Zoster Sine Herpete: two unusual cases of varicella-zoster reactivation with atypical complaints of acute chest pain and severe headache.

In this case report, we describe two unusual presentations of varicella-zoster virus (VZV) reactivation without rash, a condition known as Zoster Sine Herpete (ZSH). In Case 1, a 58-year-old woman presented with severe right-sided chest pain under her breast that radiated to the ipsilateral back. After the initial workup ruled out cardiac and musculoskeletal etiologies, the characteristic dermatomal distribution of pain made us suspect VZV reactivation. A diagnosis of ZSH was made with positive VZV IgG and IgM serologies and symptomatic relief after famciclovir treatment. In Case 2, a 43-year-old woman presented with a severe headache and resolved sharp right flank pain. She was diagnosed with varicella meningitis after cerebrospinal fluid showed positive VZV DNA. Intravenous acyclovir treatment resulted in symptom resolution. The most common presentation of VZV reactivation is Herpes Zoster, or shingles, making ZSH a frequently missed diagnosis. High clinical suspicion is warranted to prevent life-threatening complications of ZSH.

Chronic myelitis associated with zoster sine herpete: A case report.

RATIONALE: Neurological complications of varicella-zoster virus (VZV) infection include cerebral infarction, meningoencephalitis, segmental sensory disturbance, facial nerve palsy, and myelitis. Chronic myelitis is rarely reported. Diagnosis of VZV infection can be confirmed by elevated anti-VZV immunoglobulin G (IgG) antibody or detection of VZV DNA in the cerebrospinal fluid (CSF), the former reported to be superior. The detection rate of VZV DNA is generally thought to decrease with time after the onset of the condition. The utility of VZV DNA polymerase chain reaction (PCR) is thus thought to be limited to the acute phase of the disease. The presence of skin lesions also helps to render a diagnosis; however, cases of zoster sine herpete (ZSH), the occurrence of segmental symptoms without skin lesions, renders the diagnosis of VZV infection more difficult. Antiviral drugs, such as acyclovir, are the treatment of choice to resolve VZV infections. PATIENT CONCERNS: A 65-year-old Japanese man felt heaviness and a throbbing pain on the ulnar side of the right forearm. He was previously diagnosed with cervical spondylosis, and received nonsteroidal anti-inflammatory drugs with little improvement. Contrast cervical magnetic resonance imaging showed a swelling and an increased signal intensity of the spinal cord, and an enhancing lesion, all of which were suggestive of myelitis. DIAGNOSIS: We found no evidence for diagnoses of sarcoidosis, Behçet disease, multiple sclerosis, or neuromyelitis optica spectrum disorder. The CSF analysis revealed an elevation of the total protein concentration and that the patient was positive for VZV DNA, while anti-VZV IgG was not elevated. The patient was therefore diagnosed with ZSH myelitis. INTERVENTIONS: We administered acyclovir and valaciclovir as the first therapy. At the time of recurrence, we used high-dose acyclovir, vidarabine, and high-dose methylprednisolone pulse therapy. OUTCOMES: The patient's dysesthetic pain in the right upper limb improved following the first antiviral therapy. Two months later, he suffered a recurrence, but the second therapy significantly relieved his symptoms. LESSONS: VZV infection should be regarded as an important differential diagnosis of chronic myelitis. VZV DNA PCR should be performed even in the chronic phase of the condition to introduce the possibility of antiviral therapy as a treatment option.

Typical or Atypical Ramsay-Hunt Syndrome in Delayed Facial Palsy After Stapedectomy?

OBJECTIVES: The aim of this study was to define the typical pattern for varicella zoster virus (VZV) reactivation in delayed facial palsy (DFP) after stapedectomy for otosclerosis. MATERIALS AND METHODS: Review of the relevant literature, personal casistics, and case-report. RESULTS: In total, 48 cases of DFP after stapes surgery have been described so far, including the reported case with exclusive manifestation of atypical Ramsay Hunt syndrome (RH); in the personal series of 1253 stapedectomies, DFP occurred in only one case (0.08%). Complete DFP (House-Brackmann grade VI) rapidly developed 12 days after surgery; RH appeared 2 days later, confirming the role of VZV. The DFP started improving after 8 weeks and completely recovered 6 months later. CONCLUSION: Acute otalgia prior to DFP should raise the suspicion of VZV reactivation. Atypical RH is the most frequent pattern that occurs in DFP after stapedectomy.

