Primary infection with varicella- zoster virus (VZV) causes chickenpox, whereas reactivation of latent VZV causes herpes zoster (also known as shingles), typically a localized infection confined to one dermatome or adjacent dermatomes. Both types of infection are known to have a vast array of presentations and complications among HIV-infected patients.
A 38-year-old man with stage C3 HIV infection and hepatitis C virus (HCV) coinfection and obstructive sleep apnea presented with a painful rash on the left cheek that had a distribution consistent with the third branch of the left trigeminal nerve. The patient was given famciclovir and gabapentin for management of presumed zoster, which was confirmed by a direct fluorescent antibody test.
Two days later, the man returned to the clinic with left ear pressure, pain, and diminished hearing. Physical examination revealed a temperature of 37C (98.6F), a blood pressure of 128/68 mm Hg, and a heart rate of 83 beats per minute. The vesicular lesions that were noted on the left side of the face 2 days earlier were still present and several new lesions had developed on the left portion of his scalp. The patient did not experience visual symptoms and no lesions developed on the tip of the nose. No facial asymmetry or weakness was present. The left tympanic membrane was bulging, and a hemorrhagic middle ear effusion was discovered (Figure).
image shows a bulging
middle ear effusion.
Findings from an examination of the right ear were unremarkable. An otolaryngologist visualized a normal external auditory canal and a bulging, erythematous tympanic membrane with an effusion that did not appear to be purulent. An audiogram revealed mild conductive hearing loss in the affected ear and normal hearing in the other ear. A tympanogram was not obtained because of the patient's ear pain.
Amoxicillin/clavulanic acid was prescribed to prevent secondary infections. The otolaryngologists chose noninvasive management, but they planned to reconsider tympanocentesis if symptoms did not improve.
The following day, the patient returned to the clinic complaining that blood had drained from his ear during the night. On examination, a small slit perforation, with scant amounts of drainage, was found in the tympanic membrane. Attempts were made to culture the drainage but insufficient fluid was obtained. No vesicular lesions were noted within the canal.
- Adour KK. Otological complications of herpes zoster. Ann Neurol. 1994;35(suppl):S62-S64.
- Morris MS, Prasad S. Otologic disease in the acquired immunodeficiency syndrome. Ear Nose Throat J. 1990;69:451-453.
- Fujiwara Y, Yanagihara N, Kurata T. Middle ear mucosa in Ramsay Hunt syndrome. Ann Otol Rhinol Laryngol. 1990;99(5 pt 1):359-362.
- Van de Steene V, Kuhweide R, Vlaminck S, Casselman J. Varicella zoster virus: beyond facial paralysis. Acta Otorhinolaryngol Belg. 2004; 58:61-66.
- Leong SC, Karkanevatos A. Unusual presentation of Ramsay-Hunt syndrome without-facial nerve palsy. Br J Hosp Med (Lond). 2005;66:542- 543.
- Vafai A, Berger M. Zoster in patients infected with HIV: a review. Am J Med Sci. 2001;321:372- 380.
- Veenstra J, van Praag RM, Krol A, et al. Complications of varicella zoster virus reactivation in HIV-infected homosexual men. AIDS. 1996; 10:393-399.