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 Table of Contents  
Year : 2022  |  Volume : 34  |  Issue : 4  |  Page : 477-478

Dysgeusia: A misdiagnosed case of an early manifestation of varicella-zoster infection

Department of Oral Medicine and Radiology, KMCT Dental College, Calicut, Kerala, India

Date of Submission28-Dec-2021
Date of Decision15-Nov-2022
Date of Acceptance18-Nov-2022
Date of Web Publication09-Dec-2022

Correspondence Address:
Anlin Anto
Department of Oral Medicine and Radiology, KMCT Dental College Calicut, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaomr.jiaomr_351_21

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Bitter taste dysgeusia is a rare symptom where patients experience all foods as bitter. While its cause is still unknown, it has been increasingly reported in infections. The altered taste sensation associated with herpes zoster infection is not uncommon. However, it is rare in primary varicella infections. In this case report, we present what we believe to be the first case of bitter taste dysgeusia presenting as a prodromal symptom in primary varicella zoster infection.

Keywords: Bitter taste, chicken pox, dysgeusia

How to cite this article:
Anto A, Ashir K R, Ummer N, Ahsan A. Dysgeusia: A misdiagnosed case of an early manifestation of varicella-zoster infection. J Indian Acad Oral Med Radiol 2022;34:477-8

How to cite this URL:
Anto A, Ashir K R, Ummer N, Ahsan A. Dysgeusia: A misdiagnosed case of an early manifestation of varicella-zoster infection. J Indian Acad Oral Med Radiol [serial online] 2022 [cited 2023 Feb 3];34:477-8. Available from: http://www.jiaomr.in/text.asp?2022/34/4/477/363036

   Introduction Top

Humans can detect and distinguish the five basic taste qualities—salty, sour, sweet, bitter, and umami. Out of these, the bitter taste is the most unpleasant. According to Robert J. Lee and Noam A Cohen, bitterness is perceived on the tongue and throughout the body, where they defend against microbial invaders.[1]

Varicella zoster virus (VZV) is an exclusively human neurotropic alpha-herpesvirus. Varicella is characterized by fever concurrent with a self-limiting rash on the skin and sometimes mucosa. Headache, malaise, and loss of appetite are also attributed to VZV.[2] Oral manifestations like dysgeusia have been less widely investigated. Here, we present a case in which an atypical initial presentation of bitter taste dysgeusia later developed into chickenpox.

   Case Report Top

A general physician referred a 41-year-old-woman without any medical history with a complaint of abnormal bitter taste sensation in the oral cavity. A general examination revealed generalized pallor; however, her vitals were normal. She had no history of weight loss or anorexia, no eating disorder, and did not crave unusual foodstuff. Her cranial nerve examination showed no abnormalities. The salivary flow test was normal. A tongue smear test showed no evidence of Candida infection. Laboratory investigations revealed a normal complete blood count, serum vitamin B12 folate, and zinc level of 65 mcg/dl. Since zinc deficiency is associated with dysgeusia, she has empirically prescribed a 50 mg zinc sulfate capsule daily for two months and was encouraged to have a zinc-rich diet. She returned 5 days later with intense throat pain and a bitter taste. On general examination, multiple vesicles were noticed on the ears, nose, and nape of the neck, with itching. An antihistamine was prescribed, suspecting an allergic reaction to zinc, but the patient later developed multiple vesicles with a fever. She was advised to consult a general physician. She was diagnosed with varicella zoster infection, for which she was prescribed antivirals and antipyretic drugs, leading to the resolution of the lesion with no further complications.

   Discussion Top

Dental practitioners are often the first clinicians to be presented with complaints about changes in taste. This raises a problem in terms of appropriate evaluative responses. Local factors influencing taste include infections of the oral cavity, such as candidiasis or a dental abscess, trauma, or hyposalivation. Over 250 drugs have been associated with oral dysgeusia, of which the most common are outlined in [Table 1].
Table 1: Etiology of dysgeusia[3]

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Dysgeusia associated with mandibular herpes zoster infection is reported in the literature. Gustatory dysfunction is likely related to the lingual nerve's involvement.[4] However, the altered taste is a rare symptom of primary varicella zoster. Here we are trying to correlate the possible mechanism behind bitter taste during the initial phase of the disease. Taste cells exposed to the oral environment face great challenges in defense against potential pathogens. Some immune-response-associated molecules are expressed at higher levels in taste tongue epithelial cells than in non-taste cells.

TNF was co-expressed with the sweet and umami receptor T1R3 but not with the G-protein Gustducin (mostly bitter receptor cells). In contrast, IL-10 was co-expressed with Gustducin but not with T1R3. TNF receptors were expressed in all taste cells at differential levels, while IL-10 receptors were preferentially expressed in T1R3+ TNF+ cells, suggesting that TNF could act on all taste cells under inflammatory conditions, while IL-10 may preferentially target TNF-producing-taste cells to limit TNF production. According to Feng et al., TNF signaling preferentially modulates bitter taste responses in animals. This mechanism may contribute to taste dysfunction, particularly taste distortion, associated with infections and chronic inflammatory diseases.[5]

   Conclusion Top

Taste complaints present several difficulties to the oral medicine practitioner, not the least of which is obtaining an objective assessment of the nature and degree of dysfunction. Varicella zoster can establish a latent infection for the host's lifetime, and it retains the capacity after many decades to emerge at unpredictable times to cause HZ, which can lead to postherpetic neuralgia. Thus, clinicians should be attuned to these issues and be prepared to make appropriate evaluations and referrals.


Written informed consent was obtained from the patient to publish this report by the journal's patient consent policy.


The completion of this article could not have been possible without the assistance of so many people whose names may not all be enumerated. Their contribution is sincerely appreciated and gratefully acknowledged. However, I would like to express my gratitude particularly to the following:

Dr Prejith Sampath, Dr Shahna Hameed, Dr Rahul, Dr Sharanya, Dr Shanima for their endless support, kind, and understanding spirit during my case presentation—above all the great almighty, the author of knowledge and wisdom for his countless love.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Ikeda M, Ikui A, Komiyama A, Kobayashi D, Tanaka M. Causative factors of taste disorders in the elderly, and therapeutic effects of zinc. J Laryngol Otol 2008;122:155-60.  Back to cited text no. 1
Sekine H, Takao K, Yoshinaga K, Kokubun S, Ikeda M. Effects of zinc deficiency and supplementation on gene expression of bitter taste receptors (TAS2Rs) on the tongue in rats. Laryngoscope 2012;122:2411-7.  Back to cited text no. 2
Brown E, Staines K. Vestibular schwannoma presenting as oral dysgeusia: An easily missed diagnosis. Case Rep Dent 2016;18:1-6.  Back to cited text no. 3
Heymans F, Lacroix JS, Terzic A, Landis BN. Gustatory dysfunction after mandibular zoster. Neurol Sci 2011;32:461-4.  Back to cited text no. 4
Wang R, van Keeken NM, Siddiqui S, Dijksman LM, Maudsley S, Derval D, et al. Higher TNF-α, IGF-1, and leptin levels are found in tasters than nontasters. Front Endocrinol 2014;29:5-125.  Back to cited text no. 5


  [Table 1]


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