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J Korean Dysphagia Soc 2024; 14(1): 66-70

Published online January 30, 2024 https://doi.org/10.34160/jkds.23.019

© The Korean Dysphagia Society.

Dysphagia Only with Unilateral Multiple Ulcerative Lesions in Varicella-Zoster Virus Infection: A Case Report

Sunwoo Hwang, M.D.1, Ji Yong Yoon, M.D.2, Junil So, M.D.1, Hongseo Hwang, M.D.2, Hayoung Byun, M.D.1,3, Chang Han Lee, M.D.2,3, Min-Kyun Oh, M.D., Ph.D2,3,4

1Department of Rehabilitation Medicine, Gyeongsang National University Hospital, Jinju, 2Department of Rehabilitation Medicine, Gyeongsang National University Changwon Hospital, Changwon, 3Department of Rehabilitation Medicine, Gyeongsang National University College of Medicine, Jinju, 4Institute of Medical Science, Gyeongsang National University, Jinju, Korea

Correspondence to:Min-Kyun Oh, Department of Rehabilitation Medicine, Gyeongsang National University Changwon Hospital, 11 Samjeongja-ro, Seongsan-gu, Changwon 51472, Korea
Tel: +82-55-214-2400, Fax: +82-55-214-1031, E-mail: solioh21@hanmail.net

Received: October 26, 2023; Revised: November 8, 2023; Accepted: December 11, 2023

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Pharyngeal dysphagia can be caused by structural abnormalities or neurological disorders such as stroke, meningitis, and other conditions. Herpes zoster (HZ), caused by the varicella-zoster virus (VZV), is a rare cause of pharyngeal dysphagia. The symptoms of HZ usually involve a painful rash with vesicles along the dermatome area, but it can also affect the cranial nerves (CN), such as CN VII (Ramsay-Hunt syndrome), and less commonly, other CN. A 69-year-old man presented with a sore throat and dysphagia symptoms. A laryngoscopy revealed multiple ulcerative mucosal lesions on the right soft palate and lateral pharynx. The patient was treated with oral valacyclovir, and although the lesions disappeared, the dysphagia symptoms remained. While dysphagia associated with a VZV infection is rare, it can occur with the additional symptoms of vocal cord paralysis. This paper reports a rare case of pharyngeal dysphagia caused by a VZV infection, and the patient presented only with the initial symptoms of sore throat and dysphagia without skin lesions or signs of vocal cord paralysis.

Keywords: Dysphagia, Herpes zoster, Varicella zoster virus, Viral infections, Neurology

For a proper swallowing process, it is essential to have a harmonious interaction between the motor and sensory functions of the structures comprising the oropharynx. In simpler terms, any structural or functional irregularities in these components can result in swallowing disorders1. Pharyngeal dysphagia is caused by several diseases that involve structural or functional abnormalities in the gastrointestinal tract. If there are no structural lesions, neurological disorders can be suspected, such as stroke, meningitis, mening-oradiculitis, meningoencephalitis, cerebellitis, myelo-pathy, and herpes zoster (HZ)2. Among them, HZ is a disease caused by the varicella-zoster virus (VZV), the same virus that causes chickenpox. After recovery from chickenpox, the virus becomes latent in neurons, reactivates within a few years, and causes symptoms of HZ. The most common symptom of HZ is a painful rash with vesicles along the dermatome area. Less commonly, it can involve cranial nerve (CN) VII and develop facial nerve palsy, a vesicular rash of the external auditory canal, and hearing loss, known as Ramsay-Hunt syndrome3. There are also reports of HZ involving CN V. However, few cases of HZ that involve CN IX and X are associated with pharyngeal dysphagia2. Most cases involving CN IX and X were accompanied by additional symptoms such as hoar-seness and hypogeusia. We report a rare case of pha-ryngeal dysphagia caused by VZV infection only with unilateral multiple ulcerative lesions and dysphagia without any other symptoms caused by VZV infection.

