A rare case of Herpes zoster oticus in an immunocompetent patient

Abstract

IntroductionRamsay Hunt syndrome (RHS) is first described by James Ramsay Hunt in 1907 [1]. It is caused by the reactivation of latent varicella-zoster virus (VZV) that has remained dormant within sensory root ganglia (commonly the geniculate ganglion) of the sensory branch of the facial nerve. Involvement of sensory branch of the geniculate ganglion of facial nerve leads Herpes zoster (HZ) oticus which is also known as RHS. Individuals with decreased cell-mediated immunity resulting from carcinoma, radiation therapy, chemotherapy or human immunodeficiency virus (HIV) infection are at greater risk for reactivation of latent VZV. Physical stress and emotional stress often are cited as precipitating factors. Incidence and clinical severity increases when host immunity is compromised. However it is uncommon to see Herpes zoster oticus in healthy individuals. In this report, we describe the clinical course of a patient who presented with Herpes zoster oticus in the absence of a known immunosuppressive condition. A brief review of literature on this topic is also presented. Case ReportA previously healthy 65-year old man presented with a 3-days history of vesicular lesions with erythematous base on neck. It was followed by the spread of vesicular eruption to involve external external auditory meatus of right side, and pinna over next 2-days. These are fluid filled vesicular eruptions which bust and break down on 2nd-3rd day with subsequent scab formation. There is no facial weakness. On examination, there was no lower motor neuron facial palsy. A neurologic examination revealed no weakness in the marginal mandibular branch of the left facial nerve. There is no any sign of loss of ipsilateral nasolabial fold or weakness in the temporal branch of the facial nerve. There were painful adherent crusts and scabs in left conchae and external auditory meatus (Fig. 1), associated with unclear hearing of left ear. The oral cavity and oropharynx were normal. Ocular examination demonstrated no nystagmus and normal conjunctiva. He has given history of stressful life events (sudden 3 deaths in family) in past 4 months. Review of systems was negative. The patient is not able to tell history of chickenpox during childhood or any recent exposure to it. There was no past history of diabetes, cardiac or pulmonary disease or lymphoma. The patient has not been on immunosuppressive or other medications. There is history of Psoriasis 2 years back showing on and off symptoms but on regular treatment. Patient is alcoholic, habit of tobacco chewing and occasional Pan chewing. On examination, the patient was afebrile (37.4°C). He had vesicles but not pustules, with crusting and swelling, in the distribution of the cervical division of VII (facial) cranial nerve. The left pinna is swollen, tender and red. There was no tympanic membrane involvement. Vesicles and scabs in various stages were also present lateral side of neck, in front of sternum and external ear ( Fig. 1) and behind Right pinna (Fig. 2) AbstractHerpes zoster oticus in healthy pe...

Clinico-Etiological study of benign lesions of pinna and its management

“…Therefore, elderly patients should be recognized to prevent this virus risk and apt treatment must be initiated at the earliest. 14 Sebaceous cysts were observed only in 2 cases and were managed with complete excision.…”

Ramsey Hunt Syndrome: A Review Article

“…[5,7] Persons with reduced cell-mediated immunity resulting from carcinoma, radiation therapy, chemotherapy, or human immunodeficiency virus (HIV) infection are particularly at risk. [8] However, it can also rarely be seen in immune-competent patients. [8] The thoracic segment is involved in the majority of herpes zoster cases.…”

“…[8] However, it can also rarely be seen in immune-competent patients. [8] The thoracic segment is involved in the majority of herpes zoster cases. [2] It has been reported that the head and neck involvement of herpes zoster is 13-35%.…”

“…[7,10] Herpes Zoster is a disease seen mostly in elderly people (>60 years). [8] It is stated that Ramsey Hunt Syndrome constitutes 7-12% of all peripheral facial paralysis. [11,12]…”

“…[12] The severity of the disease depends on the cellular immunity of the patient. [8] Other causes of peripheral facial paralysis can be counted as otitis media, local trauma to the facial nerve, post-surgical complications, neoplasms, and sarcoidosis. [17] In addition, Lyme disease may cause peripheral facial paralysis in endemic areas.…”