO is a member of the following medical societies: American Academy of Neurology, American Medical Association, American Society of Law Medicine and Ethics, California Medical Association, and San Francisco Medical Society
Disclosure: Cephalon Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching; King Honoraria Consulting

Medical Editor

Maria D Mileno, MD, Assistant Professor, Department of Internal Medicine, Division of Infectious Diseases, Brown University
Maria D Mileno, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, International Society of Travel Medicine, and Sigma Xi
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Gordon L Woods, MD, Consulting Staff, Department of Internal Medicine, University Medical Center
Gordon L Woods, MD is a member of the following medical societies: Society of General Internal Medicine
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

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.

 
 
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