Purpose: A 70-year-old female with history of Hepatitis C cirrhosis status-post liver transplantation, presented with pain, rash, and swelling on her left face, mouth, and tongue for 2 days. She had ear pain, yellow discharge from her lesions, fever, odynophagia, and hearing loss from the left ear. She had been compliant with her immunosuppressive regimen. Exam: afebrile, EOMI, normal fundoscopic exam, vesicles on erythematous base V1-V3 distribution on the left face/auricle; tender to palpation, with yellow discharge from external ear. Whitish plaque with underlying erythema noted on anterior two-thirds of the tongue on the left. Neurology: no evidence of facial weakness/palsy, nystagumus, motor weakness or paralysis; normal cerebellar exam. Laboratory studies: WBC 4.5: neutrophils 72%, lymphocytes 24%, BUN 33, Creatinine 2. The patient was treated with intravenous acyclovir with improvement in rash/symptoms and discharged with valacyclovir. Zoster is a highly contagious virus spread by inhalation of infective droplets or contact with lesions. After primary varicella infection, the virus establishes latency in the dorsal root ganglion of the spinal cord. With a decline in cell-mediated immunity (seen in the aging and immunosuppressed population) the virus can reactivate. Those on mycophenolate mofetil have an increased risk of Varicella-Zoster virus (VZV) reactivation. The dermatomal rash of herpes zoster allows for a diagnosis to be made on clinical grounds. In the immunosuppressed, appearance of rash may be delayed for several days after the onset of pain and cutaneous lesions may be atypical. Healing may be slow and patients may remain infectious for several weeks. Zoster oticus (Ramsay Hunt syndrome II, RHS) is a major otologic complication of VZV reactivation and may include: facial paralysis, loss of taste anterior 2/3 tongue, vertigo, vesicles in the auditory canal and auricle, ear pain, tinnitus, hyperacusis, and hearing loss. It is considered a polycranial neuropathy with frequent involvement of cranial nerves V, IX, and X. It occurs in less than 1% of all patients with herpes zoster. Anti-viral agents (acyclovir, valacyclovir, famciclovir) promote rapid healing of skin lesions, lessen severity and duration of pain, and reduce the incidence of post herpetic neuralgia (PHN). Treatment should be initiated within 72 hours of rash onset. Zoster cases in the immunocompromised may require intravenous acyclovir and hospital admission. These patients may have a delayed onset of rash, so a high index of suspicion is necessary to allow for prompt initiation of treatment.