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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Herpes zoster is a relatively common disease worldwide&#44; with a detected lifetime incidence between 10&#37; and 20&#37;&#46; The classic clinical picture is characterized by clusters of papular and vesicular lesions on an erythematous base distributed unilaterally along a single dermatome&#46; This characteristic presentation makes herpes zoster easily recognizable&#44; even by non-dermatologist clinicians of different specialties&#46; Involvement of 2 or more unilateral and contiguous dermatomes is not an uncommon finding in older patients and patients with other risk factors for immunosuppression&#46; However&#44; simultaneous involvement of 2 non-contiguous dermatomes&#8212;unilaterally or even bilaterally&#8212;is an exceptional finding that can make diagnosis difficult&#46; In the literature&#44; this manifestation has been called herpes zoster duplex<span class="elsevierStyleItalic">&#46;</span><a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> Isolated cases of patients with involvement of more than 2 non-contiguous dermatomes have been called herpes zoster multiplex&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present 2 cases of herpes zoster duplex and 1 of herpes zoster multiplex diagnosed in our department between 2015 and 2017&#46; The clinical and epidemiological characteristics are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The 2 cases of herpes zoster duplex &#40;cases 1 and 2&#41; occurred in immunocompetent patients aged 27 and 66 years&#44; respectively&#44; who consulted for the acute appearance of unilateral or bilateral vesicular lesions with zosteriform distribution&#46; Neither patient experienced pain in the affected dermatomes or presented fever or other extracutaneous symptoms throughout the process&#46; The patient who presented with herpes zoster multiplex &#40;case 3&#44; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; was a male aged 41years who had already started treatment with famciclovir 72<span class="elsevierStyleHsp" style=""></span>h earlier&#44; prescribed by his primary care physician&#46; In spite of this treatment&#44; new lesions continued to appear&#46; None of the 3 patients reported any prior episodes of herpes zoster&#46; In all 3 cases&#44; viral culture of the exudate confirmed the diagnosis a posteriori&#44; with detection of the varicella zoster virus in all 3 cases&#46; The results of serologies performed to rule out HIV infection were negative in all 3 patients&#46; With the diagnosis of herpes zoster duplex in cases 1 and 2 and multiplex in case 3&#44; antiviral treatment was prescribed at standard doses complemented by topical care with zinc sulphate and fusidic acid until the lesions were completely healed&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The probability of developing herpes zoster duplex or multiplex is extremely low&#44; with a documented incidence in the largest series of less than 0&#46;1&#37; of all herpes zoster cases&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In 2015&#44; Zhang and Zhou<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> reviewed all the cases of herpes zoster duplex reported in the literature&#44; affecting in total 36 patients&#46; They highlighted several associated risk factors in that series&#58; Asian origin &#40;over 66&#37;&#41;&#44; older age &#40;44&#46;4&#37; were over 50 years of age&#41;&#44; female sex &#40;63&#46;9&#37; were women&#41;&#44; and immunosuppression &#40;47&#46;2&#37;&#41; associated with a variety of causes &#40;immunosenescence&#44; HIV&#44; hematologic malignancies&#44; solid organ tumors&#44; chemotherapy&#44; and prolonged therapy with corticosteroids or other immunosuppressive drugs&#41;&#46; In a review of the literature published in 1999&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> only 7 cases of herpes zoster multiplex were found&#44; almost all associated with causes of immunosuppression&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Following primary varicella-zoster virus infection&#44; the virus establishes a latent infection in the dorsal and trigeminal root ganglia&#59; this has been demonstrated by viral DNA analysis in autopsies&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> Reactivation of the virus in the ganglion with the highest latent viral load&#8212;mediated by multiple triggers&#8212;gives rise to the characteristic herpetic lesions in the affected dermatome&#46; In herpes zoster duplex and multiplex&#44; simultaneous reactivation of the virus in different&#44; non-contiguous dorsal ganglia gives rise to the uncharacteristic clinical presentation and is also facilitated by immunosuppression&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> However&#44; other factors that have not yet been elucidated must also play a role because most of the cases reported&#44; including our 3 patients&#44; have occurred in immunocompetent patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#44;3&#44;7&#8211;9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In routine clinical practice&#44; classic herpes zoster is usually diagnosed on the basis of the clinical presentation&#46; When there is doubt&#44; however&#44; or when the presentation is atypical&#44; confirmation of the diagnosis by testing is recommended&#46; In our 3 cases&#44; diagnosis was confirmed