Pharyngolaryngeal Involvement by Varicella-Zoster Virus

Ramsay Hunt syndrome in atopic dermatitis patient treated with dupilumab

The Ramsay-Hunt syndrome results from reactivation of the varicella-zoster virus at the geniculate ganglion level. The syndrome is characterized by a combination of symptoms such as ipsilateral facial paralysis, otalgia, and vesicles near the ear and auditory canal. The gold standard in the treatment of Ramsay-Hunt syndrome remains the combination of antiviral therapy with corticosteroids and adequate analgesic therapy. We present a case of a 45-year-old patient with severe form of atopic dermatitis, who developed this syndrome during treatment with dupilumab. The risks and benefits of dupilumab treatment in this patient were considered. Because both bronchial asthma and atopic dermatitis worsened when dupilumab was discontinued, it was indicated to continue this therapy with low-dose of acyclovir.

Characteristic Video Laryngeal Endoscopic "Pharyngeal Rotation" in Unilateral Pharyngeal Constrictor Muscle Paresis: A Case of Herpes Zoster Pharyngitis

Herpes zoster pharyngitis (HZP) is a rare condition that should be considered as a differential diagnosis of acute dysphagia secondary to unilateral glossopharyngeal and/or vagal nerve palsy. Although early treatment is important to avoid adverse sequelae, serological diagnosis of varicella zoster virus (VZV) takes over a few days. Therefore, it is important to actively suspect VZV infection based on physical findings. Mucocutaneous lesions, curtain signs, and laryngeal palsy are well-known characteristic physical findings. In addition to these findings, the video laryngeal endoscopic finding that the pharyngeal constrictor muscles contract on only one side during swallowing, showing an appearance of "pharyngeal rotation", is one of the characteristic findings of glossopharyngeal/vagal nerve palsy and can support the diagnosis. We report the case of an 82-year-old Asian female who presented with acute dysphagia, sore throat, left ear pain, and fever that persisted for several days. Initial video laryngeal endoscopy revealed a markedly decreased pharyngeal reflex and significant salivary retention without mucosal vesicular lesions. Repeat videoendoscopic evaluation of swallowing revealed characteristic pharyngeal rotation, which was helpful in diagnosing unilateral pharyngeal constrictor muscle paresis, thus suggesting unilateral glossopharyngeal/vagal nerve palsy. An increase in serum antibody titers (IgG and IgM) against VZV was observed. Bilateral differences and rotation of the pharynx during pharyngeal contraction can be detected endoscopically in pharyngeal constrictor muscle paresis caused by glossopharyngeal/vagal nerve palsy and should be evaluated during video laryngeal endoscopy in patients with dysphagia.

Laryngeal herpes zoster with multiple symptoms in a child

Herpes zoster caused by reactivation of latent varicella-zoster virus (VZV) usually develop in later adulthood. In the pediatric population, herpes zoster is unusual, and involvement of pharyngolaryngeal lesion and cranial nerves is rare. Here, we report a 14-year-old boy who was diagnosed with laryngeal herpes zoster (LHZ), and developed subsequent cranial nerve symptoms suspected of vagus neuropathy. This case provides additional evidence that children can develop LHZ and subsequent cranial nerve symptoms. LHZ should be considered if a pediatric patient with a history of varicella, has unilateral throat pain, with or without cranial nerve symptoms.

Varicella Zoster Virus Reactivation Involving the Vagus Nerve

OBJECTIVES

To characterize the presentation, clinical course and functional outcomes of patients with varicella zoster virus (VZV) reactivation involving the vagus nerve. To highlight the role of otolaryngology in acute and long-term management of laryngopharyngeal VZV and its sequelae.

METHODS

Retrospective review of 3 patients with laryngopharyngeal VZV, managed at a tertiary referral center.

RESULTS

All cases presented with vesicular lesions involving mucosa of the laryngopharynx. Each experienced vocal fold hypomobility, among other otolaryngologic sequelae. All were treated with systemic antivirals and corticosteroids. Mucosal lesions resolved within 7 days of treatment initiation; functional deficits persisted for months to years. Dysphonia improved to a plateau at 3 months, while dysphagia took longer to resolve. One patient with disseminated disease experienced bilateral vocal fold paralysis requiring temporary tracheostomy.

