The n e w e ng l a n d j o u r na l of m e dic i n e images in clinical medicine Lindsey R. Baden, M.D., Editor Disseminated Zoster Rachelle M. Beste, M.D. M. Fernanda Bellolio, M.D. Mayo Clinic Rochester, MN beste.rachelle@mayo.edu A healthy 57-year-old man presented to the emergency department with pain in the left side of the face, a burning sensation in the tongue, and a diffuse vesiculopapular rash involving the chest, back, and bilateral extremities. He reported a 2-day history of isolated facial pain and preauricular lesions, for which his primary care physician had prescribed valacyclovir the previous day for presumed herpes zoster of the trigeminal nerve. He reported having had chickenpox as a child. The physical examination revealed vesicular eruptions along the V3 trigeminal dermatome, including the left side of the tongue and mandible, with similar vesicular lesions on the torso. He had no facial paralysis or other neurologic symptoms, and he reported no vertigo or ear or eye pain. There were no lesions in the ear canal or corneal lesions, as viewed with fluorescein. A chest radiograph and results of liverfunction testing were within normal limits. Owing to concern for disseminated zoster, he was treated with intravenous acyclovir. The lesions improved within 24 hours. Polymerase-chain-reaction assays of samples obtained from the mandible, tongue, and chest lesions were positive for varicella–zoster virus. Antibody testing for human immunodeficiency virus 1 and 2 was negative; no other testing for underlying immunosuppression was performed. He was prescribed a 2-week course of oral valacyclovir. DOI: 10.1056/NEJMicm1404522 Copyright © 2015 Massachusetts Medical Society. 1150 n engl j med 372;12 nejm.org march 19, 2015 The New England Journal of Medicine Downloaded from nejm.org on March 27, 2015. For personal use only. No other uses without permission. Copyright © 2015 Massachusetts Medical Society. All rights reserved.