SHM Converge Scientific Abstract ePoster Gallery-All of the Problems, None of the Rash

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This case describes a 41-year-old man with 6 days of severe dysphagia, hoarseness, right ear pain, right-sided headache, and right arm pain, without any rash. Exam showed right vocal cord paralysis and palate asymmetry, while imaging revealed a right-sided enlarged lymph node and vocal cord paralysis. Because symptoms suggested possible neurologic or infectious involvement, lumbar puncture was performed and showed lymphocytic CSF pleocytosis with positive VZV PCR, confirming zoster sine herpete (ZSH), a herpes zoster reactivation without the typical vesicular rash.<br /><br />The patient was treated with IV acyclovir and gabapentin. Initial swallow evaluation showed impaired swallowing and aspiration risk. After 13 days, he still had dysphagia, cough, and weight loss, so prednisone was added. Within 48 hours, repeat swallow evaluation showed complete recovery of vocal cord movement and no aspiration. He was discharged to complete a 21-day course of IV acyclovir and a short prednisone taper, with outpatient infectious disease and ENT follow-up. At one-month follow-up, flexible laryngoscopy showed normal vocal cord function.<br /><br />The discussion emphasizes that shingles usually presents with a painful dermatomal rash, but in ZSH, reactivation of varicella-zoster virus occurs without rash, making diagnosis difficult. ZSH should be considered in patients with unexplained unilateral neuropathic pain or focal paralysis, especially when symptoms fit a dermatomal pattern. Because evidence is limited, there are no firm treatment guidelines, but antiviral therapy is generally recommended, along with pain control using agents such as gabapentin or pregabalin.

Asset Subtitle

Paula D. Bailey

Meta Tag

Author List Cordelia C. Witten, Olivia Henderson, Paula D. Bailey

Category Clinical Vignettes

Concept Zoster Sine Herpete

Concept Neuropathic Pain

Concept Cranial Nerve Involvement

Concept Varicella-Zoster Virus

Concept Rash

Distinguished Non-Finalist

Presenter Organization University of Kentucky

Presenting Author Paula D. Bailey

Track Adult

Keywords

zoster sine herpete

varicella-zoster virus

vocal cord paralysis

dysphagia

hoarseness

lymphocytic pleocytosis

lumbar puncture

acyclovir

gabapentin

prednisone

Zoster Sine Herpete

Neuropathic Pain

Cranial Nerve Involvement

Varicella-Zoster Virus

Rash