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Odynophagia, peripheral facial nerve paralysis, mucocutaneous lesions

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A 54-year-old woman presented with a 7-day history of odynophagia, pharyngeal swelling, and painful skin lesions on her left ear.

She had been on antiretroviral therapy for human immunodeficiency virus infection but had not been fully compliant with the treatment.

See editorial Figure 1.

Vesicular eruption on the left concha and external auditory meatus.

On examination, she had painful erythematous vesicles and pustules on the left auricle and in the external auditory canal (Figure 1), as well as small vesicles and circumscribed erosions on the left anterior twothirds of her tongue (Figure 2) and left palate.

Facial sensory function was normal; however, she had lagophthalmos, a flattened nasolabial fold, ptosis of the oral commissure, and a loss of the forehead wrinkles on the left side of her face—all signs of peripheral facial nerve paralysis.

Q: Which is the most likely diagnosis?

Ramsay Hunt syndrome Herpes simplex Contact dermatitis Malignant external otitis Erysipelas Figure 2.

Multiple vesicles and pustules on the left side of the tongue and soft palate.

A: This patient had Ramsay Hunt syndrome, also known as herpes zoster oticus.

It is a rare complication of herpes zoster in which the reactivation of latent varicella-zoster virus infection in the geniculate ganglion causes the triad of ipsilateral facial paralysis, ear pain, and vesicles in the auditory canal and auricle.

Taste perception, hearing (eg, tinnitus, hyperacusis), and lacrimation can be affected.

Ramsay Hunt syndrome is generally considered a polycranial neuropathy of cranial nerves VII (facial) and VIII (acoustic).

In some cases other cranial neuropathies may be present and may involve cranial nerves V (trigeminal), IX (glossopharyngeal), and X (vagus).

Vestibular disturbances such as vertigo are also often reported.

It is more severe in patients with immune deficiency.

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