A 69-year-old man presented to our clinic with a 1-week history of sore throat and dysphagia symptoms. Seven months ago, he underwent upper gastrointestinal endoscopy during a medical check-up, and there were no specific findings. Neurological examinations were normal, especially with no facial palsy or hearing loss. For further evaluation, pharyngeal enhanced com-puted tomography (ECT) and laryngoscopy were per-formed. Pharyngeal ECT showed no specific findings except for the enlarged lymph nodes. True vocal cord motility was normal during laryngoscopy, but multiple ulcerative mucosal lesions were seen on the right soft palate and right lateral pharynx.(Fig. 1A) Under suspicion of VZV infection, the patient was treated with oral valacyclovir (500 mg/day for 7 days). Four days after treatment, VZV polymerase chain reaction (PCR) was positive in the blood. Twenty days after treatment, the ulcerative lesions in the soft palate and pharynx and the sore throat symptom disappeared, but the dysphagia symptoms remained.(Fig. 1B) LN enlargement had resolved in follow-up pharyngeal ECT compared to the prior study. The patient was referred to the department of rehabilitation for a videofluoroscopic swallowing study (VFSS) to examine swallowing function. The findings of VFSS showed the presence of pharyngeal dysphagia, such as weak swallow reflex, aspiration, and bolus retention.(Fig. 2A) The patient was recommended to undergo swal-lowing rehabilitation treatment and follow-up VFSS. He conducted rehabilitation therapy for dysphagia and a follow-up VFSS examination three months later. Nonetheless, no significant changes were observed in the follow-up VFSS examination, and the dysphagia symptoms persisted.(Fig. 2B) He is currently under rehabilitation outpatient clinic follow-up.

Figure 1. Laryngoscope images obtained in the ear-nose-and-throat department: prior to antiviral therapy (A) and post-treatment images (B). Multiple ulcerative lesions on the right soft palate and right lateral pharynx are observed in (A) Twenty days after treatment, the lesion was observed to disappear in (B).

Figure 2. Videofluoroscopic swallowing study shows the presence of pharyngeal dysphagia, such as weak swallow reflex, aspiration of liquid and soft blend diet food, and bolus retention in the initial (A) and the follow-up examination three months later (B).

The main symptom of HZ is skin lesions, which appear as grouped erythematous vesicles and pustules in one or two adjacent dermatomes. However, the VZV infection can also affect the cranial nerves, resul-ting in facial palsy, hearing loss, dizziness, dysphagia, and other neurological symptoms. Nevertheless, cranial nerve palsies are only developed by about 5% of patients with herpes zoster4, and dysphagia associated with VZV infection is relatively rare3.

Although the mechanism of descending involvement of lower cranial nerves is uncertain, several hypo-theses have been proposed. First, the invasion of cranial nerves may have been due to anatomical loca-tions. The CN VII joins the CN VIII via the anterior and posterior locations of the geniculate ganglion. And simultaneous viral infection is possible because of the connection with the CN IX and CN X. Secondly, CN IX, CN X, CN XI, and CN XII are supplied by the ascending pharyngeal artery. This hypothesis supports the possibility of polyneuropathy after vasculitis due to viral infection5.

The diagnosis of VZV infection is made clinically because of the distinctive manifestation. But in rare cases, the absence of skin or mucosal lesions makes the diagnosis difficult. Currently, PCR is the diag-nostic standard to detect VZV due to its high accu-racy, sensitivity, and immediacy2.

The treatment of HZ-associated dysphagia involves antiviral therapy, pain management, and supportive care. Indications for antiviral therapy of VZV include an immunocompromised state, moderate to severe pain, severe rash, involvement of the face or eye, age ≥50 years, and complications of zoster, such as dysphagia2.

One of the uncommon symptoms of VZV infection is dysphagia. In rare cases, dysphagia has been repo-rted as a symptom of VZV infection. A 76-year-old woman with a normal immune system reported expe-riencing dysphagia and mild dysphonia for four weeks, but no visible skin or mucosal lesions were found2. A 57-year-old immunocompetent male suffered from dysphagia and hoarseness five days before the skin lesion appeared6, and a 67-year-old woman presented with a sore throat for five days, followed shortly after by hoarseness and left-sided posterior hypogeusia7. Thus, dysphagia caused by VZV infection was previously rarely reported, but it often occurred with additional symptoms of vocal cord paralysis, even if there were no visible skin lesions.

