eMedicine Specialties > Pediatrics: General Medicine > Dermatology

Zoster: Differential Diagnoses & Workup

Author: Camila K Janniger, MD, Clinical Professor of Dermatology, Clinical Associate Professor of Pediatrics, Chief of Pediatric Dermatology, New Jersey Medical School
Coauthor(s): Andrea N Driano, MD, Consulting Staff, Department of Emergency Medicine, Children's Hospital and Medical Center, Seattle WA
Contributor Information and Disclosures

Updated: Apr 8, 2009

Differential Diagnoses

Acropustulosis
Herpes Simplex Virus Infection
Impetigo

Other Problems to Be Considered

Bell palsy
Cholecystitis and biliary colic
Coxsackievirus infection
Conjunctivitis
Corneal ulceration and ulcerative keratitis
Renal calculi
Trigeminal neuralgia
Poison ivy, poison oak, and poison sumac
Ramsay-Hunt syndrome
Herpes simplex virus infection: This infection may be recurrent and may appear in a dermatomal distribution, mimicking herpes zoster and leading to misdiagnosis if no confirmatory laboratory tests are performed.8

Workup

Laboratory Studies

  • Patient history and clinical findings are the primary basis for a herpes zoster (shingles) diagnosis. Although varicella zoster virus (VZV) can be cultured, its growth rate is usually too slow to make a timely contribution to diagnosis.
  • A Tzanck smear, prepared from fluid contained in vesicular lesions, confirms the lesion is herpetic. The test does not differentiate among herpes zoster (shingles), VZV (chickenpox), and herpes simplex.
  • Direct fluorescent assay (DFA) from vesicular fluid or corneal lesion can yield the varicella-zoster viral antigen.
  • A polymerase chain reaction (PCR) from vesicular fluid or corneal scraping can yield the VZV (chickenpox) nucleic acid.
  • Detection of VZV (chickenpox) DNA in plasma can facilitate the early recognition of VZV (chickenpox) infection in immunocompromised hosts.9

Histologic Findings

Skin biopsy may be performed to reveal an intraepidermal vesicle with degeneration of epidermal cells and acantholysis.

  • Typical signs such as multinucleated epithelial cells or "ghosts" of them are usually, but not invariably, evident.10
  • Lymphocytes may be found in the lower part of the epidermis, accompanied by a combination of spongiosis and vacuolar alteration.
  • The papillary dermis is often edematous.
  • Extravasated erythrocytes in variable numbers are a common finding.
  • A brisk lymphocytic infiltrate is present in the upper dermis.
  • Some of these lymphocytes may have large and polygonal nuclei. They are dense perivascular and sparse interstitial, superficial, and deep collections, sometimes assuming a patchy lichenoid pattern, and may be prominent in and around adnexal structures, often peppering follicles, sebaceous glands, and eccrine glands.
  • Neutrophils and nuclear dust are occasionally seen; eosinophils are rare.

Conventional microscopy is routinely used to confirm infection by herpesviruses, although, occasionally, polymerase chain reaction may then be used to show herpesvirus-specific DNA.

More on Zoster

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

  1. Nouri K, Ricotti CA Jr, Bouzari N, Chen H, Ahn E, Bach A. The incidence of recurrent herpes simplex and herpes zoster infection during treatment with arsenic trioxide. J Drugs Dermatol. Feb 2006;5(2):182-5. [Medline].

  2. Papadopoulos AJ, Birnkrant AP, Schwartz RA, Janniger CK. Childhood herpes zoster. Cutis. Jul 2001;68(1):21-3. [Medline].

  3. Ogita S, Terada K, Niizuma T, Kosaka Y, Kataoka N. Characteristics of facial nerve palsy during childhood in Japan: frequency of varicella-zoster virus association. Pediatr Int. Jun 2006;48(3):245-9. [Medline].

  4. Korber A, Franckson T, Grabbe S, Dissemond J. Ambilateral reactivation of herpes zoster V2 following cataract operation of both eyes. J Eur Acad Dermatol Venereol. May 2007;21(5):712-3. [Medline].

  5. Najjar DM, Youssef OH, Flanagan JC. Palpebral subconjunctival hemorrhages in herpes zoster ophthalmicus. Ophthal Plast Reconstr Surg. Mar-Apr 2008;24(2):162-4. [Medline].

  6. Sharma A, Makrandi S, Modi M, Sharma A, Marfatia Y. Immune reconstitution inflammatory syndrome. Indian J Dermatol Venereol Leprol. Nov-Dec 2008;74(6):619-21. [Medline].

  7. Strangfeld A, Listing J, Herzer P, et al. Risk of herpes zoster in patients with rheumatoid arthritis treated with anti-TNF-alpha agents. JAMA. Feb 18 2009;301(7):737-44. [Medline].

