Herpes simplex virus presenting as an oropharyngeal mass

Abstract

Objective(s)

Present a clinically challenging case of an immunocompetent 74‐year‐old male who presented with marked dyspnea and hemoptysis. After the airway was secured, direct laryngoscopy revealed a large, fungating, hemorrhagic mass of the left lateral pharyngeal wall and surrounding structures.

Methods

Chart review of a single patient. This patient provided consent for his case materials and images to be used for educational purposes and publication.

Results

The clinical appearance of the mass was suspicious for an aggressive neoplasm. Initial biopsy of the mass was nonspecific, revealing necrosis and inflammation, but was negative for malignancy. Due to concern for bacterial supraglottitis, empiric treatment with antibiotics was initiated. Cultures were positive for Fusobacterium necrophorum. Repeat biopsy samples showed signs of underlying human simplex virus (HSV) infection, which was confirmed with polymerase chain reaction (PCR) testing. After addition of acyclovir, the patient began to improve clinically and was eventually decannulated. There was complete resolution of the mass at his 1‐month follow‐up.

Conclusion

HSV supraglottitis is a rare, rapidly progressive, and highly morbid condition. Lack of overt patient risk factors, frequently inconclusive biopsies, and clinical appearance mimicking other etiologies make diagnosis challenging. Superimposed bacterial infection is even less common and may contribute to increased disease severity and progression.

This is the case of a 74‐year‐old immunocompetent male who presented acutely with signs of airway compromise caused by a fungating oropharyngeal mass, concerning for a malignancy. Biopsies were negative for malignancy, and after a thorough workup, the patient was found to have herpes simplex virus supraglottitis with associated Fusobacterium necrophorum superinfection. The patient ended up making a full recovery after treatment with appropriate antimicrobials.

1. INTRODUCTION

Herpes simplex virus (HSV) infection is a rare cause of supraglottitis, a serious condition characterized by inflammation of laryngeal structures such as the arytenoids, epiglottis, false vocal cords, laryngeal ventricles, and aryepiglottic folds. Presentation is variable, and can manifest as inflammation, ulceration, and rarely, a mass resembling a neoplasm. ¹ , ² , ³ Presented here is an unusual and challenging case of HSV supraglottitis with superimposed Fusobacterium necrophorum infection causing a necrotizing pharyngeal mass.

2. CASE REPORT

A 74‐year‐old never‐smoker, never‐drinker, immunocompetent male with a past medical history of atrial fibrillation on oral anticoagulants was transferred from an outside hospital due to gross hemoptysis and concern for impending airway compromise. He had a 3‐day history of foul‐smelling hemoptysis, worsening dysphagia, and difficulty breathing. Bedside fiberoptic exam revealed near complete airway obstruction from an ulcerated, bleeding, friable mass involving the oropharynx and supraglottis. The decision was made to move to the OR for emergent awake tracheotomy for airway stabilization. Evaluation via direct laryngoscopy at this time demonstrated a fungating mass that encompassed the left lateral pharyngeal wall, left tonsil, left epiglottis, and uvula with diffuse necrotic changes throughout the left tonsil and pharynx (Figure 1A). Biopsy of the lesion demonstrated necrosis and inflammation with scattered atypical squamous cells but was negative for malignancy. Head and neck computed tomography (CT) scan found non‐specific, diffuse mucosal thickening of the oropharynx (Figure 2A). Piperacillin‐tazobactam and vancomycin was started empirically due to concern for bacterial supraglottitis. Labs and tissue stains were negative for fungus, Coccidioidies, human immunodeficiency virus (HIV), and syphilis; white blood cell count was normal at 7.8 K/μL. Oropharyngeal cultures grew F. necrophorum, necessitating continuation of piperacillin‐tazobactam. On post‐operative day (POD) 3, direct laryngoscopy again revealed a supraglottic mass but now with improved appearance of the oropharynx. Repeat biopsies were consistent with prior results. Repeat direct laryngoscopy on POD 8 demonstrated further improved appearance of the oropharynx and supraglottic larynx. Biopsy samples were consistent with prior findings, but now with the addition of rare superficial epithelial cells showing multinucleation, margination of chromatin, and nuclear molding; characteristic histologic findings of herpesvirus infection (Figure 3A,B). Immunohistochemical (IHC) staining for HSV 1/2 cocktail revealed strong nuclear expression and subsequent polymerase chain reaction testing on formalin fixed paraffin embedded biopsy tissue confirmed HSV‐1 (Figure 3C). He was discharged on POD 11 on a three‐week course of amoxicillin‐clavulanate and acyclovir. CT scan on POD 15 showed improvement in, but not resolution of the mass with marked improvement in the airway patency (Figure 2B). He was decannulated on POD 18 and had resolution of his ulcerative mass at 1 month follow‐up (Figure 1B).