by viral culture of two cell lines &#40;MRC-5 human lung fibroblasts and A549 human lung tumor epithelial cells&#41;&#46; The cultures were maintained for 3 weeks&#44; during which it was checked for cytopathic effect every 3 to 4 days&#46; The appearance of a cytopathic effect was confirmed by staining with monoclonal antiviral antibodies &#40;Argene<span class="elsevierStyleSup">&#174;</span> Anti Varicella Zoster Virus Ref 11-017&#41;&#44; with fluorescence being observed under the microscope in positive cases&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The treatment of patients with herpes zoster duplex and multiplex is the same as that used in classic cases&#44; and involves antiviral coverage&#44; pain control&#44; and topical care&#46; In our patients&#44; follow-up confirmed complete cure without sequelae after the antiviral treatment was completed with the usual dose and treatment duration&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In summary&#44; we consider it important to recognize these rare presentations and their potential association with causes of immunosuppression&#46; In the presence of typical herpetic skin lesions with metameric distribution&#44; the involvement of non-contiguous and&#47;or bilateral dermatomes should not lead us to change the generally accepted treatment regimen&#44; although such cases should be monitored closely&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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    "fechaRecibido" => "2017-12-05"
    "fechaAceptado" => "2018-03-24"
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Rodr&#237;guez-Lomba E&#44; S&#225;nchez-Herrero A&#44; Su&#225;rez-Fern&#225;ndez R&#44; Pulido-P&#233;rez A&#46; La excepci&#243;n que confirma la regla&#58; herpes zoster duplex y multiplex&#46; Actas Dermosifiliogr&#46; 2019&#59;110&#58;690&#8211;693&#46;</p>"
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    ]
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      0 => array:7 [
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Case 3&#46; Herpes zoster multiplex presenting with clusters of vesicles in a zosteriform distribution affecting the L5 dermatome on the left leg &#40;A and B&#44; tibial crest and plantar arch&#41; as well as D6 &#40;C&#41; on the left side and S2 &#40;D&#41; on the right side&#46;</p>"
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; COPD&#44; chronic obstructive pulmonary disease&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Case&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Antiviral Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Woman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Left S2-S3Right S1-S2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Immunocompetent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">COPD treated with systemic corticosteroid therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Viral culture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Aciclovir 800&#160;mg 5 times a day for 7&#160;d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Woman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Left V1Left V3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Immunocompetent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Viral culture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Valaciclovir 1&#160;g every 8&#160;h for 7&#160;d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Man&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Left D6Left L5Right S2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Hepatitis C&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Famciclovir 500&#160;mg every 8&#160;h for 7&#160;d&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Review of Diagnosed Cases of Herpes Zoster Duplex and Multiplex in the Emergency Department of the Hospital Gregorio Mara&#241;&#243;n During the Period 2015-2017&#46;</p>"
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          "identificador" => "bibs0015"
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                          "etal" => false
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                      "autores" => array:1 [
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              "etiqueta" => "7"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Herpes zoster duplex bilaterales in an immunocompetent adolescent boy&#58; A case report and literature review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            0 => "C&#46; Yan"
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                    0 => array:2 [
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                      "Revista" => array:6 [
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Herpes zoster duplex unilateralis&#58; Two cases and brief literature review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "J&#46;H&#46; Son"
                            1 => "B&#46;Y&#46; Chung"
                            2 => "H&#46;O&#46; Kim"
                            3 => "H&#46;J&#46; Cho"
                            4 => "C&#46;W&#46; Park"
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Case and Research Letters
Herpes Zoster Duplex and Multiplex: The Exception That Confirms the Rule
La excepción que confirma la regla: herpes zoster duplex y multiplex
E. Rodríguez-Lomba
Autor para correspondencia
enriquerlomba@outlook.com

Corresponding author.
