Case report: Atypical Ramsey Hunt syndrome (zoster sine herpete): Two case reports

Introduction:  Ramsay Hunt Syndrome is an uncommon disease caused by reactivation of latent varicella zoster virus infection in the geniculate ganglion. The classic triad consists ofotalgia, vesicles in the auditory canal and ipsilateral facial paralysis. Without treatment, full recovery of the facial paralysis occurs in 20% of cases; this is much improved if treatment is started within 72 hours. Zoster sine herpete is a subtype of RH syndrome and consists of facial paralysis without vesicular rash in the skin and mucosa. 

Methodology:  We present the clinical cases of two patients who presented to our clinic with peripheral facial paralysis but without auricular skin rash. Serological laboratory tests were positive for HZV. Both were placed on corticosteroid and antiviral therapy.

According to House Beckerman classification the grade of paralysis, improved for the first case from grade 4 to grade 1 and for the second case, from grade 5 to grade 4. The time of initiation of corticosteroid and antiviral therapy was different. In the first case, therapy was started immediately and in the second case after 5 days.

Conclusion: RHS is a rare syndrome that should not be underestimated. It is presented by a typical tirade: facial paralysis, auricular skin rash and otalgia. A special manifestation is the Zoster sine herpete form, which is diagnosed by serology and PCR for viral DNA. Immediate initiation of treatment (within 72h) is an important factor in prognosis.