Herpes simplex virus presenting as an oropharyngeal mass

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.

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

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.

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.