[Hypogeusia and High Signals in the Nuclei of the Solitary Tract on MRI due to Varicella-Zoster Virus Infection: A Case Report].

A 63-year-old man noticed hypogeusia after presenting hiccups for several days. He was serologically diagnosed with varicella-zoster virus (VZV) infection, but had no skin lesions typical of herpes (zoster sine herpete). Hypogeusia was confirmed by electrogustometry and the filter-paper disk method, which showed damage in the areas innervated by the cord of tympanum, glossopharyngeal nerve, and greater petrosal nerve. High signals in the nuclei of the solitary tract of the medulla oblongata and the enhancement of the bilateral intracranial segments of the cranial nerve IX and X complex were observed by magnetic resonance imaging (MRI). The signal changes in the nuclei of the solitary tract on MRI were seen for more than 2 months, and hypogeusia lasted for more than 7 months. Hypogeusia caused by VZV infection has rarely been reported; however, similar cases could have gone undiagnosed or underdiagnosed in patients with idiopathic hypogeusia. (Received August 18, 2016; Accepted September 29, 2016; Published February 1, 2017).

The alpha-herpesviridae in dermatology : Herpes simplex virus types I and II.

This review on herpes simplex virus type I and type II (HSV­I, HSV­II) summarizes recent developments in clinical manifestations and treatment interventions for primary and recurrent orolabial and genital herpes, as well as those regarding vaccination issues. Among the clinical presentations, the relationship between pyogenic granuloma and chronic HSV­I infection; HSV-related folliculitis; verrucous HSV­I and HSV­II lesions; the role of recurrent HSV­I infection in burning mouth syndrome; HSV­I and HSV­II infection of the periareolar area; zosteriform HSV; the "knife-cut sign"; and the preferential colonization and infection of preexisting dermatoses by HSV­I or HSV­II are discussed. The usual antiviral treatment regimens for primary and recurrent orolabial and genital herpes are compared to short-term and one-day treatment options. New anti-HSV­I and anti-HSV­II agents include amenavir, pritelivir, brincidofovir, valomaciclovir, and FV-100. Therapeutic or preventive vaccination against HSV­I and HSV­II infections still remains a highly desirable treatment aim, which, unfortunately, has no clinically relevant applications to date.

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.

[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.

Burning pain from chest to back · allodynia and hyperesthesia · extreme sensitivity at the left T5 dermatome · Dx?

A 27-year-old woman in the 21st week of her first pregnancy came to our clinic complaining of a constant burning pain that spread around her left chest wall to her back. She graded the pain as a 10 on a 0 to 10 visual analog scale. The pain, which began 3 months earlier, became worse when she took a deep breath, ate, or walked, but was alleviated by applying warm compresses. Our patient hadn't slept well since the pain began. Her medical history was noteworthy for chickenpox at age 5.

Persistent hiccups and vomiting with multiple cranial nerve palsy in a case of zoster sine herpete.

A 76-year-old man came to our hospital complaining of hiccups and vomiting lasting for five days. A neurological examination showed dysfunction of cranial nerves V, VII, VIII, IX and X on the left side. Cerebrospinal fluid polymerase chain reaction for varicella zoster virus-DNA was positive. The patient responded well to treatment with intravenous acyclovir and steroids. To the best of our knowledge, this is the first case report of zoster sine herpete presenting with persistent hiccups and vomiting. It is important to keep in mind that herpes zoster can present with symptoms that closely resemble those of intractable hiccups and nausea of neuromyelitis optica. Early detection of the virus is critical for making appropriate treatment decisions.

Varicella-zoster virus in the saliva of patients with herpes zoster.

Fifty-four patients with herpes zoster were treated with valacyclovir. On treatment days 1, 8, and 15, pain was scored and saliva examined for varicella-zoster virus (VZV) DNA. VZV DNA was found in every patient the day treatment was started and later disappeared in 82%. There was a positive correlation between the presence of VZV DNA and pain and between VZV DNA copy number and pain (P <.0005). VZV DNA was present in 1 patient before rash and in 4 after pain resolved and was not present in any of 6 subjects with chronic pain or in 14 healthy subjects. Analysis of human saliva has potential usefulness in the diagnosis of neurological disease produced by VZV without rash.

