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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">After attending the emergency department of another hospital&#44; an 84-year-old man was diagnosed with left abdominal herpes zoster &#40;HZ&#41;&#46; Because clinical signs had developed more than 72&#8239;hours earlier&#44; no antiviral treatments were administered&#46; One week later&#44; the patient came to our outpatients due to the sudden appearance of an asymptomatic mass in the area affected by HZ&#46; Five years earlier he had developed a rectal neoplasm that was treated with surgery and radiation therapy&#46; Physical examination revealed hyperesthesia and lesions in the crusting phase on dermatomes T10 to T12&#46; Painless&#44; reducible bulging of the abdominal wall that increased with Valsalva maneuvers was evident in the area affected by HZ &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; A midline laparotomy scar showed no signs of complication&#46; An abdominal computed tomography scan was requested to rule out abdominal mass or hernia&#46; The results revealed thinning of the abdominal wall without evidence of hernia&#46; An electroneuromyographic study revealed no alterations&#46; Given the temporal relationship between the appearance of the rash and the protrusion&#44; the case was oriented as abdominal pseudohernia due to HZ&#46; After 8 months&#44; the patient showed a complete clinical recovery &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">While sensory alterations are one of the main neurological complications of HZ&#44; motor nerves can also be affected&#44; resulting in paralysis of the facial muscles&#44; extremities&#44; diaphragm&#44; or abdominal muscles&#44; in some cases with visceral involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Abdominal pseudohernia is a protrusion limited to the abdominal wall without an actual underlying defect&#46; The first case of paralysis of the abdominal musculature caused by HZ was described in 1886 by Broadbent&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Despite the high incidence of HZ&#44; this entity is only observed in between 0&#37; and 2&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> It manifests as abdominal distention with unilateral bulging on the affected side&#46; The T11 dermatome is the most affected&#44; followed by T12 and T10&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Symptoms can appear 2 to 6 weeks before the rash&#44; but usually develop about 2 weeks after&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> It has been predominantly described in elderly patients and those with hematologic neoplasms&#44; as well as immunocompromised individuals&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The exact underlying mechanism is not entirely clear&#44; but it is thought to involve viral infection at the level of the anterior horn of the spinal cord as a consequence of neural spread of the varicella-zoster virus from the dorsal root ganglia&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Pathological studies<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;7</span></a> have demonstrated ganglion lesions combined with degeneration of the sensory and motor roots together with severe neuritis&#44; which may explain the electrophysiological findings characteristic of the disease&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Diagnosis is primarily clinical&#44; based on temporal correlation of HZ with the appearance of abdominal distension&#46; Physical examination may reveal decreased or absent segmental reflexes&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> An electroneuromyographic study can be useful to confirm diagnosis&#44; although alterations are observed in only 35&#37;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;8</span></a> of cases&#46; Abdominal computed tomography shows a thinned abdominal wall and rules out the presence of an abdominal mass or hernia&#46; Gadolinium-diethylenetriamine penta-acetic acid &#40;DTPA&#41; nuclear magnetic resonance imaging can help define the extent of inflammation and exclude compression of the spinal nerve roots&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The differential diagnosis should include diseases that present with alterations in the innervation of the abdominal wall musculature and can cause pseudohernia&#44; such as lumbar hernia&#44; polyradiculoneuropathy&#44; diabetic neuropathy&#44; and syringomyelia&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Treatment is the same as for HZ&#44; with antiviral drugs and analgesia if required&#46; Short courses of corticosteroids<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> have also been used for their anti-inflammatory effects&#44; as well as multiple vitamin preparations&#44;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;7</span></a> which can help restore damaged nerve fibers&#44; although there is little evidence to support the use of these treatments&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The prognosis for motor weakness is usually good&#44; with complete or near complete recovery in 55&#37; to 75&#37;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> of cases within a period of 2 to 18 months&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The most common complication of pseudohernia is constipation&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> although other complications&#44; including paralytic ileus and voiding disorders&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> have been described in 19&#46;4&#37;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> of patients&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In conclusion&#44; abdominal pseudohernia is a rare complication of HZ that usually has a good prognosis&#46; Although the suspected diagnosis is clinical&#44; it is advisable to perform a noninvasive imaging test to rule out a true hernia&#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 no conflict of interest&#46;</p></span></span>"
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Case and Research Letters
Abdominal Pseudohernia Due to Herpes Zoster
Pseudohernia abdominal por herpes zóster
N. Setó-Torrent
Autor para correspondencia
nurisetorrent@gmail.com

Corresponding author.
