Case Presentation: An 80-year-old male with coronary artery disease and previous coronary artery bypass grafting was admitted to the hospital with high-risk chest pain. The pain was substernal, non-radiating, with a tight quality, relieved by sublingual nitroglycerin, and intensifying over the previous week. Cardiology was consulted. Although acute coronary syndrome was ruled out with serial troponin measurements and EKGs, his pain persisted. The following day, herpetiform vesicles erupted along the patient’s chest, face, arms, and back. His temperature was 100.2oF and all other vital signs were normal. A complete blood count, comprehensive metabolic panel, and chest radiograph were normal. He was diagnosed with disseminated herpes zoster based on the physical exam findings. The patient was treated with oral valacyclovir and monitored in the hospital for 48 hours with gradual crusting of the vesicles, no evidence of visceral involvement, and no signs of secondary bacterial infection. He was discharged to complete a ten-day course of antiviral therapy.

Discussion: Herpes zoster is a reactivation of the varicella-zoster virus causing a painful dermatomal rash in older adults. Disseminated herpes zoster, defined as rash affecting three or more dermatomes, is almost exclusively identified in immunocompromised hosts but has been reported in immunocompetent patients with multiple medical comorbidities and the elderly. As in this case, herpes zoster affecting the thorax can mimic angina because neuralgia precedes the eruption of vesicles by several days. Alternatively, some studies suggest that an eruption of zoster with no identifiable trigger may be a signal for underlying cardiovascular disease. In either case, antiviral therapy is the mainstay of treatment. Patients should receive the herpes zoster vaccine six weeks after an outbreak as they are at increased risk for future episodes.

Conclusions: Herpes zoster is a potential diagnosis for patients admitted to the hospital with chest pain. Early diagnosis can decrease the duration of post-herpetic neuralgia and minimize the need for cardiac diagnostics and therapies that may have unintentional harms.