When CN IX and CN X are affected by VZV infe-ction, dysphagia, and vocal cord palsy can occur. The CN IX innervates the pharynx and the posterior third of the tongue, while the CN X innervates the pharynx, larynx, and esophagus. When these nerves are infected by VZV, the inflammation and damage caused by the virus can disrupt the normal functioning of the muscles involved in swallowing. Specifically, the CN IX plays a key role in triggering the swallowing reflex by sensing the presence of food or liquid in the back of the throat and sending signals to the brainstem8. The CN X then coordinates the movement of the muscles involved in swallowing, including the pharyngeal and esophageal muscles. CN X also plays an important role in controlling the vocal cords. When VZV affects CN X, it can disrupt the normal functioning of the muscles involved in vocal cord movement. As a result, the vocal cords may become paralyzed or weakened, leading to changes in voice quality and difficulty speaking9. Most of the previously reported cases involved VZV affecting both nerves, resulting in dys-phagia and vocal cord palsy2,3,7.

However, in our case, the patient presented only initial symptoms of a sore throat and dysphagia without any other signs of vocal cord paralysis. There were no specific findings on the neurological exam and imaging performed to identify the cause of the symp-toms. Upon further evaluation, unilateral mucosal lesions were found on laryngoscopy. As a result, it was difficult to deduce that the symptoms of sore throat and dysphagia were caused by VZV infection alone, and suspicion of VZV infection arose only after discovering unilateral ulcerative mucosal lesions later on. When cranial nerves are involved in VZV infection, antiviral treatment with acyclovir or valacyclovir, combined with corticosteroids, has been associated with improved outcomes in patients with VZV-related cranial neuropathy. Furthermore, early initiation of therapy is important in enhancing the chances of complete recovery from cranial nerve involvement due to VZV infection10.

The healing period for dysphagia caused by VZV can vary depending on various factors, such as the severity and duration of symptoms and the patient’s immune system. Nisa et al.7 reported a systematic review of patients with herpes zoster involving the pharynx, and based on an analysis of 54 cases, they found that 26% of the total patients showed complete recovery of the affected cranial nerves, while 63% of patients showed incomplete recovery. The incomplete recovery rates by affected cranial nerves were reported as CN V (24%), VII (30%), VIII (21%), IX-X (19%), XI (2%), and XII (6%)7.

In the case we experienced, we started antiviral therapy suspecting VZV infection after discovering unilateral multiple ulcerative lesions on laryngoscopy seven days after the onset of dysphagia symptoms. And then, the prescription of antiviral drugs led to an improvement in symptoms. Sore throat and ulcerative lesions disappeared rapidly within a week of antiviral drug treatment, but the patient’s swallowing function did not show significant improvement, even after two months. It may have been difficult to suspect dys-phagia caused by VZV due to its different symptoms from previously reported cases. As a result of delayed treatment, long-term neurological complications, and functional impairment were left behind.

In conclusion, we presented a rare case of phary-ngeal dysphagia caused by VZV infection. Although HZ-associated dysphagia is rare, it should be consi-dered in the differential diagnosis of patients pre-senting with dysphagia symptoms. Early diagnosis and appropriate management can improve the patient’s prognosis and quality of life.

The case study was conducted according to the guidelines of the Declaration of Helsinki, and appro-ved by the Institutional Review Board of Gyeongsang National University Hospital (Protocol Code GNUH- 2023-06-006) in Jinju, South Korea.

