Herpes zoster differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; L. Katie Morrison, MD; Associate Editor(s)-in-Chief: Varun Kumar, M.B.B.S. [2]; João André Alves Silva, M.D. [3]; Sara Mehrsefat, M.D. [4]

Overview

Diagnosis of Herpes zoster might not be possible in the absence of a rash (i.e., before rash or in cases of zoster without rash). It is sometimes confused with herpes simplex, and, occasionally, with impetigo, contact dermatitis, folliculitis, scabies, insect bites, papular urticaria, candidal infection, dermatitis herpetiformis, and drug eruptions.

Differentiating Herpes Zoster from other Diseases

Skin lesions caused by Herpes Zoster infection must be differentiated from:[1][2][3][4][5][6][7][8][9]

Disease Findings
Atopic dermatitis
  • The skin of a patient with atopic dermatitis reacts abnormally to irritants such as food and environmental allergens
  • The skin on the flexural surfaces of the joints (elbows and knees) are most commonly affected regions
  • It usually present with red, flaky and very itchy skin
  • It also becomes vulnerable to surface infections caused by bacteria
Pyoderma gangrenosum
Herpes simplex
  • Primary orofacial herpes/HSV-1 presents itself as multiple, round, superficial oral ulcers
  • Genital herpes/HSV-2 can be more difficult to diagnose than oral herpes since most HSV-2-infected persons have no classical signs and symptoms
  • Adults with non-typical presentation are more difficult to diagnose. However, prodromal symptoms that occur before the appearance of herpetic lesions helps to differentiate HSV from other conditions
  • Herpes infection can recur even after successful initial treatment. The first episode is usually longer (two to four weeks) more painful and severe than the recurrent episodes
Contact dermatitis
  • Skin reaction resulting from exposure to allergens, irritants or sunlight
  • It usually presents as a localized rash or irritation of the skin only on the superficial regions of the skin
Folliculitis
Scabies
Papular urticaria
  • Skin condition, commonly caused by an allergic reaction commonly caused by direct contact with an allergenic substance, or an immune response to food, other allergen, or emotional stress
  • The rash can be triggered by quite innocent events, such as mere rubbing or exposure to cold.
  • It is characterized by raised red skin welts. Welts from hives can appear anywhere on the body (face, lips, tongue, throat, and ears)
  • Welts may vary in size from about 5 mm to the size of a dinner plate, typically itch severely, sting, or burn, and often have a pale border
Candidal infection
Dermatitis herpetiformis
  • Systemic condition, usually extremely itchy. In many people the vesicles or papules appear on pressure points, such as the elbows, knees, back and buttocks.
  • Symptoms sometimes appear to be symmetrical (most prevalent at pressure points)
  • It may also present as a patch of red skin with little water blisters scattered about
  • The unpredictable skin rash may appear or be exacerbated by any irritation such as dry skin, scratching or clothing that is rough or scratchy
Drug eruptions
Kawasaki disease
Measles
Rubella
Hand foot and mouth disease
  • Most commonly caused disease is the Coxsackie A
  • It may be asymptomatic or cause mild symptoms, or it may produce fever and painful blisters in the mouth (herpangina), on the palms and fingers of the hand, or on the soles of the feet. There can also be blisters in the throat or above the tonsils
  • Adults can also be affected and can present with
    • High grade fever
    • Sore throat
    • Painfull Itchy rash especially on the hands/fingers and bottom of feet, several days after high temperature
Monkeypox
  • Presentation is similar to smallpox, although it is often a milder form
  • Presents with fever, headache, myalgia, back pain, swollen lymph nodes, a general feeling of discomfort, and exhaustion.
  • Within 1 to 3 days after the appearance of fever, the patient develops a papular rash, often first on the face (lesions usually develop through several stages before crusting and falling off)
Cytomegalovirus
Acne
Syphilis
Molluscum contagiosum
  • Lesions is caused by poxvirus that results in a chronic localized infection
  • Commonly flesh-colored, dome-shaped, and pearly in appearance (often 1-5 millimeters in diameter, with a dimpled center)
  • Generally not painful, but they may itch or become irritated
  • In about 10% of the cases, eczema develops around the lesions
Mononucleosis
  • Mononucleosis is an acute clinical manifestation of EBV
  • Initially presents with malaise, headache, and low-grade fever
  • After progression of the disease, it may present with more specific signs of tonsillitis and/or pharyngitis, cervical lymph node enlargement and tenderness, and moderate to high fever
  • In most cases of infectious mononucleosis is a clinical diagnosis
    • EBV serology test should be done if mononucleosis is suspected
    • The laboratory hallmark of the disease is the presence of atypical lymphocytes
Toxic erythema
Rat-bite fever
  • Commonly presents with fever, chills, open sore at the site of the bite and rash, which may show red or purple plaques
Parvovirus B19
  • The rash of fifth disease is typically described as "slapped cheeks," with erythema across the cheeks and sparing the nasolabial folds, forehead, and mouth
Stevens-Johnson syndrome
Rocky Mountain spotted fever
Impetigo
  • Commonly presents with pimple-like lesions surrounded by erythematous skin.
  • Lesions are pustules, filled with pus, which then break down over 4-6 days and form a thick crust
  • Associated with insect bites, cuts, and other forms of trauma to the skin
  • Diagnosis is often based on clinical manifestations
Varicella-zoster virus
  • Commonly starts as a painful rash on one side of the face or body
  • The rash forms blisters that typically scab over in 7-10 days and clears up within 2-4 weeks
Scarlet fever
Meningococcemia
Rickettsialpox
Insect bite
  • The insect injects formic acid, which can cause an immediate skin reaction often resulting in a rash and swelling in the injured area,
  • Often associated with formation of vesicles.