CONCLUSIONS

Vagal neuropathy secondary to VZV reactivation is a rare clinical entity with a variety of laryngeal manifestations. Early initiation of systemic therapy and serial endoscopic evaluations are critical components of acute management when laryngopharyngeal involvement is suspected. Otolaryngologists should plan for long-term phonatory and deglutitive therapy in these cases, as neurologic sequelae can persist for months to years following initial insult.

LEVEL OF EVIDENCE

Level 4 (Case-series).

Herpes Zoster of The Larynx: A Narrow Diagnostic and Therapeutic Window

We hereby present a rare case of laryngeal zoster presenting with unilateral odynophagia and hemifacial pain in an immunocompetent host. Visualization of the characteristic vesicles is challenging given their short-lived and at times delayed appearance; thus, laryngeal zoster may be a largely unrecognized cause of laryngitis and cranial neuropathies. Heightened awareness may improve prompt diagnosis, referral and initiation of antiviral therapy, while guiding patient counselling on the associated long-term sequelae such as voice and swallowing impairments, and post-herpetic neuralgia.

The risk of laryngitis with herpes zoster infection: A nested case-control study using data from the Korean National Sample Cohort

BACKGROUND

Whether herpes zoster infection (HZI) affects laryngitis incidence remains unknown.

OBJECTIVE

The purpose of this population-based retrospective study was to analyze the relationship between laryngitis and HZI using data from the Korean Health Insurance Review and Assessment Service-National Sample Cohort.

METHODS

This study analyzed 1,197,093 medical claim codes from 2018. Patients with HZI (ICD-10: B02) were retrospectively identified. Laryngeal diseases were defined by ICD-10 codes for five subgroups: 1) malignant disease, 2) benign disease, 3) vocal cord palsy, 4) inflammatory disease, and 5) reflux disease.

RESULTS

Among the Korean population older than 20 years, 12,809 experienced HZI. Subjects with HZI were more likely to be older (mean age: 51.54 years vs. 48.06 years, p <0.0001). The proportion of subjects with laryngeal disease was higher in those with HZI than in those without HZI (55.55% vs. 41.37%, p <0.0001). Laryngeal disease was significantly associated with HZI in multiple regression analysis (odds ratio (OR) = 1.77, 95% confidence interval: 1.71-1.84) after adjusting for age, sex, hypertension, diabetes, dyslipidemia, ischemic heart disease, cerebral stroke, and depression. Among laryngeal disease subgroups, inflammatory disease (OR = 1.05; 95% CI: 1.01-1.09) and reflux (OR = 1.20; 95% CI: 1.15-1.25) were associated with HZI.

CONCLUSIONS

HZI is independently associated with laryngitis. Results of this study have implications for etiological investigations and prevention strategies for laryngitis.

Ramsay Hunt syndrome with multiple cranial neuropathy: a literature review

BACKGROUND

Ramsay Hunt Syndrome (RHS) is a neurotological disorder involving the reactivation of the varicella-zoster virus (VZV) in the geniculate ganglion of the facial nerve (Sweeney and Gilden in J Neurol Neurosurg Psychiatry 71:149-154, 2001). The characteristic presentation involves ipsilateral lower motor neuron type facial paresis, auricular pain with or without hearing impairment, and vesicular lesions of the external auditory canal and outer ear. Involvement of the facial and vestibulocochlear nerve is typical in RHS, whilst multiple cranial neuropathies are rare and associated with poorer prognosis and systemic complications (Arya et al. in Am J Case Rep 19:68-71, 2017; Shinha and Krishna in IDCases 2:47-48, 2015; Shim et al. in Acta Otolaryngol 131:210-215, 2011; Coleman et al. in J Voice 26:e27-e28, 2012; Morelli et al. in Neurol Sci 29:497-498, 2008;). Likely mechanisms involved in the pathogenesis of cranial polyneuropathy include direct peri-neural and trans-axonal spread of viral inflammation between contiguous cranial nerves and haematogenous dissemination between nerves with shared blood supply. Impairments in speech, swallowing, hearing, and oculo-protection can contribute to morbidity and requires a multidisciplinary approach to patient care.

METHODS

We present a rare case of RHS with multiple cranial neuropathies followed by a comprehensive review of current literature with regard to the pathophysiology, diagnostic workup, and the management strategies employed in these patients.