  1. Kim DY. The pathologic mechanisms and epidemiology of dysphagia associated with COVID-19. J Korean Dys-phagia Soc 2021;11:87-92. https://doi.org/10.34160/jkds.2021.11.2.001.
    CrossRef
  2. Muhle P, Suntrup-Krueger S, Dziewas R, Warnecke T. Pharyngeal dysphagia due to Varicella zoster virus meningoradiculitis and full recovery: case report and endoscopic findings. SAGE Open Med Case Rep 2018;6:2050313X18756560. https://doi.org/10.1177/2050313x18756560.
    Pubmed KoreaMed CrossRef
  3. Mantero V, Rigamonti A, Valentini S, Fiumani A, Piamarta F, Bonfanti P, et al. Isolated acute dysphagia due to varicella-zoster virus. J Clin Virol 2014;59:268-9. https://doi.org/10.1016/j.jcv.2014.01.008.
    Pubmed CrossRef
  4. Amlie-Lefond C, Jubelt B. Neurologic manifestations of varicella zoster virus infections. Curr Neurol Neurosci Rep 2009;9:430-4. https://doi.org/10.1007/s11910-009-0064-z.
    Pubmed CrossRef
  5. Shim JH, Park JW, Kwon BS, Ryu KH, Lee HJ, Lim WH, et al. Dysphagia in Ramsay Hunt's syndrome - a case report -. Ann Rehabil Med 2011;35:738-41. https://doi.org/10.5535/arm.2011.35.5.738.
    Pubmed KoreaMed CrossRef
  6. Jung JW, Jang YJ, Hong EH, Kim KH, Kim KJ, Park EJ. Dysphagia with unilateral vocal cord paralysis in herpes zoster: a case report. Ann Dermatol 2022;34:475-7. https://doi.org/10.5021/ad.20.165.
    Pubmed KoreaMed CrossRef
  7. Nisa L, Landis BN, Giger R, Leuchter I. Pharyngolaryngeal involvement by varicella-zoster virus. J Voice 2013;27:636-41. https://doi.org/10.1016/j.jvoice.2013.02.011.
    Pubmed CrossRef
  8. Kitagawa J, Shingai T, Takahashi Y, Yamada Y. Phary-ngeal branch of the glossopharyngeal nerve plays a major role in reflex swallowing from the pharynx. Am J Physiol Regul Integr Comp Physiol 2002;282:R1342-7. https://doi.org/10.1152/ajpregu.00556.2001.
    Pubmed CrossRef
  9. Alwan M, Paddle PM. Vocal cord paralysis: pathophysiology, etiologies, and evaluation. Int J Head Neck Surg 2021;12:153-60.
    CrossRef
  10. Tsau PW, Liao MF, Hsu JL, Hsu HC, Peng CH, Lin YC, et al. Clinical presentations and outcome studies of cranial nerve involvement in herpes zoster infection: a retrospective single-center analysis. J Clin Med 2020;9:946. https://doi.org/10.3390/jcm9040946.
    Pubmed KoreaMed CrossRef

Article

Case Report

J Korean Dysphagia Soc 2024; 14(1): 66-70

Published online January 30, 2024 https://doi.org/10.34160/jkds.23.019

Copyright © The Korean Dysphagia Society.

Dysphagia Only with Unilateral Multiple Ulcerative Lesions in Varicella-Zoster Virus Infection: A Case Report

Sunwoo Hwang, M.D.1, Ji Yong Yoon, M.D.2, Junil So, M.D.1, Hongseo Hwang, M.D.2, Hayoung Byun, M.D.1,3, Chang Han Lee, M.D.2,3, Min-Kyun Oh, M.D., Ph.D2,3,4

1Department of Rehabilitation Medicine, Gyeongsang National University Hospital, Jinju, 2Department of Rehabilitation Medicine, Gyeongsang National University Changwon Hospital, Changwon, 3Department of Rehabilitation Medicine, Gyeongsang National University College of Medicine, Jinju, 4Institute of Medical Science, Gyeongsang National University, Jinju, Korea

Correspondence to:Min-Kyun Oh, Department of Rehabilitation Medicine, Gyeongsang National University Changwon Hospital, 11 Samjeongja-ro, Seongsan-gu, Changwon 51472, Korea
Tel: +82-55-214-2400, Fax: +82-55-214-1031, E-mail: solioh21@hanmail.net

Received: October 26, 2023; Revised: November 8, 2023; Accepted: December 11, 2023

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Pharyngeal dysphagia can be caused by structural abnormalities or neurological disorders such as stroke, meningitis, and other conditions. Herpes zoster (HZ), caused by the varicella-zoster virus (VZV), is a rare cause of pharyngeal dysphagia. The symptoms of HZ usually involve a painful rash with vesicles along the dermatome area, but it can also affect the cranial nerves (CN), such as CN VII (Ramsay-Hunt syndrome), and less commonly, other CN. A 69-year-old man presented with a sore throat and dysphagia symptoms. A laryngoscopy revealed multiple ulcerative mucosal lesions on the right soft palate and lateral pharynx. The patient was treated with oral valacyclovir, and although the lesions disappeared, the dysphagia symptoms remained. While dysphagia associated with a VZV infection is rare, it can occur with the additional symptoms of vocal cord paralysis. This paper reports a rare case of pharyngeal dysphagia caused by a VZV infection, and the patient presented only with the initial symptoms of sore throat and dysphagia without skin lesions or signs of vocal cord paralysis.

