This 60-year-old man, who was on immunosuppressive therapy for chronic lymphocytic leukemia developed low grade fever, sore throat, and disseminated red papules, vesicles, and vesicles with a central umbilicated crust. A Tzanck smear was positive and polymerase chain reaction studies confirmed the diagnosis of disseminated zoster. He had a history of chicken pox when he was a child. The histopathology, including the Tzanck prep, show characteristic features for a herpesvirus infection. The pathology for varicella zoster virus (VZV) has considerable overlap with that for herpes simplex virus (HSV), and thus one must look to the clinical data. The classic features are the "3-Ms", that is Multinucleation, Margination (of chromatin), and Molding (of nuclei). This case has all these features. This cytopathic effect involves epidermal keratinocytes, usually just flanking or in the roof of the vesicle.
This high power image of the same Tzanck prep shows several examples of infected cells. These cells are large and multinucleated, with molding of nuclei against each other. The center of each nucleus is steel gray with peripheral condensation of chromatin, so-called margination (best seen in cell on right). The enormous size of the cells is appreciated by comparing with the background neutrophils.