CONCLUSION

RHSs with multiple cranial neuropathies are important to recognise as they are associated with significant morbidity and poor prognosis. A multidisciplinary approach to patient management is required to address the several complications that can arise from cranial nerve deficits, especially in regard to speech and swallow.

Imaging manifestations on sequential magnetic resonance imaging in pharyngolaryngeal involvement by varicella zoster virus

Clarifying temporal changes in magnetic resonance imaging (MRI) offers a good chance to understand the pathology of neural lesions; however, such information is scarce in varicella zoster virus (VZV) neuropathies for the glossopharyngeal and vagus nerves. Here, we present the changes in sequential MR images of such a pathology over a period of 12 months from symptom onset.A 27-year-old woman with difficulty in swallowing and hoarseness due to a palatal palsy and arytenoid fixation on the left presented 2 days after onset. MRI revealed a lesion which largely filled the left jugular foramen on T2-weighted images (T2-WI) with high diffusion-weighted imaging (DWI) signals, which has never been previously described, on the 3rd day after onset. The DWI signals were highest on day 3, then deteriorated over 2 months until the signal was only detectable at the intracranial level, but not in the jugular foramen. The glossopharyngeal nerve had returned to normal by 2 months.The time course of the glossopharyngeal and vagus nerve swelling detected on T2-WI suggests that nerve swelling reduces over several months, even though the paralytic symptoms persist. Furthermore, the high DWI signal suggests that nerve swelling was caused by edematous swelling of the nerve fibers, rather than fiber disruption with water displacement in the extracellular space. These findings may provide good clues to speculate on the dynamically changing pathology of VZV neuropathies of the glossopharyngeal and vagus nerves.

Cranial polyneuropathy caused by herpes zoster infection: a retrospective single-center analysis

PURPOSE

Cranial polyneuropathy (CP) is a rare complication of herpes zoster (HZ) infection. This entity often produces situations of a diagnostic dilemma, as can be seen in a wide spectrum of clinical presentations. The aim of this study was to report the clinical characteristics, treatment, and outcomes of 11 patients from a single-institution experience.

METHODS

A retrospective analysis of patients treated for HZ CP over a 12-year period was performed.

RESULTS

The present study included 11 patients with CP caused by HZ infection-7 (63.63%) females, and 4 (36.36%) males. The mean age at presentation was 63 years (range, 38-85 years). Cranial nerve VII was affected in nine (81.82%) cases, CN VIII in six (54.55%) cases, CN V in five (45.45%) cases, CN III and IX in two (18.18%) cases, and CN VI and X in one (9.09%) case. The treatment of choice was acyclovir in all patients, while corticosteroids were administered in six (54.55%) patients. Complete CN recovery was observed in seven (63.63%) patients, while four (36.36%) patients suffered from permanent CN damage-two (18.18%) CN VII, one (9.09%) CN VII and VIII, and one (9.09%) CN VI.

CONCLUSION

Herpes zoster CP presents an interesting diagnostic and therapeutic challenge. Successful management of these patients depends on a thorough knowledge of the anatomy and topodiagnostic of CNs. Early administration of antiviral agents is crucial in terms of responsiveness to treatment and expedite recovery.

Manifestaciones clínicas del síndrome de Ramsay-Hunt en una serie de 20 casos

Introducción y objetivo: la experiencia clínica nos ha mostrado las distintas formas de presentación y la variabilidad sintomatológica que puede revelar el síndrome de Ramsay-Hunt o herpes zóster ótico. Las descripciones que ofrece la literatura nos han servido para corroborar los hallazgos de un conjunto de pacientes, cuyas características y evolución hemos ido reuniendo en el tiempo. Dada la importancia del tratamiento precoz, el objetivo de este trabajo ha consistido en realizar una exposición estructurada de este complejo síndrome con sus diversas manifestaciones. Método: estudio retrospectivo. Resultados: 20 pacientes ejemplifican los diferentes aspectos de este proceso. Discusión: se trata de una patología infrecuente, con una tríada sintomática patognomónica que consiste en otalgia, erupción vesicular y parálisis facial. Sin embargo, este síndrome no siempre se expresa de forma completa ni con la aparición de los síntomas en el orden indicado, añadiéndose con frecuencia otros cocleovestibulares. La posibilidad de que la infección se propague de forma centrífuga y centrípeta facilita el que se afecten otros nervios sensitivos y motores, ocasionando una polineuropatía craneal (herpes zóster cefálico) y raquídea o incluso, con mucha menor frecuencia, la aparición de una meningoencefalitis. No conocemos con precisión los mecanismos por los que progresa este proceso ni los factores desencadenantes, aunque en ocasiones les haya predisponentes. Establecer un diagnóstico es fundamental para iniciar el tratamiento, cuya precocidad facilita la resolución del proceso. Conclusiones: siendo la sospecha clínica la principal herramienta de un diagnóstico precoz, nos ha parecido de interés realizar esta revisión, dada la infrecuencia del herpes zóster ótico.