Keywords: Dysphagia, Herpes zoster, Varicella zoster virus, Viral infections, Neurology

INTRODUCTION

For a proper swallowing process, it is essential to have a harmonious interaction between the motor and sensory functions of the structures comprising the oropharynx. In simpler terms, any structural or functional irregularities in these components can result in swallowing disorders1. Pharyngeal dysphagia is caused by several diseases that involve structural or functional abnormalities in the gastrointestinal tract. If there are no structural lesions, neurological disorders can be suspected, such as stroke, meningitis, mening-oradiculitis, meningoencephalitis, cerebellitis, myelo-pathy, and herpes zoster (HZ)2. Among them, HZ is a disease caused by the varicella-zoster virus (VZV), the same virus that causes chickenpox. After recovery from chickenpox, the virus becomes latent in neurons, reactivates within a few years, and causes symptoms of HZ. The most common symptom of HZ is a painful rash with vesicles along the dermatome area. Less commonly, it can involve cranial nerve (CN) VII and develop facial nerve palsy, a vesicular rash of the external auditory canal, and hearing loss, known as Ramsay-Hunt syndrome3. There are also reports of HZ involving CN V. However, few cases of HZ that involve CN IX and X are associated with pharyngeal dysphagia2. Most cases involving CN IX and X were accompanied by additional symptoms such as hoar-seness and hypogeusia. We report a rare case of pha-ryngeal dysphagia caused by VZV infection only with unilateral multiple ulcerative lesions and dysphagia without any other symptoms caused by VZV infection.

CASE REPORT

A 69-year-old man presented to our clinic with a 1-week history of sore throat and dysphagia symptoms. Seven months ago, he underwent upper gastrointestinal endoscopy during a medical check-up, and there were no specific findings. Neurological examinations were normal, especially with no facial palsy or hearing loss. For further evaluation, pharyngeal enhanced com-puted tomography (ECT) and laryngoscopy were per-formed. Pharyngeal ECT showed no specific findings except for the enlarged lymph nodes. True vocal cord motility was normal during laryngoscopy, but multiple ulcerative mucosal lesions were seen on the right soft palate and right lateral pharynx.(Fig. 1A) Under suspicion of VZV infection, the patient was treated with oral valacyclovir (500 mg/day for 7 days). Four days after treatment, VZV polymerase chain reaction (PCR) was positive in the blood. Twenty days after treatment, the ulcerative lesions in the soft palate and pharynx and the sore throat symptom disappeared, but the dysphagia symptoms remained.(Fig. 1B) LN enlargement had resolved in follow-up pharyngeal ECT compared to the prior study. The patient was referred to the department of rehabilitation for a videofluoroscopic swallowing study (VFSS) to examine swallowing function. The findings of VFSS showed the presence of pharyngeal dysphagia, such as weak swallow reflex, aspiration, and bolus retention.(Fig. 2A) The patient was recommended to undergo swal-lowing rehabilitation treatment and follow-up VFSS. He conducted rehabilitation therapy for dysphagia and a follow-up VFSS examination three months later. Nonetheless, no significant changes were observed in the follow-up VFSS examination, and the dysphagia symptoms persisted.(Fig. 2B) He is currently under rehabilitation outpatient clinic follow-up.

Figure 1. Laryngoscope images obtained in the ear-nose-and-throat department: prior to antiviral therapy (A) and post-treatment images (B). Multiple ulcerative lesions on the right soft palate and right lateral pharynx are observed in (A) Twenty days after treatment, the lesion was observed to disappear in (B).

Figure 2. Videofluoroscopic swallowing study shows the presence of pharyngeal dysphagia, such as weak swallow reflex, aspiration of liquid and soft blend diet food, and bolus retention in the initial (A) and the follow-up examination three months later (B).

DISCUSSION

The main symptom of HZ is skin lesions, which appear as grouped erythematous vesicles and pustules in one or two adjacent dermatomes. However, the VZV infection can also affect the cranial nerves, resul-ting in facial palsy, hearing loss, dizziness, dysphagia, and other neurological symptoms. Nevertheless, cranial nerve palsies are only developed by about 5% of patients with herpes zoster4, and dysphagia associated with VZV infection is relatively rare3.

Although the mechanism of descending involvement of lower cranial nerves is uncertain, several hypo-theses have been proposed. First, the invasion of cranial nerves may have been due to anatomical loca-tions. The CN VII joins the CN VIII via the anterior and posterior locations of the geniculate ganglion. And simultaneous viral infection is possible because of the connection with the CN IX and CN X. Secondly, CN IX, CN X, CN XI, and CN XII are supplied by the ascending pharyngeal artery. This hypothesis supports the possibility of polyneuropathy after vasculitis due to viral infection5.

