Laboratory Studies

Confirmation methods for lab testing are the following:

PCR to detect VZV DNA from the base of a deroofed vesicular lesion is the most reliable and sensitive method, and is now considered the gold standard. False-negative PCR results are more likely to occur from lesions in vaccinated persons.
Direct immunofluorescence (DFA) to detect VZV antigen is the second choice; sensitivity is only 60–70% of cases detectable by PCR.
Viral culture of VZV is possible but is insensitive, time-consuming, and expensive because it requires special media.
Serologic tests may be used to confirm disease but are less reliable than PCR or DFA for virus identification. A fourfold or greater rise in serum varicella IgG titers from acute- and convalescent-phase samples indicates a recent VZV infection. However, persons in whom vaccination produced a high VZV IgG titer may not achieve the required fourfold increase in the convalescent sample. Serologic tests are also less useful in immunocompromised people who are less likely to mount an effective immune response. Testing for VZV IgM by using commercial kits is not recommended because available methods lack sensitivity and specificity.

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 two to 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.

Treatment & Management

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Media Gallery

Typical zoster in the vicinity of right popliteal fossa in a vertebral nerve L4 distribution.
Human herpesvirus (HHV) type 3. Intraoral herpes zoster closely resembles recurrent HHV-1 infection, but the lesions generally follow a dermatome and stop sharply at the midline, as shown here. However, the rules for common sites of occurrence of HHV-1 and HHV-3 often do not apply to patients who are immunocompromised. Courtesy of Sheldon Mintz, DDS.

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Author

Zartash Zafar Khan, MD, FACP Infectious Disease Consultant

Zartash Zafar Khan, MD, FACP is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America, International Society for Infectious Diseases

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Pranatharthi Haran Chandrasekar, MBBS, MD Professor, Chief of Infectious Disease, Department of Internal Medicine, Wayne State University School of Medicine

Pranatharthi Haran Chandrasekar, MBBS, MD is a member of the following medical societies: American College of Physicians, American Society for Microbiology, International Immunocompromised Host Society, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

Wayne E Anderson, DO, FAHS, FAAN Assistant Professor of Internal Medicine/Neurology, College of Osteopathic Medicine of the Pacific Western University of Health Sciences; Clinical Faculty in Family Medicine, Touro University College of Osteopathic Medicine; Clinical Instructor, Departments of Neurology and Pain Management, California Pacific Medical Center

Wayne E Anderson, DO, FAHS, FAAN is a member of the following medical societies: American Academy of Neurology, American Headache Society, California Medical Association, California Neurology Society, International Headache Society, San Francisco Medical Society, San Francisco Neurological Society

Disclosure: Nothing to disclose.

Maria D Mileno, MD Associate Professor of Medicine, Division of Infectious Diseases, The Warren Alpert Medical School of 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, Sigma Xi, The Scientific Research Honor Society

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of prior coauthor Amar Safdar, MD, to the development and writing of this article.