{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,12,12]],"date-time":"2025-12-12T07:26:53Z","timestamp":1765524413061,"version":"3.48.0"},"reference-count":6,"publisher":"Walter de Gruyter GmbH","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"abstract":"Abstract<\/jats:title>\n \n Objectives<\/jats:title>\n Diagnostic reasoning often favors simplicity, with clinicians seeking a single unifying explanation for a patient\u2019s presentation. However, in certain cases, a narrow approach can lead to diagnostic oversight and delay. In this case, an early attribution of symptoms to leukocytoclastic vasculitis (LCV) postponed the recognition and treatment of an underlying varicella-zoster virus (VZV) infection.<\/jats:p>\n <\/jats:sec>\n \n Case presentation<\/jats:title>\n An 88-year-old woman presented with palpable purpuric macules in a linear distribution along the right pretibial region, dorsum of the foot, and toes, accompanied by severe unilateral pain radiating from the foot to the buttock. The pain preceded the rash by one day, and no vesicles were noted by the patient or clinician. Clinically, the morphology was consistent with leukocytoclastic vasculitis, but the pain followed a dermatomal distribution, raising concern for varicella-zoster virus (VZV) infection. A biopsy ultimately confirmed both leukocytoclastic vasculitis and viral cytopathic changes. The patient improved with a combination of valacyclovir, prednisone, and gabapentin.<\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n This case illustrates a diagnostically challenging presentation in which two distinct pathologies mimicked and masked one another. Anchoring on a unifying diagnosis led to premature closure, delaying antiviral therapy. Herpes zoster without vesicles is uncommon but documented, and VZV-induced vasculitis is rare. Together, they created a deceptive clinical picture. The case reinforces several key teaching points: the value of maintaining diagnostic flexibility, the importance of empiric antiviral treatment when herpes zoster is suspected, and the need to recognize cognitive biases that can distort clinical judgment. When findings are discordant or incomplete, clinicians should resist diagnostic simplification and remain open to diagnosing coexisting conditions.<\/jats:p>\n <\/jats:sec>","DOI":"10.1515\/dx-2025-0134","type":"journal-article","created":{"date-parts":[[2025,11,8]],"date-time":"2025-11-08T05:59:03Z","timestamp":1762581543000},"source":"Crossref","is-referenced-by-count":0,"title":["When two truths collide: overlapping herpes zoster and leukocytoclastic vasculitis in an atypical presentation"],"prefix":"10.1515","author":[{"ORCID":"https:\/\/orcid.org\/0009-0002-9598-5991","authenticated-orcid":false,"given":"Hunter","family":"Cohn","sequence":"first","affiliation":[{"name":"12267 Wayne State University School of Medicine , Detroit , USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jeannie","family":"Hennessy","sequence":"additional","affiliation":[{"name":"Northeast Dermatology , Gahanna , OH , USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Stephanie","family":"Cotell","sequence":"additional","affiliation":[{"name":"Northeast Dermatology , Gahanna , OH , USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Stephanie","family":"Fabbro","sequence":"additional","affiliation":[{"name":"Division of Dermatology , OhioHealth Riverside Methodist Hospital , Columbus , OH , USA"},{"name":"Rixis Dermatology , Columbus , OH , USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"374","published-online":{"date-parts":[[2025,11,10]]},"reference":[{"key":"2025121206535485831_j_dx-2025-0134_ref_001","doi-asserted-by":"crossref","unstructured":"Pipitone, N, Salvarani, C. The role of infectious agents in the pathogenesis of vasculitis. Best Pract Res Clin Rheumatol 2008;22:897\u2013911. https:\/\/doi.org\/10.1016\/j.berh.2008.09.009.","DOI":"10.1016\/j.berh.2008.09.009"},{"key":"2025121206535485831_j_dx-2025-0134_ref_002","doi-asserted-by":"crossref","unstructured":"Furuoka, K, Fukumoto, T, Masuda, Y, Tanigawa, A, Kosaka, H, Nagano, T, et al.. Segmental cutaneous leukocytoclastic vasculitis associated with herpes zoster: a case report and literature review. Dermatol Rep 2023;15:9709. https:\/\/doi.org\/10.4081\/dr.2023.9709.","DOI":"10.4081\/dr.2023.9709"},{"key":"2025121206535485831_j_dx-2025-0134_ref_003","doi-asserted-by":"crossref","unstructured":"Espy, MJ, Teo, R, Ross, TK, Svien, KA, Wold, AD, Uhl, JR, et al.. Diagnosis of varicella-zoster virus infections in the clinical laboratory by LightCycler PCR. J\u00a0Clin Microbiol 2000;38:3187\u20139. https:\/\/doi.org\/10.1128\/JCM.38.9.3187-3189.2000.","DOI":"10.1128\/JCM.38.9.3187-3189.2000"},{"key":"2025121206535485831_j_dx-2025-0134_ref_004","doi-asserted-by":"crossref","unstructured":"Harbecke, R, Oxman, MN, Arnold, BA, Johnson, GR, Levin, MJ, et al.. A real-time PCR assay to identify and discriminate among wild-type and vaccine strains of varicella-zoster virus and herpes simplex virus in clinical specimens, and comparison with the clinical diagnoses. J\u00a0Med Virol 2009;81:1310\u201322. https:\/\/doi.org\/10.1002\/jmv.21506.","DOI":"10.1002\/jmv.21506"},{"key":"2025121206535485831_j_dx-2025-0134_ref_005","doi-asserted-by":"crossref","unstructured":"Nandeesh, B, Tirumalae, R. Direct immunofluorescence in cutaneous vasculitis: experience from a referral hospital in India. Indian J Dermatol 2013;58:22\u20135. https:\/\/doi.org\/10.4103\/0019-5154.105280.","DOI":"10.4103\/0019-5154.105280"},{"key":"2025121206535485831_j_dx-2025-0134_ref_006","doi-asserted-by":"crossref","unstructured":"Wood, M, Shukla, S, Fiddian, A, Crooks, R. Treatment of acute herpes zoster: effect of early (< 48 h) versus late (48\u201372 h) therapy with acyclovir and valaciclovir on prolonged pain. J\u00a0Infect Dis 1998;178:81\u2013S84. https:\/\/doi.org\/10.1086\/514271.","DOI":"10.1086\/514271"}],"container-title":["Diagnosis"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.degruyterbrill.com\/document\/doi\/10.1515\/dx-2025-0134\/xml","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.degruyterbrill.com\/document\/doi\/10.1515\/dx-2025-0134\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,12]],"date-time":"2025-12-12T07:21:51Z","timestamp":1765524111000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.degruyterbrill.com\/document\/doi\/10.1515\/dx-2025-0134\/html"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,11,10]]},"references-count":6,"alternative-id":["10.1515\/dx-2025-0134"],"URL":"https:\/\/doi.org\/10.1515\/dx-2025-0134","relation":{},"ISSN":["2194-8011","2194-802X"],"issn-type":[{"type":"print","value":"2194-8011"},{"type":"electronic","value":"2194-802X"}],"subject":[],"published":{"date-parts":[[2025,11,10]]}}}