The diagnosis of VZV infection is made clinically because of the distinctive manifestation. But in rare cases, the absence of skin or mucosal lesions makes the diagnosis difficult. Currently, PCR is the diag-nostic standard to detect VZV due to its high accu-racy, sensitivity, and immediacy2.

The treatment of HZ-associated dysphagia involves antiviral therapy, pain management, and supportive care. Indications for antiviral therapy of VZV include an immunocompromised state, moderate to severe pain, severe rash, involvement of the face or eye, age ≥50 years, and complications of zoster, such as dysphagia2.

One of the uncommon symptoms of VZV infection is dysphagia. In rare cases, dysphagia has been repo-rted as a symptom of VZV infection. A 76-year-old woman with a normal immune system reported expe-riencing dysphagia and mild dysphonia for four weeks, but no visible skin or mucosal lesions were found2. A 57-year-old immunocompetent male suffered from dysphagia and hoarseness five days before the skin lesion appeared6, and a 67-year-old woman presented with a sore throat for five days, followed shortly after by hoarseness and left-sided posterior hypogeusia7. Thus, dysphagia caused by VZV infection was previously rarely reported, but it often occurred with additional symptoms of vocal cord paralysis, even if there were no visible skin lesions.

When CN IX and CN X are affected by VZV infe-ction, dysphagia, and vocal cord palsy can occur. The CN IX innervates the pharynx and the posterior third of the tongue, while the CN X innervates the pharynx, larynx, and esophagus. When these nerves are infected by VZV, the inflammation and damage caused by the virus can disrupt the normal functioning of the muscles involved in swallowing. Specifically, the CN IX plays a key role in triggering the swallowing reflex by sensing the presence of food or liquid in the back of the throat and sending signals to the brainstem8. The CN X then coordinates the movement of the muscles involved in swallowing, including the pharyngeal and esophageal muscles. CN X also plays an important role in controlling the vocal cords. When VZV affects CN X, it can disrupt the normal functioning of the muscles involved in vocal cord movement. As a result, the vocal cords may become paralyzed or weakened, leading to changes in voice quality and difficulty speaking9. Most of the previously reported cases involved VZV affecting both nerves, resulting in dys-phagia and vocal cord palsy2,3,7.

However, in our case, the patient presented only initial symptoms of a sore throat and dysphagia without any other signs of vocal cord paralysis. There were no specific findings on the neurological exam and imaging performed to identify the cause of the symp-toms. Upon further evaluation, unilateral mucosal lesions were found on laryngoscopy. As a result, it was difficult to deduce that the symptoms of sore throat and dysphagia were caused by VZV infection alone, and suspicion of VZV infection arose only after discovering unilateral ulcerative mucosal lesions later on. When cranial nerves are involved in VZV infection, antiviral treatment with acyclovir or valacyclovir, combined with corticosteroids, has been associated with improved outcomes in patients with VZV-related cranial neuropathy. Furthermore, early initiation of therapy is important in enhancing the chances of complete recovery from cranial nerve involvement due to VZV infection10.

The healing period for dysphagia caused by VZV can vary depending on various factors, such as the severity and duration of symptoms and the patient’s immune system. Nisa et al.7 reported a systematic review of patients with herpes zoster involving the pharynx, and based on an analysis of 54 cases, they found that 26% of the total patients showed complete recovery of the affected cranial nerves, while 63% of patients showed incomplete recovery. The incomplete recovery rates by affected cranial nerves were reported as CN V (24%), VII (30%), VIII (21%), IX-X (19%), XI (2%), and XII (6%)7.

In the case we experienced, we started antiviral therapy suspecting VZV infection after discovering unilateral multiple ulcerative lesions on laryngoscopy seven days after the onset of dysphagia symptoms. And then, the prescription of antiviral drugs led to an improvement in symptoms. Sore throat and ulcerative lesions disappeared rapidly within a week of antiviral drug treatment, but the patient’s swallowing function did not show significant improvement, even after two months. It may have been difficult to suspect dys-phagia caused by VZV due to its different symptoms from previously reported cases. As a result of delayed treatment, long-term neurological complications, and functional impairment were left behind.