, M. Iglesias-Sancho, J. Arandes-Marcocci, M. Salleras Redonnet
Servicio de Dermatología, Hospital Universitari Sagrat Cor, Barcelona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">After attending the emergency department of another hospital&#44; an 84-year-old man was diagnosed with left abdominal herpes zoster &#40;HZ&#41;&#46; Because clinical signs had developed more than 72&#8239;hours earlier&#44; no antiviral treatments were administered&#46; One week later&#44; the patient came to our outpatients due to the sudden appearance of an asymptomatic mass in the area affected by HZ&#46; Five years earlier he had developed a rectal neoplasm that was treated with surgery and radiation therapy&#46; Physical examination revealed hyperesthesia and lesions in the crusting phase on dermatomes T10 to T12&#46; Painless&#44; reducible bulging of the abdominal wall that increased with Valsalva maneuvers was evident in the area affected by HZ &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; A midline laparotomy scar showed no signs of complication&#46; An abdominal computed tomography scan was requested to rule out abdominal mass or hernia&#46; The results revealed thinning of the abdominal wall without evidence of hernia&#46; An electroneuromyographic study revealed no alterations&#46; Given the temporal relationship between the appearance of the rash and the protrusion&#44; the case was oriented as abdominal pseudohernia due to HZ&#46; After 8 months&#44; the patient showed a complete clinical recovery &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">While sensory alterations are one of the main neurological complications of HZ&#44; motor nerves can also be affected&#44; resulting in paralysis of the facial muscles&#44; extremities&#44; diaphragm&#44; or abdominal muscles&#44; in some cases with visceral involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Abdominal pseudohernia is a protrusion limited to the abdominal wall without an actual underlying defect&#46; The first case of paralysis of the abdominal musculature caused by HZ was described in 1886 by Broadbent&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Despite the high incidence of HZ&#44; this entity is only observed in between 0&#37; and 2&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> It manifests as abdominal distention with unilateral bulging on the affected side&#46; The T11 dermatome is the most affected&#44; followed by T12 and T10&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Symptoms can appear 2 to 6 weeks before the rash&#44; but usually develop about 2 weeks after&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> It has been predominantly described in elderly patients and those with hematologic neoplasms&#44; as well as immunocompromised individuals&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The exact underlying mechanism is not entirely clear&#44; but it is thought to involve viral infection at the level of the anterior horn of the spinal cord as a consequence of neural spread of the varicella-zoster virus from the dorsal root ganglia&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Pathological studies<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;7</span></a> have demonstrated ganglion lesions combined with degeneration of the sensory and motor roots together with severe neuritis&#44; which may explain the electrophysiological findings characteristic of the disease&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Diagnosis is primarily clinical&#44; based on temporal correlation of HZ with the appearance of abdominal distension&#46; Physical examination may reveal decreased or absent segmental reflexes&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> An electroneuromyographic study can be useful to confirm diagnosis&#44; although alterations are observed in only 35&#37;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;8</span></a> of cases&#46; Abdominal computed tomography shows a thinned abdominal wall and rules out the presence of an abdominal mass or hernia&#46; Gadolinium-diethylenetriamine penta-acetic acid &#40;DTPA&#41; nuclear magnetic resonance imaging can help define the extent of inflammation and exclude compression of the spinal nerve roots&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The differential diagnosis should include diseases that present with alterations in the innervation of the abdominal wall musculature and can cause pseudohernia&#44; such as lumbar hernia&#44; polyradiculoneuropathy&#44; diabetic neuropathy&#44; and syringomyelia&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Treatment is the same as for HZ&#44; with antiviral drugs and analgesia if required&#46; Short courses of corticosteroids<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> have also been used for their anti-inflammatory effects&#44; as well as multiple vitamin preparations&#44;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;7</span></a> which can help restore damaged nerve fibers&#44; although there is little evidence to support the use of these treatments&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The prognosis for motor weakness is usually good&#44; with complete or near complete recovery in 55&#37; to 75&#37;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> of cases within a period of 2 to 18 months&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The most common complication of pseudohernia is constipation&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> although other complications&#44; including paralytic ileus and voiding disorders&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> have been described in 19&#46;4&#37;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> of patients&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In conclusion&#44; abdominal pseudohernia is a rare complication of HZ that usually has a good prognosis&#46; Although the suspected diagnosis is clinical&#44; it is advisable to perform a noninvasive imaging test to rule out a true hernia&#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 no conflict of interest&#46;</p></span></span>"
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