Pharyngeal dysphagia due to Varicella zoster virus meningoradiculitis and full recovery: Case report and endoscopic findings

Varicella zoster virus reactivation is a rare cause of pharyngeal dysphagia with long-term sequelae persisting in most cases. A 76-year-old immunocompetent woman presented with a 4-week history of dysphagia and dysphonia. Brain magnetic resonance imaging displayed a negative finding. Fiberoptic endoscopic evaluation of swallowing showed a severe dysphagia leading to a percutaneous gastrostomy eventually. Cerebrospinal fluid analysis revealed a lymphocytic pleocytosis and polymerase chain reaction amplified Varicella zoster virus DNA. Eight months after Acyclovir treatment and despite a persisting impairment of the recurrent laryngeal nerve, regular swallowing function was regained and percutaneous gastrostomy could be removed.

Herpes Zoster in the Older Adult

Herpes zoster (HZ) is the result of reactivation of latent varicella zoster virus (VZV) and occurs most frequently in older adults. Classically, HZ presents as a unilateral, selflimited, dermatomal rash. Postherpetic neuralgia (PHN) is a common sequela, presenting as severe pain that persists after the rash has resolved. In the elderly, PHN can be debilitating and requires a prompt diagnosis, treatment with antivirals, and adequate pain control. A longer-term pain management strategy is required if PHN occurs. A modestly effective vaccine exists and is recommended for older individuals.

[Clinical, epidemiological and etiological studies of adult aseptic meningitis: Report of 11 cases with varicella zoster virus meningitis]

We treated 11 cases (52.7 ± 14.9 years, all male) with varicella zoster virus (VZV) meningitis and 437 cases with adult aseptic meningitis from 2004 to 2016. The incidence rate of adult VZV meningitis in the cases with aseptic meningitis was 2.5%. Herpes zoster infections are reported to have occurred frequently in summer and autumn. VZV meningitis also occurred frequently in the similar seasons, in our patients. The diagnoses were confirmed in 9 cases with positive VZV-DNA in the cerebrospinal fluid and in 2 cases with high VZV-IgG indexes (> 2.0). For diagnosis confirmation, the former test was useful for cases within a week of disease onset, and the latter index was useful for cases after a week of disease onset. Zoster preceded the meningitis in 8 cases, while the meningitis preceded zoster in 1 case, and 2 cases did not have zoster (zoster sine herpete). Two patients were carriers of the hepatitis B virus, 1 patient was administered an influenza vaccine 4 days before the onset of meningitis, and 1 patient was orally administered prednisolone for 2 years, for treatment. Their immunological activities might have been suppressed. The neurological complications included trigeminal neuralgia, facial palsy (Ramsay Hunt syndrome), glossopharyngeal neuralgia, and Elsberg syndrome. Because the diseases in some patients can become severe, they require careful treatment.

Ramsay Hunt syndrome with cranial polyneuropathy with features of supraglottitis

A 67-year-old woman presented with a 1-week history of left otalgia and a 1-day history of odynophagia, pain extending into the face and neck, and a productive cough. Flexible nasendoscopy showed features of supraglottitis, with swollen arytenoids and pooling of saliva in the piriform fossae. Laboratory investigations revealed a mildly raised C reactive protein. A CT scan of the neck supported the diagnosis of supraglottitis and pharyngitis, with thickening of the mucosa of the left piriform fossae and left oropharynx. Standard supraglottitis treatment was instigated, but on day 4 of the admission, a vesicular rash and features of cranial nerve involvement (V, VII, VIII, X) developed. A revised diagnosis of Ramsay Hunt syndrome with cranial polyneuropathy was made and later confirmed by varicella zoster virus PCR. After 4 weeks, facial nerve function normalised, but features of other cranial nerve palsies were persistent.

