70 Journal of Laryngology and Voice | January-June 2013 | Vol 3 | Issue 1 Journal of Laryngology and Voice | July-December 2013 | Vol

3 | Issue 2
INTRODUCTION
Herpes simplex virus (HSV) infection of the larynx is
an exceedingly rare clinical entity. It has been reported
in pediatric population who present with acute upper
respiratory obstruction requiring intensive care and
ventilatory support. In adult population, chronic infection of
larynx with herpes simplex has been reported, but laryngeal
involvement in a case of primary genital herpes has never
been reported. We report a case of primary genital herpes
with extensive laryngeal involvement.
CASE REPORT
A 32-year-old married male presented to dermatology
outpatient department ( OPD) with multiple extremely painful
pus-filled lesions over scrotum and groin of 2 days duration.
History of high-risk behavior was present.
There were multiple superficial ulcers 0.5 cm in size present
over bilateral groin, scrotum, and tip of penis with slough
covering the floor. Pus discharge from urethral meatus was
present with multiple erosions over tip of penis. Ulcers with
slough were present at the angle of mouth and on the nose
on the right side.
STUDENTS CORNER
Herpes simplex laryngitis
following primary genital
herpes
Purnima Sangwan, R akesh Datta, Ashwani Sethi,
Awadhesh K. Mishra, Satwinder P. Singh
Department of Ear Nose and Throat-Head and
Neck Surgery, Army College of Medical Sciences and
Associated Base Hospital, Delhi Cantt, India
ABSTRACT
Primary genital herpes is associated with involvement of extragenital sites like thighs, buttocks, ngers
and pharynx. This involvement occurs due to autoinoculation, orogenital exposure from the source and
also seeding due to viremia in the initial period. Involvement of larynx in a case of primary genital herpes
is extremely rare prompting us to report this case.
Key words: Primary genital herpes, odynophagia, laryngitis
On 2
nd
day, patient complained of severe dysphagia and
odynophagia and was referred for otolaryngological
examination.
Ear, nose, and throat (ENT) examination revealed: Oral
cavity- NAD. Oropharynx-0.5 0.5 cm sized multiple
ulcerative lesions covered with slough were present over
uvula, soft palate, anterior and posterior tonsillar pillars, and
posterior pharyngeal wall.
Hopkinss telescopic examination revealed multiple
0. 5 cm ul cers covered wi th sl ough i nvol vi ng the
epiglottis (both lingual and laryngeal surfaces), bilateral (B/L)
aryepiglottic folds, false vocal cords, and arytenoids. True
vocal cords were free [Figures 1 and 2].
Laboratory examination showed complete blood count-
within normal limits (WNL). Immunoglobulin (Ig) M antibody
testing for HSV 1 and 2, cytomegalovirus (CMV), rubella,
and toxoplasmosis-negative. Serological test for human
immunodeficiency virus (HIV), hepatitis C virus (HCV), and
Venereal Disease Research Laboratory (VDRL)-negative. Pus
culture from urethra showed staphylococcal growth. HSV
deoxyribonucleic acid (DNA) testing using polymerase chain
reaction (PCR) was not done.
Biopsy from the laryngeal lesions was done. Histopathological
examination revealed areas of focal necrosis with ballooning
degeneration, mononuclear giant cells, and eosinophillic
intranuclear inclusion bodies; which were indicative of HSV
infection.
Address for correspondence:
Dr. Purnima Sangwan, Department of Ear Nose and
Throat-Head and Neck Surgery, Army College of
Medical Sciences and Associated Base Hospital,
Delhi Cantt, India.
E-mail: purnima.sangwan@gmail.com
Access this article online
Website:
www.laryngologyandvoice.org
DOI: 10.4103/2230-9748.132062
Quick Response Code:
71
Sangwan, et al.: Primary herpes simplex laryngitis
Journal of Laryngology and Voice | January-June 2013 | Vol 3 | Issue 1 Journal of Laryngology and Voice | July-December 2013 | Vol 3 | Issue 2
A diagnosis of primary genital herpes with pharyngitis
and laryngitis was made and patient started on tab.
acyclovir (400 mg TDS). He never developed stridor during
his illness and responded well to treatment. His genital,
pharyngeal, and laryngeal ulcers improved over the period
of next 2 weeks. He started having his normal diet and was
subsequently discharged. At the time of discharge, his genital,
oral, and laryngeal lesions had healed well.
DISCUSSION
Laryngeal infection with HSV occurs rarely. In pediatric
population laryngotracheitis due to herpes simplex have been
reported where they presented with acute upper respiratory
obstruction requiring intensive care and at times ventilatory
support.
[1]
One case of supraglottitis due to HSV has been
reported in an adult who presented with respiratory distress
requiring intubation developing over a period of few hours.
