{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,29]],"date-time":"2026-07-29T02:01:31Z","timestamp":1785290491786,"version":"3.55.0"},"reference-count":12,"publisher":"Oxford University Press (OUP)","issue":"8","license":[{"start":{"date-parts":[[2023,8,3]],"date-time":"2023-08-03T00:00:00Z","timestamp":1691020800000},"content-version":"vor","delay-in-days":2,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2023,8,1]]},"abstract":"<jats:title>Abstract<\/jats:title>\n               <jats:sec>\n                  <jats:title>Background<\/jats:title>\n                  <jats:p>Orthotopic heart transplant (OHT) recipients are at increased risk for varicella zoster reactivation, and severe complications may arise due to their immunosuppressive regimens. Managing immunosuppression in acute infection is difficult, and specific guideline recommendations or evidence from the literature are lacking. However, patient care must involve weighing the risk of transplant rejection with the consequences of worsening infection.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Case summary<\/jats:title>\n                  <jats:p>An OHT patient with a history of multiple episodes of acute rejection, latent varicella zoster virus (VZV) infection, and recent completion of anti-viral prophylaxis presented with unilateral facial droop and pain, abducens nerve palsy, crusting facial rash, and ear swelling. Imaging revealed necrotizing otitis externa, with associated otitis media, and petrous apicitis concerning for Gradenigo syndrome. A VZV-positive viral panel confirmed our suspicion for Ramsay Hunt syndrome (RHS). The patient\u2019s mentation continued to decline, and subsequent lumbar puncture also revealed VZV meningoencephalitis. The patient\u2019s mycophenolate mofetil (MMF) was suspended, with continuation of tacrolimus, and initiation of intravenous acyclovir. The patient demonstrated gradual resolution of his infection, without developing any signs of acute rejection.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Discussion<\/jats:title>\n                  <jats:p>Varicella zoster virus reactivation is common in OHT patients, particularly when viral prophylaxis is discontinued; however, cardiologists should be aware of the rarer manifestations that can manifest in these immunocompromised patients. This is the first documented case of simultaneous RHS, Gradenigo syndrome, and VZV meningoencephalitis in any patient, regardless of transplant status. We demonstrate that even in patients at very high risk of rejection, MMF can be safely discontinued and host immunity maintained with temporary tacrolimus monotherapy.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1093\/ehjcr\/ytad373","type":"journal-article","created":{"date-parts":[[2023,8,1]],"date-time":"2023-08-01T20:47:52Z","timestamp":1690922872000},"source":"Crossref","is-referenced-by-count":3,"title":["The risks of rejection vs. infection: Ramsay Hunt syndrome, Gradenigo syndrome, and varicella meningoencephalitis in a heart transplant patient"],"prefix":"10.1093","volume":"7","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4219-7780","authenticated-orcid":false,"given":"Kevin","family":"Benavente","sequence":"first","affiliation":[{"name":"Department of the Internal Medicine Residency Program , University of Hawaii, 1356 Lusitania Street #510, Honolulu, HI 96813 , USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Landon","family":"Kozai","sequence":"additional","affiliation":[{"name":"Department of the Internal Medicine Residency Program , University of Hawaii, 1356 Lusitania Street #510, Honolulu, HI 96813 , USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Krixie","family":"Silangcruz","sequence":"additional","affiliation":[{"name":"Department of the Internal Medicine Residency Program , University of Hawaii, 1356 Lusitania Street #510, Honolulu, HI 96813 , USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dipanjan","family":"Banerjee","sequence":"additional","affiliation":[{"name":"Department of the Cardiology Fellowship Program , University of Hawaii, 1301 Punchbowl Street, Pauahi 3rd Floor, Queen's Heart, Honolulu, HI 96813 , USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2023,8,3]]},"reference":[{"key":"2023081010172666200_ytad373-B1","first-page":"238","article-title":"Ramsay Hunt syndrome","volume":"10","author":"Wagner","year":"2012","journal-title":"J Dtsch Dermatol Ges"},{"key":"2023081010172666200_ytad373-B2","doi-asserted-by":"crossref","first-page":"559","DOI":"10.1136\/pmj.76.899.559","article-title":"Gradenigo\u2019s syndrome","volume":"76","author":"Motamed","year":"2000","journal-title":"Postgrad Med J"},{"key":"2023081010172666200_ytad373-B3","doi-asserted-by":"crossref","first-page":"1715","DOI":"10.1001\/archneur.64.12.noc70065","article-title":"Central nervous system infections in heart transplant recipients","volume":"64","author":"van de Beek","year":"2007","journal-title":"Arch Neurol"},{"key":"2023081010172666200_ytad373-B4","doi-asserted-by":"crossref","first-page":"e13519","DOI":"10.1111\/tid.13519","article-title":"Epidemiology and risk factors for varicella zoster virus reactivation in heart transplant recipients","volume":"23","author":"La Hoz","year":"2021","journal-title":"Transpl Infect Dis"},{"key":"2023081010172666200_ytad373-B5","doi-asserted-by":"crossref","first-page":"136","DOI":"10.1159\/000506192","article-title":"An association of varicella zoster virus, facial palsy, and meningitis in a young immunocompetent male","volume":"12","author":"Ashour","year":"2020","journal-title":"Case Rep Neurol"},{"key":"2023081010172666200_ytad373-B6","doi-asserted-by":"crossref","first-page":"2555","DOI":"10.36740\/WLek202011139","article-title":"A case of MRI-negative herpes virus encephalitis presented by Ramsay Hunt syndrome","volume":"73","author":"Dyachenko","year":"2020","journal-title":"Wiad Lek"},{"key":"2023081010172666200_ytad373-B7","doi-asserted-by":"crossref","first-page":"1056","DOI":"10.1016\/j.healun.2019.08.004","article-title":"The International Thoracic Organ Transplant Registry of the International Society for Heart and Lung Transplantation: thirty-sixth adult heart transplantation report\u20142019; 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