Case Letter
Herpes zoster incognito: an immunohistochemical diagnosis
Gianluca Nazzaro
, Stefano Veraldi
Corresponding author
Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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Descolamento bolhoso inicial na junção dermoepidérmica (Hematoxilina & eosina 40×). 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Initial bullous detachment at the dermo-epidermal junction (Hematoxylin & eosin, ×40). B, The primary involvement of the skin is on the sebaceous epithelium, as shown by immunohistochemistry specific for varicella zoster virus (Hematoxylin & eosin, ×40).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 60-year-old woman presented with a 1 week history of an erythematosus and edematous plaque on her scalp. The lesion, 2.5<span class="elsevierStyleHsp" style=""></span>cm in diameter, was associated to mild pain (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Histopathological examination showed a massive inflammatory infiltrate in the dermis, especially surrounding sebaceous glands and responsible of oedema in the papillary dermis with initial dermo-epidermal vescicle formation (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). In the suspect of a herpetic infection, immunohistochemistry was performed, revealing negativity for Herpes Simplex virus (HSV) and positivity for Varicella Zoster virus (VZV) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B). Our diagnosis was therefore herpes zoster incognito.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Herpes zoster (HZ), due to the reactivation of VZV, present in a latent state in sensory ganglia, can remain inactive for decades or also for the whole life. Essential condition is a previous contact, usually during infancy, with VZV. HZ is characterized by unilateral erythematosus-vesicular rash and a localized pain. Nevertheless, especially at the onset of an eruption or in forms considered as abortive, when lesions are macules, papules, and plaques, clinical diagnosis may be challenging. Microscopical examination can be used to confirm infection by herpesviruses, but sometimes typical signs such as multinucleated epithelial cells or ghosts of them are not encountered in a specimen. The term “herpes incognito” (from Latin, meaning not recognizable) has therefore been introduced.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The virus is transported from dorsal root or trigeminal ganglia via myelinated nerves which terminate at the isthmus of hair follicles. Consequently, the primary involvement of the skin is on follicular and sebaceous epithelium,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> as shown in the case presented. Spread of infection to the epidermis follows. This clue, that is pathognomonic of HZ and is not found in herpes simplex, can be easily confirmed by immunohistochemistry. This histological method, that can be used to distinguish the viral aetiology in tricky causes,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> demonstrates that HSV affects primarily the epidermis and the upper portions of follicles only occasionally but never sebaceous epithelium or nerves. In fact, VZV spreads preferentially from dermal nerves to folliculosebaceous units and thence to the epidermis. Nevertheless, the reason why recurrent HSV infection primarily targets the epidermis, in contrast to HZV, which is preferentially directed to folliculosebaceous units, is not fully understood.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In a study involving 75 patients with a clinical differential diagnosis of herpetic infections,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> HZ was misdiagnosed as HSV infection in 30% of the cases as the clinicians were in difficult when vesicles were absent. From a histological point of view, herpetic folliculitis was detected in 28% of HZ, while it was not encountered in herpes simplex infections.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In conclusion, HZ may present with clinical variants, such as purpuric or hemorrhagic<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> in patients in antiplatelet or anticoagulant therapy and, gangrenous, bullous or disseminated HZ in immunocompromised patients. We described a case of herpes incognito, an underreported clinical variant of HZ, representing its abortive form, with distinctive clinical and histological features.</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Financial support</span><p id="par0040" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authors’ contributions</span><p id="par0030" class="elsevierStylePara elsevierViewall">Gianluca Nazzaro: Approval of the final version of the manuscript; elaboration and writing of the manuscript; obtaining, analysis, and interpretation of the data; effective participation in research orientation; critical review of the literature; critical review of the manuscript.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Stefano Veraldi: Approval of the final version of the manuscript; critical review of the literature.