In conclusion, we presented a rare case of phary-ngeal dysphagia caused by VZV infection. Although HZ-associated dysphagia is rare, it should be consi-dered in the differential diagnosis of patients pre-senting with dysphagia symptoms. Early diagnosis and appropriate management can improve the patient’s prognosis and quality of life.

CONFLICT OF INTEREST

None.

ETHICAL APPROVAL

The case study was conducted according to the guidelines of the Declaration of Helsinki, and appro-ved by the Institutional Review Board of Gyeongsang National University Hospital (Protocol Code GNUH- 2023-06-006) in Jinju, South Korea.

FUNDING

None.

Fig 1.

Figure 1.Laryngoscope images obtained in the ear-nose-and-throat department: prior to antiviral therapy (A) and post-treatment images (B). Multiple ulcerative lesions on the right soft palate and right lateral pharynx are observed in (A) Twenty days after treatment, the lesion was observed to disappear in (B).
Journal of the Korean Dysphagia Society 2024; 14: 66-70https://doi.org/10.34160/jkds.23.019

Fig 2.

Figure 2.Videofluoroscopic swallowing study shows the presence of pharyngeal dysphagia, such as weak swallow reflex, aspiration of liquid and soft blend diet food, and bolus retention in the initial (A) and the follow-up examination three months later (B).
Journal of the Korean Dysphagia Society 2024; 14: 66-70https://doi.org/10.34160/jkds.23.019

References

  1. Kim DY. The pathologic mechanisms and epidemiology of dysphagia associated with COVID-19. J Korean Dys-phagia Soc 2021;11:87-92. https://doi.org/10.34160/jkds.2021.11.2.001.
    CrossRef
  2. Muhle P, Suntrup-Krueger S, Dziewas R, Warnecke T. Pharyngeal dysphagia due to Varicella zoster virus meningoradiculitis and full recovery: case report and endoscopic findings. SAGE Open Med Case Rep 2018;6:2050313X18756560. https://doi.org/10.1177/2050313x18756560.
    Pubmed KoreaMed CrossRef
  3. Mantero V, Rigamonti A, Valentini S, Fiumani A, Piamarta F, Bonfanti P, et al. Isolated acute dysphagia due to varicella-zoster virus. J Clin Virol 2014;59:268-9. https://doi.org/10.1016/j.jcv.2014.01.008.
    Pubmed CrossRef
  4. Amlie-Lefond C, Jubelt B. Neurologic manifestations of varicella zoster virus infections. Curr Neurol Neurosci Rep 2009;9:430-4. https://doi.org/10.1007/s11910-009-0064-z.
    Pubmed CrossRef
  5. Shim JH, Park JW, Kwon BS, Ryu KH, Lee HJ, Lim WH, et al. Dysphagia in Ramsay Hunt's syndrome - a case report -. Ann Rehabil Med 2011;35:738-41. https://doi.org/10.5535/arm.2011.35.5.738.
    Pubmed KoreaMed CrossRef
  6. Jung JW, Jang YJ, Hong EH, Kim KH, Kim KJ, Park EJ. Dysphagia with unilateral vocal cord paralysis in herpes zoster: a case report. Ann Dermatol 2022;34:475-7. https://doi.org/10.5021/ad.20.165.
    Pubmed KoreaMed CrossRef
  7. Nisa L, Landis BN, Giger R, Leuchter I. Pharyngolaryngeal involvement by varicella-zoster virus. J Voice 2013;27:636-41. https://doi.org/10.1016/j.jvoice.2013.02.011.
    Pubmed CrossRef
  8. Kitagawa J, Shingai T, Takahashi Y, Yamada Y. Phary-ngeal branch of the glossopharyngeal nerve plays a major role in reflex swallowing from the pharynx. Am J Physiol Regul Integr Comp Physiol 2002;282:R1342-7. https://doi.org/10.1152/ajpregu.00556.2001.
    Pubmed CrossRef
  9. Alwan M, Paddle PM. Vocal cord paralysis: pathophysiology, etiologies, and evaluation. Int J Head Neck Surg 2021;12:153-60.
    CrossRef
  10. Tsau PW, Liao MF, Hsu JL, Hsu HC, Peng CH, Lin YC, et al. Clinical presentations and outcome studies of cranial nerve involvement in herpes zoster infection: a retrospective single-center analysis. J Clin Med 2020;9:946. https://doi.org/10.3390/jcm9040946.
    Pubmed KoreaMed CrossRef

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