, A. Sánchez-Herrero, R. Suárez-Fernández, A. Pulido-Pérez
Servicio de Dermatología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Herpes zoster is a relatively common disease worldwide&#44; with a detected lifetime incidence between 10&#37; and 20&#37;&#46; The classic clinical picture is characterized by clusters of papular and vesicular lesions on an erythematous base distributed unilaterally along a single dermatome&#46; This characteristic presentation makes herpes zoster easily recognizable&#44; even by non-dermatologist clinicians of different specialties&#46; Involvement of 2 or more unilateral and contiguous dermatomes is not an uncommon finding in older patients and patients with other risk factors for immunosuppression&#46; However&#44; simultaneous involvement of 2 non-contiguous dermatomes&#8212;unilaterally or even bilaterally&#8212;is an exceptional finding that can make diagnosis difficult&#46; In the literature&#44; this manifestation has been called herpes zoster duplex<span class="elsevierStyleItalic">&#46;</span><a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> Isolated cases of patients with involvement of more than 2 non-contiguous dermatomes have been called herpes zoster multiplex&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present 2 cases of herpes zoster duplex and 1 of herpes zoster multiplex diagnosed in our department between 2015 and 2017&#46; The clinical and epidemiological characteristics are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The 2 cases of herpes zoster duplex &#40;cases 1 and 2&#41; occurred in immunocompetent patients aged 27 and 66 years&#44; respectively&#44; who consulted for the acute appearance of unilateral or bilateral vesicular lesions with zosteriform distribution&#46; Neither patient experienced pain in the affected dermatomes or presented fever or other extracutaneous symptoms throughout the process&#46; The patient who presented with herpes zoster multiplex &#40;case 3&#44; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; was a male aged 41years who had already started treatment with famciclovir 72<span class="elsevierStyleHsp" style=""></span>h earlier&#44; prescribed by his primary care physician&#46; In spite of this treatment&#44; new lesions continued to appear&#46; None of the 3 patients reported any prior episodes of herpes zoster&#46; In all 3 cases&#44; viral culture of the exudate confirmed the diagnosis a posteriori&#44; with detection of the varicella zoster virus in all 3 cases&#46; The results of serologies performed to rule out HIV infection were negative in all 3 patients&#46; With the diagnosis of herpes zoster duplex in cases 1 and 2 and multiplex in case 3&#44; antiviral treatment was prescribed at standard doses complemented by topical care with zinc sulphate and fusidic acid until the lesions were completely healed&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The probability of developing herpes zoster duplex or multiplex is extremely low&#44; with a documented incidence in the largest series of less than 0&#46;1&#37; of all herpes zoster cases&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In 2015&#44; Zhang and Zhou<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> reviewed all the cases of herpes zoster duplex reported in the literature&#44; affecting in total 36 patients&#46; They highlighted several associated risk factors in that series&#58; Asian origin &#40;over 66&#37;&#41;&#44; older age &#40;44&#46;4&#37; were over 50 years of age&#41;&#44; female sex &#40;63&#46;9&#37; were women&#41;&#44; and immunosuppression &#40;47&#46;2&#37;&#41; associated with a variety of causes &#40;immunosenescence&#44; HIV&#44; hematologic malignancies&#44; solid organ tumors&#44; chemotherapy&#44; and prolonged therapy with corticosteroids or other immunosuppressive drugs&#41;&#46; In a review of the literature published in 1999&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> only 7 cases of herpes zoster multiplex were found&#44; almost all associated with causes of immunosuppression&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Following primary varicella-zoster virus infection&#44; the virus establishes a latent infection in the dorsal and trigeminal root ganglia&#59; this has been demonstrated by viral DNA analysis in autopsies&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> Reactivation of the virus in the ganglion with the highest latent viral load&#8212;mediated by multiple triggers&#8212;gives rise to the characteristic herpetic lesions in the affected dermatome&#46; In herpes zoster duplex and multiplex&#44; simultaneous reactivation of the virus in different&#44; non-contiguous dorsal ganglia gives rise to the uncharacteristic clinical presentation and is also facilitated by immunosuppression&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> However&#44; other factors that have not yet been elucidated must also play a role because most of the cases reported&#44; including our 3 patients&#44; have occurred in immunocompetent patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#44;3&#44;7&#8211;9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In routine clinical practice&#44; classic herpes zoster is usually diagnosed on the basis of the clinical presentation&#46; When there is doubt&#44; however&#44; or when the presentation is atypical&#44; confirmation of the diagnosis by testing is recommended&#46; In our 3 cases&#44; diagnosis was confirmed by viral culture of two cell lines &#40;MRC-5 human lung fibroblasts and A549 human lung tumor epithelial cells&#41;&#46; The cultures were maintained for 3 weeks&#44; during which it was checked for cytopathic effect every 3 to 4 days&#46; The appearance of a cytopathic effect was confirmed by staining with monoclonal antiviral antibodies &#40;Argene<span class="elsevierStyleSup">&#174;</span> Anti Varicella Zoster Virus Ref 11-017&#41;&#44; with fluorescence being observed under the microscope in positive cases&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The treatment of patients with herpes zoster duplex and multiplex is the same as that used in classic cases&#44; and involves antiviral coverage&#44; pain control&#44; and topical care&#46; In our patients&#44; follow-up confirmed complete cure without sequelae after the antiviral treatment was completed with the usual dose and treatment duration&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In summary&#44; we consider it important to recognize these rare presentations and their potential association with causes of immunosuppression&#46; In the presence of typical herpetic skin lesions with metameric distribution&#44; the involvement of non-contiguous and&#47;or bilateral dermatomes should not lead us to change the generally accepted treatment regimen&#44; although such cases should be monitored closely&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:3 [