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Financial support" ] 1 => array:2 [ "identificador" => "sec0005" "titulo" => "Authors’ contributions" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-03-11" "fechaAceptado" => "2019-07-23" "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Nazzaro G, Veraldi S. Herpes zoster incognito: an immunohistochemical diagnosis. An Bras Dermatol. 2020;95:401–2.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 603 "Ancho" => 905 "Tamanyo" => 148439 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Erythematous plaque with recent onset at the top of a 60 year-old woman.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1088 "Ancho" => 1500 "Tamanyo" => 310115 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Inflammatory infiltrate surrounding follicular epithelium and sebaceous gland. Initial bullous detachment at the dermo-epidermal junction (Hematoxylin & eosin, ×40). B, The primary involvement of the skin is on the sebaceous epithelium, as shown by immunohistochemistry specific for varicella zoster virus (Hematoxylin & eosin, ×40).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Herpes Incognito most commonly is herpes zoster and its histopathologic pattern is distinctive" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Böer" 1 => "N. Herder" 2 => "N. Blodorn-Schlicht" 3 => "T. Falk" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.dad.0000199858.56090.32" "Revista" => array:6 [ "tituloSerie" => "Am J Dermatopathol" "fecha" => "2006" "volumen" => "28" "paginaInicial" => "181" "paginaFinal" => "186" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16625086" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Exclusive involvement of folliculosebaceous units by herpes – a reflection of early herpes zoster" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "N. Walsh" 1 => "R. Boutilier" 2 => "D. Glasgow" 3 => "M. Shaffelbug" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.dad.0000158300.48286.2d" "Revista" => array:6 [ "tituloSerie" => "Am J Dermatopathol" "fecha" => "2005" "volumen" => "27" "paginaInicial" => "189" "paginaFinal" => "194" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15900120" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Herpes zoster of the penis: an immunohistochemistry diagnosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. Veraldi" 1 => "D. Fanoni" 2 => "G. Nazzaro" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1600-0560.2012.01900.x" "Revista" => array:6 [ "tituloSerie" => "J Cutan Pathol" "fecha" => "2012" "volumen" => "39" "paginaInicial" => "811" "paginaFinal" => "812" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22574937" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Refining criteria for diagnosis of cutaneous infections caused by herpes viruses through correlation of morphology with molecular pathology" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A. Böer" 1 => "N. Herder" 2 => "N. Blödorn-Schlicht" 3 => "V. Steinkraus" 4 => "T.M. 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Nazzaro" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jcv.2015.05.028" "Revista" => array:6 [ "tituloSerie" => "J Clin Virol" "fecha" => "2015" "volumen" => "69" "paginaInicial" => "122" "paginaFinal" => "124" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26209393" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/03650596/0000009500000003/v4_202007210853/S0365059620300775/v4_202007210853/en/main.assets" "Apartado" => array:4 [ "identificador" => "82769" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Letter" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/03650596/0000009500000003/v4_202007210853/S0365059620300775/v4_202007210853/en/main.pdf?idApp=UINPBA00008Z&text.app=https://clinics.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059620300775?idApp=UINPBA00008Z" ]
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| 2023 September | 93 | 85 | 178 |
| 2023 August | 62 | 47 | 109 |
| 2023 July | 62 | 32 | 94 |
| 2023 June | 79 | 44 | 123 |
| 2023 May | 51 | 26 | 77 |
| 2023 April | 54 | 26 | 80 |
| 2023 March | 68 | 49 | 117 |
| 2023 February | 55 | 37 | 92 |
| 2023 January | 53 | 43 | 96 |
| 2022 December | 64 | 30 | 94 |
| 2022 November | 66 | 48 | 114 |
| 2022 October | 84 | 55 | 139 |
| 2022 September | 51 | 65 | 116 |
| 2022 August | 41 | 59 | 100 |
| 2022 July | 39 | 50 | 89 |
| 2022 June | 38 | 61 | 99 |
| 2022 May | 39 | 54 | 93 |
| 2022 April | 44 | 51 | 95 |
| 2022 March | 41 | 70 | 111 |
| 2022 February | 44 | 30 | 74 |
| 2022 January | 81 | 75 | 156 |
| 2021 December | 42 | 54 | 96 |
| 2021 November | 49 | 58 | 107 |
| 2021 October | 65 | 90 | 155 |
| 2021 September | 38 | 44 | 82 |
| 2021 August | 56 | 53 | 109 |
| 2021 July | 40 | 40 | 80 |
| 2021 June | 28 | 49 | 77 |
| 2021 May | 50 | 80 | 130 |
| 2021 April | 105 | 249 | 354 |
| 2021 March | 87 | 65 | 152 |
| 2021 February | 27 | 14 | 41 |
| 2021 January | 24 | 15 | 39 |
| 2020 December | 28 | 23 | 51 |
| 2020 November | 19 | 20 | 39 |
| 2020 October | 11 | 7 | 18 |
| 2020 September | 19 | 10 | 29 |
| 2020 August | 13 | 7 | 20 |
| 2020 July | 20 | 10 | 30 |
| 2020 June | 18 | 22 | 40 |
| 2020 May | 19 | 10 | 29 |
| 2020 April | 0 | 6 | 6 |
Show all
