Images in Clinical Medicine

Positive Tzanck Smear

Lisa M. Cohen, M.D.

N Engl J Med 1997; 337:535August 21, 1997

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Figure 1 A 67-year-old man had a three-day history of pain, vesicles, and erythema of the right side of the forehead and frontal scalp, sharply demarcated at the midline. Material scraped from the floor of a vesicle was smeared on a slide and stained with Wright's stain. The diagnostic cell (×400) is the multinucleated giant cell, an epithelial cell containing numerous nuclei, nuclear molding (clustered nuclei fitted to each other's shapes), and viral inclusions that give the nuclei a homogeneous, glassy appearance. Although the Tzanck test can be positive in infections with herpes simplex, herpes zoster, and varicella, the dermatomal distribution of the eruption confirmed the diagnosis of herpes zoster affecting the first branch of the trigeminal nerve. The patient was treated with oral acyclovir (800 mg five times per day for 10 days), and the eruption gradually resolved without sequelae.

Lisa M. Cohen, M.D.
Harvard Medical School, Cambridge, MA 02139

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