LAUSR

A 54-year-old man presented with 6-day duration of otalgia and blistering of the left ear. He had no other skin involvement. The patient denied any hearing loss, headaches, or facial weakness. He had no prior history of local trauma, use of topical agents, or recent illness. He was not diabetic and had no history of human immunodeficiency virus. He denied any recent travel. He initially presented to urgent care 3 days prior and received a course of empiric amoxicillin clavulanate as well as polymyxin and neomycin ear drops for suspected otitis externa, without improvement. He was on no other medications. Physical examination revealed erythema and mild edema of the left auricle with multiple tense gray vesicles (Fig. 1). There were no neurological deficits or lymphadenopathy. Bacterial cultures of vesicular fluid were negative. Punch biopsy of the skin revealed ballooning degeneration of keratinocytes and staining for varicella zoster virus (VZV) was positive. Polymerase-chain reaction (PCR) of vesicular fluid also detected VZV, confirming the diagnosis of herpes zoster. The patient was started on valacyclovir and a short course of oral prednisone. He experienced resolution of symptoms without neurologic complications. Herpes zoster is caused by reactivation of latent VZV which lies dormant in the dorsal root ganglia after primary infection. Diagnosis of VZV is mainly clinical but further supported by viral culture or polymerase chain reaction (PCR) of vesicular fluid, tzanck smear, and skin biopsy. Ramsay Hunt syndrome (RHS) is a complication of herpes zoster characterized by the triad of otalgia, vesicles of the auricle, and facial paralysis. In RHS, the virus is reactivated in the geniculate ganglion and the vestibulocochlear nerve may be involved, leading to hearing loss and vestibular symptoms. While our patient did not meet criteria for RHS, as he had no facial paralysis, there was concern that he may develop hearing loss based on auricular involvement and otalgia. In consultation with otolaryngology, the