Zika virus (ZIKV) is a flavivirus that was met with relatively little acclaim when it was discovered in 1947. Initial clinical reports of ZIKV included asymptomatic infection or mild, febrile illness; however, the view of ZIKV as an insignificant virus changed dramatically following the epidemic in the Western Hemisphere that started in 2015. This epidemic featured central nervous system involvement in children and adults, and a devastating congenital syndrome following infection of pregnant women. While the pathogenicity of ZIKV was virtually undescribed prior to this epidemic, in the past few years, numerous reports have described receptor–ligand interactions, aspects of tissue tropism, host–pathogen interactions, and diversity across viral clades. In this paper, the variety of clinical presentations and virulence determinants of ZIKV are reviewed.