eMedicine Specialties > Emergency Medicine > Infectious Diseases

Herpes Zoster: Differential Diagnoses & Workup

Author: Richard S Krause, MD, Senior Faculty, Department of Emergency Medicine, State University of New York at Buffalo School of Medicine
Contributor Information and Disclosures

Updated: Nov 23, 2009

Differential Diagnoses

Appendicitis, Acute
Herpes Simplex
Bell Palsy
Herpes Zoster
Cholecystitis and Biliary Colic
Herpes Zoster Ophthalmicus
Conjunctivitis
Herpes Zoster Oticus
Corneal Ulceration and Ulcerative Keratitis
Renal Calculi
Glaucoma, Acute Angle-Closure
Trigeminal Neuralgia

Other Problems to Be Considered

Coxsackievirus
Superficial pyoderma

Workup

Laboratory Studies

  • Diagnosis of herpes zoster is based primarily on clinical findings, specifically the characteristic location and appearance of the skin eruption in association with localized pain. However, in some patients, the presentation of herpes zoster can be atypical and may require additional testing. This is particularly true in immunocompromised patients.
  • Varicella-zoster virus can be cultured successfully; this has limited use in the ED due to the long time required for viral growth.
  • If necessary, a definitive diagnosis can be confirmed by sending swabs to the laboratory. 
    • Lift the top of the lesion and swab the exposed base. The swab should then be rolled across a sterile glass side, which is air dried and sent to the laboratory for staining with immunofluorescent antibodies.
    • The swab can also be placed in viral transport medium for detection of viral DNA by polymerase chain reaction.
  • Tzanck smear can be obtained from the vesicular lesions; however, the smear does not differentiate between varicella-zoster virus and other herpes virus infections such as herpes simplex.
    • A Tzanck smear is a simple test that may be performed by the clinician or in a laboratory.
      • A fresh blister is unroofed and material from the base is smeared on a slide.
      • Wright stain is applied, and the smear is examined under the microscope.
      • A positive result shows distinctive giant cells with multiple nuclei.
      • This test has a significant false-negative rate of at least 20%. Therefore, a negative result does not rule out a herpes virus infection and should not preclude empiric treatment.
  • Empiric treatment, when indicated, should not be delayed pending the results of diagnostic tests.

Imaging Studies

  • No imaging tests are indicated in typical cases of cutaneous VZ infection.

Other Tests

  • Monoclonal antibody tests
  • Blood mononuclear cell testing for viral DNA (research)

Procedures

  • Biopsy for direct immunofluorescence testing (rarely performed)

More on Herpes Zoster

Overview: Herpes Zoster
Differential Diagnoses & Workup: Herpes Zoster
Treatment & Medication: Herpes Zoster
Follow-up: Herpes Zoster
Multimedia: Herpes Zoster
References
[ CLOSE WINDOW ]

References

  1. Donahue JG, Choo PW, Manson JE, Platt R. The incidence of herpes zoster. Arch Intern Med. Aug 1995;155(15):1605-9. [Medline].

  2. [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].

  3. [Best Evidence] Irving G, Jensen M, Cramer M, Wu J, Chiang YK, Tark M, et al. Efficacy and tolerability of gastric-retentive gabapentin for the treatment of postherpetic neuralgia: results of a double-blind, randomized, placebo-controlled clinical trial. Clin J Pain. Mar-Apr 2009;25(3):185-92. [Medline].

  4. Dworkin RH, Johnson RW, Breuer J, Gnann JW, Levin MJ, Backonja M, et al. Recommendations for the management of herpes zoster. Clin Infect Dis. Jan 1 2007;44 Suppl 1:S1-26. [Medline].

  5. Beutner KR, Friedman DJ, Forszpaniak C, Andersen PL, Wood MJ. Valaciclovir compared with acyclovir for improved therapy for herpes zoster in immunocompetent adults. Antimicrob Agents Chemother. Jul 1995;39(7):1546-53. [Medline].

  6. Colin J, Prisant O, Cochener B, Lescale O, Rolland B, Hoang-Xuan T. Comparison of the efficacy and safety of valaciclovir and acyclovir for the treatment of herpes zoster ophthalmicus. Ophthalmology. Aug 2000;107(8):1507-11. [Medline].

  7. Whitley RJ, Weiss H, Gnann JW Jr, Tyring S, Mertz GJ, Pappas PG, et al. Acyclovir with and without prednisone for the treatment of herpes zoster. A randomized, placebo-controlled trial. The National Institute of Allergy and Infectious Diseases Collaborative Antiviral Study Group. Ann Intern Med. Sep 1 1996;125(5):376-83. [Medline].

  8. Tyring S, Engst R, Corriveau C, Robillard N, Trottier S, Van Slycken S, et al. Famciclovir for ophthalmic zoster: a randomised aciclovir controlled study. Br J Ophthalmol. May 2001;85(5):576-81. [Medline].

  9. National Center for Immunization and Respiratory Diseases. Varicella Vaccine - Q&A about High Risk. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/vaccines/vpd-vac/varicella/vac-faqs-clinic-highrisk.htm. Accessed December 11, 2008.

  10. Brody MB, Moyer D. Varicella-zoster virus infection. The complex prevention-treatment picture. Postgrad Med. Jul 1997;102(1):187-90, 192-4. [Medline].

  11. Kost RG, Straus SE. Postherpetic neuralgia--pathogenesis, treatment, and prevention. N Engl J Med. Jul 4 1996;335(1):32-42. [Medline].

  12. Nikkels AF, Pierard GE. Recognition and treatment of shingles. Drugs. Oct 1994;48(4):528-48. [Medline].

  13. Straus SE. Overview: the biology of varicella-zoster virus infection. Ann Neurol. 1994;35 Suppl:S4-8. [Medline].

  14. Wareham DW, Breuer J. Herpes zoster. BMJ. June 2007;334(7605):1211-1215. [Medline].

  15. Wood MJ. Current experience with antiviral therapy for acute herpes zoster. Ann Neurol. 1994;35 Suppl:S65-8. [Medline].

  16. Wood MJ, Johnson RW, McKendrick MW, Taylor J, Mandal BK, Crooks J. A randomized trial of acyclovir for 7 days or 21 days with and without prednisolone for treatment of acute herpes zoster. N Engl J Med. Mar 31 1994;330(13):896-900. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

herpes zoster, herpes zoster symptoms, herpes zoster treatment, shingles, zoster, herpesvirus, varicella-zoster virus, VZV, VZV infection, VZV reactivation, varicella-zoster virus infection, zoster sine herpete, chickenpox, chicken pox, vesicular rash, zoster keratitis, Ramsay Hunt syndrome, herpes zoster oticus, transitory unilateral facial paralysis, postherpetic neuralgia, disseminated zoster

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Richard S Krause, MD, Senior Faculty, Department of Emergency Medicine, State University of New York at Buffalo School of Medicine
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.

Medical Editor

Jeffrey Glenn Bowman, MD, MS, Consulting Staff, Highfield MRI, Columbus, Ohio
Disclosure: Nothing to disclose.

Pharmacy Editor

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

Managing Editor

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.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM, Director of Emergency Services, Director of Chest Pain Center, Department of Emergency Medicine, Ft Sanders Sevier 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.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.