[Case of zoster sine herpete presenting with dysphagia diagnosed by PCR analysis of VZV DNA in auricular skin exudates].

A 66-year-old woman was admitted to our hospital because of hoarseness and dysphagia after right earache and pharyngalgia. She showed right glossopharyngeal nerve and vagus nerve palsies, but no other neurological deficits. There was no skin rash within the regions of her ear, oral cavity, pharynx and larynx. Slight increase of mononuclear cells was noted in the cerebrospinal fluid. MR brain imaging was normal. We diagnosed her as zoster sine herpete (ZSH) and treated her with acyclovir, after which she almost completely recovered. The examination of antibodies and DNA of varicella zoster virus (VZV) in the serum and cerebrospinal fluid revealed a pattern of previous zoster infection without evidences of reactivation. However, VZV DNA was detected in auricular skin exudates with PCR. We conclude that PCR analysis of VZV DNA in auricular skin exudates can be a useful diagnostic tool for the diagnosis of zoster sine herpete presenting with painful glossopharyngeal nerve and vagus nerve palsies.

Lateral sinus thrombosis associated with zoster sine herpete.

Herpes zoster results from reactivation of the varicella zoster virus (VZV). Zoster sine herpete (ZSH) is an uncommon manifestation of VZV infection and presents with similar symptoms but without the vesicular rash. We describe an unusual case of lateral sinus thrombosis (LST) that developed during the clinical course of ZSH in the C2 distribution. A 55-year-old woman presented with a 3-day history of left temporal and postauricular pain, nausea, vomiting, and mild photophobia. She denied otalgia, otorrhea, and hearing loss. Examination revealed hyperesthesia in the left C2 nerve root distribution without evidence of herpetic rash. A computed tomography scan showed minimal fluid in the left mastoid cavity (not mastoiditis) and thrombus within the left lateral and sigmoid dural sinus. Magnetic resonance imaging and magnetic resonance angiogram confirmed these findings. Laboratory studies revealed elevated neurotrophic immunoglobulin G levels to VZV. Hypercoagulable studies were normal. She was subsequently treated with Neurontin, acyclovir, and anticoagulation. Her symptoms improved, and she was discharged 3 days later. LST is generally a complication of middle ear infection. Nonseptic LST, however, may result from dehydration, oral contraceptive use, coagulopathy, or thyroid disease. This unusual case raises the suspicion that thrombosis resulted from VZV associated thrombophlebitis in the ipsilateral cerebral venous sinuses along the second cervical nerve root distribution. A high index of suspicion is necessary in such cases so that a different treatment course can be identified and antiviral medication initiated promptly.

Risk factors for postherpetic neuralgia in patients with herpes zoster.

OBJECTIVES: To identify risk factors for postherpetic neuralgia (PHN) using a validated definition of this chronic neuropathic pain syndrome, to determine combinations of risk factors that identify patients with a high risk of developing PHN, and to examine the characteristics of patients with subacute herpetic neuralgia, that is, pain that persists beyond the acute phase of herpes zoster but that resolves before PHN can be diagnosed. METHODS: The authors examined baseline and follow-up data from 965 herpes zoster patients enrolled within 72 hours of rash onset in two clinical trials of famciclovir. RESULTS: Univariate and multivariate analyses indicated that older age, female sex, presence of a prodrome, greater rash severity, and greater acute pain severity made independent contributions to identifying which patients developed PHN. Patients with subacute herpetic neuralgia who did not develop PHN were significantly younger and had less severe acute pain than PHN patients but were significantly more likely to have severe and widespread rash than patients without persisting pain. CONCLUSIONS: The independent contributions to the prediction of PHN made by older age, female sex, presence of a prodrome, greater rash severity, and greater acute pain severity suggest that these risk factors reflect different mechanisms that each contribute to the development of PHN. Subacute herpetic neuralgia that does not progress to PHN may reflect peripheral tissue damage and inflammation caused by a particularly severe or widespread rash.