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Skin-nontumor / Clinical Dermatology

Infectious disorders

Herpes simplex or varicella zoster

Reviewer: Mowafak Hamodat MB.CH.B, MSc., FRCPC, Eastern Health, St. Johns (Canada) (see Reviewers page)
Revised: 21 November 2010, last major update September 2010
Copyright: (c) 2002-2010, PathologyOutlines.com, Inc.


● Painful diseases caused by herpes simplex virus (HSV) or varicella zoster virus (VZV, also causes chickenpox)

Clinical features

● For both viruses, after primary infection, viral particles reside in sensory ganglia and are dormant until they erupt as recurrent herpes simplex virus or shingles (zoster)
● The two viruses are differentiated by culture (difficult to culture zoster) or immunologic methods

Herpes simplex:
● Historically, HSV1 was associated with herpes labialis (90%), and HSV2 was associated with herpes genitalis (90%), although in some recent studies, most genital lesions are caused by HSV1
● Visceral involvement is most often seen in the lung, liver and brain
● Today, diagnosis is often confirmed by PCR or immunohistochemistry
● The multinucleated cells are the diagnostic features of the historic Tzank test, a Giemsa stained smear of vesicle contents
● In the past, the laboratory diagnosis of herpes infection was confirmed by growth in tissue culture, electron microscopy, immunofluorescence of viral specific protein or viral DNA hybridization

Varicella zoster
● Varicella zoster is associated with leukemia and lymphoma, SLE and post-radiation or post-chemotherapy status
● Occurs in 40-50% of patients in the first year following bone marrow transplantation
● Shingles has dermatomal distribution or severe involvement of trigeminal nerve-first division (ophthalmic division) with corneal ulceration and herpetic keratitis

Case reports

● 37 year old HIV+ man with nodules on leg due to zoster (Pacific Dermatologic Association)

Clinical description

● Grouped vesicles on an erythematous base, later become pustules, then crusts


● Acyclovir; also valacyclovir, penciclovir and famciclovir (eMedicine)

Clinical images


Dermatomal distribution of zoster

Verrucous varicella-zoster on leg


Micro description

● Keratinocytes are multinucleated, acantholytic with distinct nuclear inclusions, found initially in follicular epithelium
● Late epidermal necrosis or full-thickness acantholysis
● Dermal nerve twigs may exhibit a perineural infiltrate of lymphocytes and neutrophils, sometimes associated with intraneural involvement
● Schwann cell hypertrophy and frank neural necrosis are occasionally encountered

Micro images


Multinucleated cells, some with intranuclear inclusions

Virtual slides


Herpes                         Varicella

End of Skin-nontumor / Clinical Dermatology > Infectious disorders > Herpes simplex or varicella zoster

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