References

  1. 1.0 1.1 Dworkin RH, Johnson RW, Breuer J, Gnann JW, Levin MJ, Backonja M; et al. (2007). "Recommendations for the management of herpes zoster". Clin Infect Dis. 44 Suppl 1: S1–26. doi:10.1086/510206. PMID 17143845.
  2. Fatahzadeh M, Schwartz RA (2007). "Human herpes simplex virus infections: epidemiology, pathogenesis, symptomatology, diagnosis, and management". J. Am. Acad. Dermatol. 57 (5): 737–63, quiz 764–6. doi:10.1016/j.jaad.2007.06.027. PMID 17939933.
  3. Walsh TJ, Dixon DM (1996). "Deep Mycoses". In Baron S et al eds. Baron's Medical Microbiology (via NCBI Bookshelf) (4th ed. ed.). Univ of Texas Medical Branch. ISBN 0-9631172-1-1.
  4. Pappas PG (2006). "Invasive candidiasis". Infect. Dis. Clin. North Am. 20 (3): 485–506. doi:10.1016/j.idc.2006.07.004. PMID 16984866.
  5. Bellini WJ, Helfand RF (2003). "The challenges and strategies for laboratory diagnosis of measles in an international setting". J Infect Dis. 187 Suppl 1: S283–90. doi:10.1086/368040. PMID 12721927.
  6. Dajani AS, Ferrieri P, Wannamaker LW (1972). "Natural history of impetigo. II. Etiologic agents and bacterial interactions". J Clin Invest. 51 (11): 2863–71. doi:10.1172/JCI107109. PMC 292435. PMID 4263498.
  7. CARPENTER RR, PETERSDORF RG (1962). "The clinical spectrum of bacterial meningitis". Am J Med. 33: 262–75. PMID 13876790.
  8. Bolotin D, Petronic-Rosic V (2011). "Dermatitis herpetiformis. Part I. Epidemiology, pathogenesis, and clinical presentation". J Am Acad Dermatol. 64 (6): 1017–24, quiz 1025-6. doi:10.1016/j.jaad.2010.09.777. PMID 21571167.
  9. Chen X, Anstey AV, Bugert JJ (2013). "Molluscum contagiosum virus infection". Lancet Infect Dis. 13 (10): 877–88. doi:10.1016/S1473-3099(13)70109-9. PMID 23972567.
  10. Maarbjerg S, Gozalov A, Olesen J, Bendtsen L (2014). "Trigeminal neuralgia--a prospective systematic study of clinical characteristics in 158 patients". Headache. 54 (10): 1574–82. doi:10.1111/head.12441. PMID 25231219.
  11. Oxman MN (1995). "Immunization to reduce the frequency and severity of herpes zoster and its complications". Neurology. 45 (12 Suppl 8): S41–6. PMID 8545018.

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