Case Presentation: A 41-year-old man with history of depression and anxiety presented with a 6-day history of severe dysphagia, hoarseness, right ear pain, right-sided headache, and right arm pain with subjective weakness. A local ENT physician had discovered right vocal cord paralysis and referred him for further work up. In our facility basic labs were unremarkable with only a mildly elevated white blood cell count of 10,000. CT scan confirmed right vocal cord paralysis but had no other acute findings. CSF studies were diagnostic when varicella DNA was found via PCR. Patient was started gabapentin for his neuropathic pain and a full course of acyclovir IV was completed. On reevaluation 2 weeks later, FEES revealed significant improvement of his vocal cord paralysis and neuropathic symptoms were improved.

Discussion: Reactivation of varicella zoster virus (VZV), or herpes zoster (HZ), typically presents with a painful vesicular rash in a dermatomal distribution when latent viral particles reactivate in cranial nerves, dorsal roots or autonomic ganglia. This reactivation is caused by any condition that weakens cell mediated immunity and these include advanced age, trauma, immunosuppression, and chronic systemic disease and can be accompanied by a variety of complications. When not accompanied by the rash, reactivation has been termed zoster sine herpete (ZSH) and is even more difficult to diagnose.Our patient did not have the rash but did have a history of primary VZV infection in childhood. He also did not have an obvious condition that would decrease cell mediated immunity but did report situational stress which has been implicated in HZ. He did describe the classic dermatomal neuropathic pain, which should raise suspicion of VZV reactivation. That along with the unilateral isolated paralysis of the vocal cord necessitated investigation for varicella DNA. His CSF revealed the diagnosis.Due to very limited evidence, there are no guidelines for the treatment of ZSH. It is reasonable to treat with antivirals to possibly reduce the risk of long term sequelae and treatment of pain with anti-inflammatories and ligands of the α2δ subunit of the calcium channel (gabapentin or pregabalin) is prudent.

Conclusions: ZSH can be missed or misdiagnosed due to lack of typical presentation with rash. Hospitalists should have a high suspicion in patients with unexplained unilateral neuropathic pain in a dermatomal distribution, especially when accompanied by unilateral muscle paralysis. Rapid diagnosis and treatment with antivirals is felt to decrease risk of long term post herpetic neuralgia so we bring this case to raise awareness.