[2]

Also in adults, chronic herpes simplex infection of the larynx
presenting as laryngeal mass,
[3,4]
herpetic laryngitis with
concurrent candidial infection,
[5]
necrotic mass involving the
glottis, and requiring total laryngectomy due to extensive
cartilage destruction have been reported in the literature.
[6]
The chronic form of herpetic laryngeal infection is most
commonly seen in immunocompromised patients.
[7]
Even in
immunocompetent adults, HSV viremia occurs in patients with
primary genital herpes simplex infection during the 1
st
week
leading to seeding of virus at multiple extragenital sites.
[8]
First episode of genital herpes is often associated with
systemic symptoms, a prolonged duration of lesions and
viral shedding, and involve multiple genital and extragenital
sites. Systemic symptoms occur in up to 67% of the patients
more commonly in females than males. Extragenital
mucocutaneous lesions occur in 20% of the patient involving
the pharynx, buttock, groin, thighs, and fingers. These lesions
occur as a result of either autoinoculation or due to orogenital
exposure during source contact.
[9]
Rarely blood borne dissemination occurs which leads
to multiple vesicles over thorax and extremities. Other
complications include aseptic meningitis, hepatitis,
pneumonitis, arthritis, thrombocytopenia, and myoglobinuria.
Diagnosis of herpes genitalis is mainly clinical, based on
the presence of characteristic ulcers, which are discrete and
extremely painful. Laboratory diagnosis is required only
in those cases where clinical diagnosis cannot be made.
Investigations include viral isolation, HSV DNA by PCR,
HSV antigen detection by enzyme immunoassay (EIA) and
serological test for antibodies against HSV glycoprotein G-1
and G-2. Treatment with oral and topical acyclovir is very
effective and should be initiated within 48 h of appearance
of lesions. Our patient was immunocompetent and had
presented with primary episode of genital herpes with
extensive involvement of oropharynx and endolarynx. His
serological test for HSV was negative, but biopsy from
the laryngeal lesions was indicative of HSV infection.
He responded well to acyclovir therapy, did not develop
respiratory distress, was conservative, and became
asymptomatic within 2 weeks. In our search of relevant
literature, primary involvement of larynx leading to acute
laryngitis in a case of primary genital herpes has never been
reported earlier.
REFERENCES
1. Chauhan N, Robinson JL, Guillemaud J, El-Hakim H. Acute herpes
simplex laryngotracheitis: Report of two pediatric cases and review
of the literature. Int J Pediatr Otorhinolaryngol 2007;71:341-5.
2. Bengualid V, Keesari S, Kandiah V, Gitler D, Berger J. Supragloitis
due to herpes simplex virus type 1 in an adult. Clin Infect Dis
1996;22:382-3.
3. Brigandi LA, Lanfranchi PV, Scheiner ED, Busch SL. Herpes
Simplex virus infection presenting as a pyriform sinus mass. Ear
Nose Throat J 2006;85:450-1.
4. Sanei-Moghaddam A, Loizou P, Fish BM. An unusual presentation
of herpes infection in the head and neck. BMJ Case Rep 2013;2013.
5. Zhang S, Farmer TL, Frable MA, Powers CN. Adult herpetic
laryngitis with concurrent candidial infection: A case report and
literature review. Arch Otolaryngol Head Neck Surg 2000;126:672-4 .
6. Sims JR, Massoll NA, Suen JY. Herpes simplex infection of the
larynx requiring laryngectomy. Am J Otolaryngol 2013;34:236-8.
7. Yeh V, Hopp ML, Goldstein NS, Meyer RD. Herpes simplex
chronic laryngitis and vocal cord lesions in a patient with
acquired immunodeficiency syndrome. Ann Otol Rhinol
Laryngol 1994;103:726-31.
Figure 1: The image shows extensive involvement of supraglottic larynx and
hypopharynx with sparing of true vocal cords
Figure 2: The image shows extensive involvement of supraglottic larynx and
hypopharynx with sparing of true vocal cords
72
Sangwan, et al.: Primary herpes simplex laryngitis
Journal of Laryngology and Voice | January-June 2013 | Vol 3 | Issue 1 Journal of Laryngology and Voice | July-December 2013 | Vol 3 | Issue 2
8. Johnston C, Magaret A, Selke S, Remington M, Corey L, Wald A.
Herpes simplex virus viremia during primary genital infection.
J Infect Dis 2008;198:31-4.
9. Corey L, Adams HG, Brown ZA, Holmes KK. Genital herpes
simplex virus infection: Clinical manifestations, course and
complications. Ann Intern Med 1983;98:958-72.
Cite this article as: Sangwan P, Datta R, Sethi A, Mishra AK,
Singh SP. Herpes simplex laryngitis following primary genital herpes.
J Laryngol Voice 2013;3:70-2.
Source of Support: Nil, Conict Interest: Nil.