Pediatric Herpes Zoster Workup

  • Author: Camila K Janniger, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: May 11, 2011
 

Approach Considerations

Patient history and clinical findings are the primary basis for a herpes zoster (shingles) diagnosis.

Go to Herpes Zoster, Herpes Zoster Ophthalmicus, and Herpes Zoster Oticus for complete information on these topics.

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Lab Studies

Culture

Although varicella zoster virus (VZV) can be cultured, its growth rate is usually too slow to make a timely contribution to diagnosis.

Tzanck smear

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

Direct fluorescent assay (DFA) from vesicular fluid or a corneal lesion can yield the varicella-zoster viral antigen.

Polymerase chain reaction

A polymerase chain reaction (PCR) from vesicular fluid or a corneal scraping can yield the VZV (chickenpox) nucleic acid.

Detection of VZV deoxyribonucleic acid (DNA) in plasma can facilitate the early recognition of VZV infection in immunocompromised hosts.[13]

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Skin Biopsy 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.[14] 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. The lymphocytes 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, PCR may then be used to show herpesvirus-specific DNA.

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Slit-Lamp Examination

Physical examination should include a slit-lamp examination to identify corneal findings if lesions are found in the distribution of the V1 branch of the trigeminal nerve. Lesions that appear on the tip of the nose indicate the presence of dendritic corneal lesions of herpetic keratitis along the course of the nasociliary nerve. Immediately refer children with zoster that involves the first branch of the trigeminal nerve to an ophthalmologist.

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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.

Specialty Editor Board

Kevin P Connelly, DO  Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University School of Medicine; 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.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

Robert A Schwartz, MD, MPH  Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, University of Medicine and Dentistry of New Jersey-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.

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.

References

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  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].

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  13. 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].

  14. 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].

  15. Sanford M, Keating GM. Zoster vaccine (Zostavax): a review of its use in preventing herpes zoster and postherpetic neuralgia in older adults. Drugs Aging. 2010;27(2):159-76. [Medline].

  16. 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].

  17. 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].

  18. Schmader K, Levin M, Gnann J, McNeil S, Vesikari T, et al. Efficacy, immunogenicity, safety, and tolerability of zoster vaccine (ZV) in subjects 50 to 59 years of age (Poster/Abstract). Infectious Diseases Society of America. The 48th Annual Meeting of the Infectious Diseases Society of America. 10-21-2010;Vancouver, British Columbia, Canada:Ref Type: Abstract: 3363.

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

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