Initially Asymptomatic Herpes Zoster

A 65-year-old woman sought evaluation of a unilateral, asymptomatic rash that involved the oral mucosa and lips. The rash consisted of ulcerations and vesicles. The suspected diagnosis of herpes zoster was confirmed 4 days later when the patient experienced lancinating pain throughout the affected area and into her scalp and neck.

The rash of herpes zoster is typically preceded by tingling sensations, pruritis, and often pain (the so-called premonitory symptoms). In this patient, the complete absence of any of these symptoms was unusual. Although the diagnosis was made clinically in this case, a viral culture or immunofluorescence studies can distinguish a herpes zoster eruption from the similar lesions of herpes simplex.

Oral valacyclovir, 1 g tid for 1 week, and a tapered dose of prednisone, 60 mg for 2 weeks, alleviated this patient’s symptoms.