A Supraglottic Pseudotumor in an Immunocompromised Patient with Nephrotic Syndrome, Herpes Zoster, and a Cytomegalovirus Infection

Abstract

Several viral infections may occasionally induce supraglottic mass lesions, resulting in an obstructive airway emergency. We herein report one such case in a 63-year-old male immunocompromised patient with nephrotic syndrome due to membranous nephropathy who also had ophthalmic herpes zoster with a laryngeal mass, which required urgent intubation and mechanical ventilation. The patient was initially treated with acyclovir; however, because a serological analysis revealed a concurrent cytomegalovirus infection, we discontinued the administration of acyclovir and gave priority to the simultaneous treatment of the cytomegalovirus and varicella-zoster virus infections with ganciclovir. The clinical course was favorable, and he was weaned from the ventilator 10 days later when a serial imaging analysis revealed no signs of the supraglottic mass, leading us to conclude that these two viral infections could have additively or synergistically contributed to the development of the local pseudotumor. The diagnostic and therapeutic concerns arising in the current case are also discussed.

Keywords: cytomegalovirus; herpes zoster ophthalmicus; laryngeal mass; nephrotic syndrome; steroid.

Figure 1

(A) A photo obtained on hospital day 5 showing a tender erythematous, vesicular, crusting lesion on the right periorbital skin. (B) An erythematous patch without a vesicular rash over the perilaryngeal skin just after intubation. (C) Axial CT of the neck demonstrating an expansive lesion in the right supraglottic region (arrow). Note that diffuse reticulation of subcutaneous fat was detected in the right cervical territory, suggesting cellulitic inflammation (arrowhead).

Figure 2

The clinical course of the current patient. From the point of admission, which was designated as hospital day 1, the orally administered PSL was transiently switched to the intravenous PSL sodium succinate (PSL-SS). The resumed oral PSL was tapered thereafter and subsequently terminated. After starting the HD treatment for the deteriorated renal function as well as strict volume control, his daily urine volume gradually decreased, while his serum levels of Cr were finally settled around 8–10 mg/dL.