        0 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Conflicts of Interest"
        ]
        1 => array:2 [
          "identificador" => "xack429033"
          "titulo" => "Acknowledgments"
        ]
        2 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2017-12-05"
    "fechaAceptado" => "2018-03-24"
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Rodr&#237;guez-Lomba E&#44; S&#225;nchez-Herrero A&#44; Su&#225;rez-Fern&#225;ndez R&#44; Pulido-P&#233;rez A&#46; La excepci&#243;n que confirma la regla&#58; herpes zoster duplex y multiplex&#46; Actas Dermosifiliogr&#46; 2019&#59;110&#58;690&#8211;693&#46;</p>"
      ]
    ]
    "multimedia" => array:2 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Case 3&#46; Herpes zoster multiplex presenting with clusters of vesicles in a zosteriform distribution affecting the L5 dermatome on the left leg &#40;A and B&#44; tibial crest and plantar arch&#41; as well as D6 &#40;C&#41; on the left side and S2 &#40;D&#41; on the right side&#46;</p>"
        ]
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      1 => array:8 [
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        "etiqueta" => "Table 1"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; COPD&#44; chronic obstructive pulmonary disease&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Case&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Dermatome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Immune Status&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Comorbid Diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Antiviral Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Woman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Left S2-S3Right S1-S2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Immunocompetent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">COPD treated with systemic corticosteroid therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Viral culture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aciclovir 800&#160;mg 5 times a day for 7&#160;d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Woman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Left V1Left V3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Immunocompetent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Viral culture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Valaciclovir 1&#160;g every 8&#160;h for 7&#160;d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Man&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Left D6Left L5Right S2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Immunocompetent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hepatitis C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Viral culture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Famciclovir 500&#160;mg every 8&#160;h for 7&#160;d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Review of Diagnosed Cases of Herpes Zoster Duplex and Multiplex in the Emergency Department of the Hospital Gregorio Mara&#241;&#243;n During the Period 2015-2017&#46;</p>"
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    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:9 [
            0 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A case of zoster duplex bilateralis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
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                            1 => "D&#46;H&#46; Kim"
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                            5 => "M&#46;K&#46; Cho"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.5021/ad.2009.21.4.423"
                      "Revista" => array:6 [
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                        "fecha" => "2009"
                        "volumen" => "21"
                        "paginaInicial" => "423"
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                        "link" => array:1 [
                          0 => array:2 [
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                          ]
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              ]
            ]
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                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1053/jd.1999.v40.a96944"
                      "Revista" => array:6 [
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                    ]
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              ]
            ]
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              "identificador" => "bib0060"
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              "referencia" => array:1 [
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Bilateral disseminated herpes zoster in an immunocompetent host"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "Y&#46; Takaoka"
                            1 => "Y&#46; Miyachi"
                            2 => "Y&#46; Yoshikawa"
                            3 => "M&#46; Tanioka"
                            4 => "A&#46; Fujisawa"
                            5 => "Y&#46; Endo"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
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                          0 => array:2 [
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                        ]
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                    ]
                  ]
                ]
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