FIGURE 1.

Images from direct laryngoscopy. (A) Direct laryngoscopy showing diffuse edema involving the epiglottis, cricoid, arytenoids, and base of tongue with necrosis of the left arytenoid and aryepiglottic fold. Fungating mass of the hypopharynx in view (POD 0). (B) Complete resolution of mass at 1 month follow‐up.

FIGURE 2.

Computed tomographic images. (A) Computed tomography (CT) scan of the neck with intravenous contrast in the sagittal plane on POD 0 showing irregular, diffuse mucosal thickening extending from the nasopharynx to the hypopharynx and supraglottic larynx causing a near complete airway obstruction. (B) Repeat CT of the neck with contrast in the sagittal plane on POD 15. Previously seen irregular thickening has decreased considerably and airway effacement has resolved.

FIGURE 3.

Representative histological sections. (A) Supraglottic biopsy sample, showing an acanthotic and focally eroded and acantholytic epithelium (H&E, 40× original magnification). (B) Cytologic features of Herpes virus infection, including superficial epithelial cells showing multinucleation, margination of chromatin, and nuclear molding (H&E, 200× original magnification). (C) Strong nuclear expression of HSV by immunohistochemistry within the atypical epithelial cells (HSV 1/2, 200× original magnification).

3. DISCUSSION

Supraglottitis is a serious, potentially life‐threatening condition due to its potential to cause airway compromise. Its initial presentation is often mistaken for other more benign conditions, which further increases both its morbidity and mortality. ¹

Etiology of supraglottitis is varied, and can include infection, trauma, chemical irritation, and immunological disease. HSV is a rare cause of viral infectious supraglottitis. ¹ , ² , ³ In these cases, the presentation is variable, and can mimic bacterial supraglottitis or present with symptoms of ulceration, inflammation, and obstruction, sometimes mimicking a neoplasm. ¹ , ² , ³ Clinical presentation regardless of etiology may vary, from acute stridor and high fever to more insidious sore throat. Symptom duration prior to hospital presentation is also variable, ranging from hours to weeks. ¹ , ³ When compared to all‐cause supraglottitis in adults, HSV supraglottitis is more likely to cause severe airway compromise, with 37% of patients requiring airway intervention compared to 15%. ¹ , ⁴

HSV supraglottitis with superimposed bacterial infection is exceedingly rare. ¹ It is hard to determine whether inflammation from viral epithelial damage predisposes the supraglottic complex to bacterial infection or vice versa. ¹ Superinfection tends to cause substantial local inflammation in the laryngopharynx, thus increasing the speed of disease progression and severity of airway obstruction. In fact, these more severe cases of supraglottitis typically demonstrate a short symptom duration prior to evaluation and severe disease at presentation, often requiring emergent airway intervention. ¹ As evidenced here, this may occur without the typical signs of systemic infection such as fever or leukocytosis. Treatment with both antiviral and antibiotic therapy has been effective in all cases. ¹ As bacterial infections are often a primary cause of supraglottitis, the finding of a bacterial superinfection may complicate the diagnosis of HSV supraglottitis and delay proper treatment.

This case presented a challenge due to the overlap between this patient's presentation and that of an aggressive malignancy. Further complicating the diagnosis were lack of overt signs of infection, multiple inconclusive biopsies of deeper level sections, and superimposed F. necrophorum infection. Notably, biopsy of virally infected tissue may often demonstrate scant, if any, infected cells. In limited samples, or samples complicated by excessive necrosis or ulceration, viral changes may not even be present. Due to its relatively low prevalence, the risk factors and demographics associated with supraglottitis in general are poorly characterized. While most cases of supraglottitis have a suspected bacterial etiology, this case demonstrates that viral infection may play a large role in the pathogenesis of this disease process, especially in the setting of an insidious presentation or ulceration on fiberoptic exam. Furthermore, it is important to consider all possible etiologies to this rare condition, especially when initial diagnostic workup is inconclusive. This case report demonstrates the value of high‐quality samples, the occasional need for multiple samples, and the importance of clinical‐pathologic correlation.

4. CONCLUSION

This case report demonstrates the difficulties in diagnosing viral, specifically HSV, supraglottitis, that on exam can present with necrotic, ulcerated lesions resembling a malignancy. Additionally, this highlights the potential for severe disease in patients with superinfected HSV lesions, and the need to keep rare causes of oropharyngeal mass, such as HSV infection, on the differential diagnosis.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Molotkova E, Buhle AC, Rush PS, McLean JE, Carpenter PS. Herpes simplex virus presenting as an oropharyngeal mass. Laryngoscope Investigative Otolaryngology. 2024;9(6):e70042. doi: 10.1002/lio2.70042