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Pharmacology · patient case with 3 questions

Rash in the ear (Ramsay Hunt syndrome)

Scenario: A patient with a RASH IN THE EAR. (The case does not name the condition — it is Ramsay Hunt syndrome.)

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Question 1

What medication is used for treatment?

  1. Ganciclovir
  2. Fluconazole
  3. Lamivudine
  4. Famciclovir
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Correct answer: D. Famciclovir

  • A. Ganciclovir is reserved for CYTOMEGALOVIRUS (CMV) infection and carries significant myelosuppressive toxicity.
  • B. Fluconazole is an antifungal for candidiasis and has no antiviral activity.
  • C. Lamivudine is a nucleoside reverse transcriptase inhibitor used for HIV and hepatitis B.
  • D. Correct. FAMCICLOVIR (like aciclovir and valaciclovir) is active against HERPES SIMPLEX and VARICELLA-ZOSTER virus. Ramsay Hunt syndrome is VZV reactivation and is treated with a high-dose antiviral COMBINED WITH CORTICOSTEROIDS, ideally started within 72 hours of onset.

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Question 2

What is the origin of the lesion?

  1. Fungal
  2. Bacterial
  3. Viral
  4. Immune-mediated
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Correct answer: C. Viral

  • A. Fungal infection does not produce dermatomal vesicular eruption with facial palsy.
  • B. There is no bacterial aetiology; the vesicular rash and cranial neuropathy are characteristic of zoster.
  • C. Correct. Ramsay Hunt syndrome is caused by reactivation of the VARICELLA-ZOSTER VIRUS. The clinical triad is ipsilateral facial paralysis, otalgia, and a vesicular rash on the auricle and external auditory canal.
  • D. Corticosteroids are used as ADJUNCTIVE therapy to reduce nerve oedema, but the cause is infectious rather than autoimmune.

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Question 3

Where does the virus remain latent in this patient?

  1. Geniculate ganglion
  2. Pterygopalatine ganglion
  3. Otic ganglion
  4. Trigeminal ganglion
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Correct answer: A. Geniculate ganglion

  • A. Correct. Ramsay Hunt syndrome — also called herpes zoster oticus or GENICULATE GANGLION herpes zoster — is reactivation of VZV in the GENICULATE GANGLION of the FACIAL NERVE (CN VII), within the facial canal of the petrous temporal bone. James Ramsay Hunt's original 1907 paper was titled 'On herpetic inflammations of the geniculate ganglion'.
  • B. The pterygopalatine ganglion is a parasympathetic ganglion relaying CN VII fibres to the lacrimal gland and nasal/palatal mucosa.
  • C. The otic ganglion is a PARASYMPATHETIC ganglion relaying CN IX fibres to the parotid gland; it is not a site of viral latency in this syndrome.
  • D. The trigeminal (Gasserian/semilunar) ganglion is where HSV-1 and VZV lie latent for lesions in the TRIGEMINAL distribution — recurrent herpes labialis and trigeminal zoster. It is not the site for Ramsay Hunt syndrome.

Note: ⚠️ SOURCE ERROR CORRECTED. That is incorrect — Ramsay Hunt syndrome is defined by VZV reactivation in the GENICULATE ganglion of CN VII (verified against StatPearls, Medscape and multiple case-series reviews). If you see the trigeminal ganglion offered for a RAMSAY HUNT stem, it is the distractor.

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