A Rare Presentation of Cranial Polyneuropathy Without Rash Caused by Varicella Zoster Virus

INTRODUCTION

Varicella Zoster Virus (VZV) is associated with many disorders of the central and peripheral nervous systems including neuralgia, meningitis, meningoencephalitis, cerebellitis, vasculopathy, myelopathy, Ramsay-Hunt syndrome, and polyneuritis cranialis. Cranial nerves V, VI, VII, VIII, IX, X, XI, and/or XII may be affected. The neurological disorders caused by VZV usually present with rash, but may rarely present without rash.

CASE REPORT

We herein present a case of polyneuritis cranialis without rash caused by VZV affecting cranial nerves VII, VIII, IX, and X. After excluding other causes of the condition, we diagnosed VZV infection based on VZV DNA in the CSF and an elevated anti-VZV IgG level in serum. The patient responded well to antiviral therapy.

CONCLUSION

VZV infection should be kept in mind during the differential diagnosis of polyneuritis cranialis; it is important to note that VZV re-activation may occur without rash.

Fatal case of cutaneous-sparing orolaryngeal zoster in a renal transplant recipient

Herpesvirus infections in solid organ transplant (SOT) recipients are a significant cause of morbidity and mortality. We report a case of herpes zoster (HZ) in a kidney transplant recipient while receiving belatacept, a CTLA-4 inhibitor that prevents acute rejection. The patient presented with oropharyngolaryngeal mucosal lesions that subsequently disseminated resulting in pneumonitis and meningo-encephalitis. Very late-onset HZ can occur and can present atypically in SOT recipients. Delayed recognition and treatment may result in poor outcomes, as illustrated by this case.

[Lower cranial polyneuropathy in zoster sine herpete presenting with pain in the ear and throat: a case report]

A 64-year-old woman developed acute paralysis of glossopharyngeal, vagus, accessory, and hypoglossal nerves on the left side after pain in the head and the left ear and throat. Cerebrospinal fluid examination revealed lymphocytic pleocytosis and elevated protein concentration. Varicella-zoster virus (VZV)-DNA was detected by PCR from cerebrospinal fluid. The diagnosis of lower cranial polyneuropathy due to VZV reactivation was made. After oral administration of an anti-viral agent and steroid, all symptoms and signs dramatically improved. Notably, there was no evidence of cutaneous or mucosal rash during the whole course of the disease. VZV reactivation should be included in the differential diagnosis of acute lower cranial polyneuropathy, especially with pain in the ear and throat, even without cutaneous or mucosal rash.

Herpetic cranial polyneuritis mimicking brain stem infarction-an atypical presentation of Ramsay Hunt syndrome

An elderly man presented with severe right ear pain and discharge, hoarseness and dysphagia causing significant involuntary weight loss. Extensive investigations by varied specialties only highlighted right vocal cord palsy and right parotid lymphadenitis. Reassessment on transfer to a rehabilitation ward noted clinically subtle right Ramsay Hunt syndrome with multiple lower cranial nerve involvement. We illustrate a case of varicella zoster virus cranial polyneuritis with bulbar symptoms mimicking bulbar stroke, requiring percutaneous endoscopic gastrostomy feeds, with significant clinical and radiological recovery over 1 year.

[Successful treatment with acyclovir and a corticosteroid for lower cranial polyneuropathy in zoster sine herpete: a case report]

A 62-year-old woman developed meningitis as well as acute paralysis of glossopharyngeal, vagus, and accessory nerves on the right side and also had dysfunction of the left hypoglossal nerve. Although there was no evidence of a typical cutaneous or mucosal herpetic lesion, PCR detection of varicella zoster virus (VZV)-DNA in cerebrospinal fluid confirmed the clinical diagnosis of polyneuritis cranialis due to VZV infection and zoster sine herpete. After starting intravenous acyclovir and methylprednisolone, her hypoglossal nerve palsy disappeared within a day and all other symptoms and signs dramatically improved. A rapid improvement observed in our patient suggests that the right cranial polyneuropathy could be caused by inflammation associated with epineurial edema (where the ninth, tenth, and eleventh cranial nerves pass through the right jugular foramen), whereas the exact mechanism of the twelfth cranial nerve involvement on the contralateral side is unknown. Our clinical findings indicate that acute lower cranial polyneuropathy in patients with zoster sine herpete should be treated immediately with combined administration of acyclovir and an anti-inflammatory corticosteroid.