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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A&#44; Inflammatory infiltrate surrounding follicular epithelium and sebaceous gland&#46; Initial bullous detachment at the dermo-epidermal junction &#40;Hematoxylin &#38; eosin&#44; &#215;40&#41;&#46; B&#44; The primary involvement of the skin is on the sebaceous epithelium&#44; as shown by immunohistochemistry specific for varicella zoster virus &#40;Hematoxylin &#38; eosin&#44; &#215;40&#41;&#46;</p>"
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Our diagnosis was therefore herpes zoster incognito&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Herpes zoster &#40;HZ&#41;&#44; due to the reactivation of VZV&#44; present in a latent state in sensory ganglia&#44; can remain inactive for decades or also for the whole life&#46; Essential condition is a previous contact&#44; usually during infancy&#44; with VZV&#46; HZ is characterized by unilateral erythematosus-vesicular rash and a localized pain&#46; Nevertheless&#44; especially at the onset of an eruption or in forms considered as abortive&#44; when lesions are macules&#44; papules&#44; and plaques&#44; clinical diagnosis may be challenging&#46; Microscopical examination can be used to confirm infection by herpesviruses&#44; but sometimes typical signs such as multinucleated epithelial cells or ghosts of them are not encountered in a specimen&#46; The term &#8220;herpes incognito&#8221; &#40;from Latin&#44; meaning not recognizable&#41; has therefore been introduced&#46;<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&#46; Consequently&#44; the primary involvement of the skin is on follicular and sebaceous epithelium&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> as shown in the case presented&#46; Spread of infection to the epidermis follows&#46; This clue&#44; that is pathognomonic of HZ and is not found in herpes simplex&#44; can be easily confirmed by immunohistochemistry&#46; This histological method&#44; that can be used to distinguish the viral aetiology in tricky causes&#44;<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&#46; In fact&#44; VZV spreads preferentially from dermal nerves to folliculosebaceous units and thence to the epidermis&#46; Nevertheless&#44; the reason why recurrent HSV infection primarily targets the epidermis&#44; in contrast to HZV&#44; which is preferentially directed to folliculosebaceous units&#44; is not fully understood&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In a study involving 75 patients with a clinical differential diagnosis of herpetic infections&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> HZ was misdiagnosed as HSV infection in 30&#37; of the cases as the clinicians were in difficult when vesicles were absent&#46; From a histological point of view&#44; herpetic folliculitis was detected in 28&#37; of HZ&#44; while it was not encountered in herpes simplex infections&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In conclusion&#44; HZ may present with clinical variants&#44; such as purpuric or hemorrhagic<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> in patients in antiplatelet or anticoagulant therapy and&#44; gangrenous&#44; bullous or disseminated HZ in immunocompromised patients&#46; We described a case of herpes incognito&#44; an underreported clinical variant of HZ&#44; representing its abortive form&#44; with distinctive clinical and histological features&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Financial support</span><p id="par0040" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authors&#8217; contributions</span><p id="par0030" class="elsevierStylePara elsevierViewall">Gianluca Nazzaro&#58; Approval of the final version of the manuscript&#59; elaboration and writing of the manuscript&#59; obtaining&#44; analysis&#44; and interpretation of the data&#59; effective participation in research orientation&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Stefano Veraldi&#58; Approval of the final version of the manuscript&#59; critical review of the literature&#46;</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&#46;</p></span></span>"
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Case Letter
Herpes zoster incognito: an immunohistochemical diagnosis
Gianluca Nazzaro
Autor para correspondência
gianluca.nazzaro@gmail.com

Corresponding author.
, Stefano Veraldi
Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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Our diagnosis was therefore herpes zoster incognito&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Herpes zoster &#40;HZ&#41;&#44; due to the reactivation of VZV&#44; present in a latent state in sensory ganglia&#44; can remain inactive for decades or also for the whole life&#46; Essential condition is a previous contact&#44; usually during infancy&#44; with VZV&#46; HZ is characterized by unilateral erythematosus-vesicular rash and a localized pain&#46; Nevertheless&#44; especially at the onset of an eruption or in forms considered as abortive&#44; when lesions are macules&#44; papules&#44; and plaques&#44; clinical diagnosis may be challenging&#46; Microscopical examination can be used to confirm infection by herpesviruses&#44; but sometimes typical signs such as multinucleated epithelial cells or ghosts of them are not encountered in a specimen&#46; The term &#8220;herpes incognito&#8221; &#40;from Latin&#44; meaning not recognizable&#41; has therefore been introduced&#46;<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&#46; Consequently&#44; the primary involvement of the skin is on follicular and sebaceous epithelium&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> as shown in the case presented&#46; Spread of infection to the epidermis follows&#46; This clue&#44; that is pathognomonic of HZ and is not found in herpes simplex&#44; can be easily confirmed by immunohistochemistry&#46; This histological method&#44; that can be used to distinguish the viral aetiology in tricky causes&#44;<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&#46; In fact&#44; VZV spreads preferentially from dermal nerves to folliculosebaceous units and thence to the epidermis&#46; Nevertheless&#44; the reason why recurrent HSV infection primarily targets the epidermis&#44; in contrast to HZV&#44; which is preferentially directed to folliculosebaceous units&#44; is not fully understood&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In a study involving 75 patients with a clinical differential diagnosis of herpetic infections&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> HZ was misdiagnosed as HSV infection in 30&#37; of the cases as the clinicians were in difficult when vesicles were absent&#46; From a histological point of view&#44; herpetic folliculitis was detected in 28&#37; of HZ&#44; while it was not encountered in herpes simplex infections&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In conclusion&#44; HZ may present with clinical variants&#44; such as purpuric or hemorrhagic<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> in patients in antiplatelet or anticoagulant therapy and&#44; gangrenous&#44; bullous or disseminated HZ in immunocompromised patients&#46; We described a case of herpes incognito&#44; an underreported clinical variant of HZ&#44; representing its abortive form&#44; with distinctive clinical and histological features&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Financial support</span><p id="par0040" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authors&#8217; contributions</span><p id="par0030" class="elsevierStylePara elsevierViewall">Gianluca Nazzaro&#58; Approval of the final version of the manuscript&#59; elaboration and writing of the manuscript&#59; obtaining&#44; analysis&#44; and interpretation of the data&#59; effective participation in research orientation&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Stefano Veraldi&#58; Approval of the final version of the manuscript&#59; critical review of the literature&#46;</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&#46;</p></span></span>"
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