  8. Koh MJ, Seah PP, Teo RY. Zosteriform herpes simplex. Singapore Med J. Feb 2008;49(2):e59-60. [Medline].

  9. Kalpoe JS, Kroes AC, Verkerk S, et al. Clinical relevance of quantitative varicella-zoster virus (VZV) DNA detection in plasma after stem cell transplantation. Bone Marrow Transplant. Jul 2006;38(1):41-6. [Medline].

  10. Boer A, Herder N, Blodorn-Schlicht N, Falk T. Herpes incognito most commonly is herpes zoster and its histopathologic pattern is distinctive!. Am J Dermatopathol. Apr 2006;28(2):181-6. [Medline].

  11. Khaliq W, Alam S, Puri N. Topical lidocaine for the treatment of postherpetic neuralgia. Cochrane Database Syst Rev. 2007;(2):CD004846. [Medline].

  12. Caple J. Varicella-zoster virus vaccine: a review of its use in the prevention of herpes zoster in older adults. Drugs Today (Barc). Apr 2006;42(4):249-54. [Medline].

  13. van Hoek AJ, Gay N, Melegaro A, Opstelten W, Edmunds WJ. Estimating the cost-effectiveness of vaccination against herpes zoster in England and Wales. Vaccine. Feb 25 2009;27(9):1454-67. [Medline].

  14. Dworkin RH, White R, O'Connor AB, Hawkins K. Health care expenditure burden of persisting herpes zoster pain. Pain Med. Apr 2008;9(3):348-53. [Medline].

  15. Coen PG, Scott F, Leedham-Green M, et al. Predicting and preventing post-herpetic neuralgia: are current risk factors useful in clinical practice?. Eur J Pain. Nov 2006;10(8):695-700. [Medline].

  16. Courter BJ. Pediatric herpes zoster with mild cutaneous dissemination. Pediatr Emerg Care. Feb 1993;9(1):33-5. [Medline].

  17. Kucukardali Y, Solmazgul E, Terekeci H, Oncul O, Turhan V. Herpes zoster ophthalmicus and syndrome of inappropriate antidiuretic hormone secretion. Intern Med. 2008;47(5):463-5. [Medline].

  18. Lopez N, Alcaraz I, Cid-Manas J, et al. Wolf's isotopic response: zosteriform morphea appearing at the site of healed herpes zoster in a HIV patient. J Eur Acad Dermatol Venereol. Mar 18 2008;[Medline].

  19. Piette ML. Herpes zoster at school-age: a case presentation and discussion of the unique aspects within the pediatric population. Hawaii Med J. Jul 1996;55(7):118-21. [Medline].

  20. Quan D, Hammack BN, Kittelson J, Gilden DH. Improvement of postherpetic neuralgia after treatment with intravenous acyclovir followed by oral valacyclovir. Arch Neurol. Jul 2006;63(7):940-2. [Medline].

  21. Smith CG, Glaser DA. Herpes zoster in childhood: case report and review of the literature. Pediatr Dermatol. May-Jun 1996;13(3):226-9. [Medline].

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

  23. Wung PK, Holbrook JT, Hoffman GS, et al. Herpes zoster in immunocompromised patients: incidence, timing, and risk factors. Am J Med. Dec 2005;118(12):1416. [Medline].

  24. Wurzel CL, Kahan J, Heitler M, Rubin LG. Prognosis of herpes zoster in healthy children. Am J Dis Child. May 1986;140(5):477-8. [Medline].

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Further Reading

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Keywords

zoster, herpes zoster, shingles, varicella-zoster virus, VZV, chickenpox, vesicular rash, human immunodeficiency virus, HIV, cardiac transplant, renal transplant, appendicitis, renal calculi, biliary colic, myeloma, colon cancer, lymphadenopathy, treatment, diagnosis

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Contributor Information and Disclosures

Author

Camila K Janniger, MD, Clinical Professor of Dermatology, Clinical Associate Professor of Pediatrics, Chief of Pediatric Dermatology, New Jersey Medical School
Camila K Janniger, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Coauthor(s)

Andrea N Driano, MD, Consulting Staff, Department of Emergency Medicine, Children's Hospital and Medical Center, Seattle WA
Disclosure: Nothing to disclose.

Medical Editor

Kevin P Connelly, DO, Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University; Medical Director, Paws for Health Pet Visitation Program of the Richmond SPCA; Pediatric Emergency Physician, Emergency Consultants Inc, Chippenham Medical Center
Kevin P Connelly, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

CME Editor

Merrily P M Poth, MD, Professor, Department of Pediatrics and Neuroscience, Uniformed Services University of the Health Sciences
Merrily P M Poth, MD is a member of the following medical societies: American Academy of Pediatrics, Endocrine Society, and Lawson-Wilkins Pediatric Endocrine Society
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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