CASE REPORT

A case of rheumatoid arthritis presenting with postherpeticneuralgia and abdominal-wall pseudohernia

Hristo P. Dobrev • Penka A. Atanassova •

Vladimir N. Sirakov • Lilia G. Zisova

Received: 14 November 2009 / Accepted: 29 December 2009 / Published online: 12 January 2010

� Springer-Verlag 2010

Abstract Postherpetic neuralgia is a common complica-

tion, while the postherpetic abdominal-wall pseudohernia

(AWP) is a quite rare complication of herpes zoster (HZ).

We report a patient [45 years of age with a history of

rheumatoid arthritis (RA) who presented with two chronic

HZ complications. A 75-year-old woman was admitted

with neuralgia following cutaneous herpes zoster 6 weeks

before. She was on long-term glucocorticoid, antimalarial

and non-steroidal anti-inflammatory treatment. Confluent

ulcers began to fill with granulation tissue, crusts, scars and

skin discoloration in the area of the left T12-L2 dermato-

mes and reducible, painless swelling of the left flank,

20 9 20 cm, without palpable defect in abdominal-wall.

There were typical joint deformity and positive rheumatoid

factor. On neurological examination superficial abdominal

reflexes were diminished in the left side, with hypesthesia

of the overlying skin. Needle electromyography revealed

denervational changes limited to the left-side muscles (on

affected dermatomes T12-L2). Thoracoabdominal CT did

not reveal the presence of existing hernia. There was an

abdominal distension, the left abdominal-wall was thinner

than the right side. The patient was treated with an oral

preparation containing benfotiamine and vitamins B6 and

B12, carbamazepine, amitriptyline, gabapentin, and local

lidocaine. Skin rash left with scarring and pigmentary

changes and the abdominal-wall swelling resolved within

8 months, however, the pain still persisted. To our best

knowledge, this is the first observation of RA-associated

postherpetic AWP. This rare motor complication appears to

be self-limited with a good prognosis for recovery, while

postherpetic neuralgia may require a combination of

treatments for adequate pain relief. Older age, female sex,

greater rash and acute pain severity are considered as risk

factors associated with severe postherpetic neuralgia. In

addition, patients with RA, mainly those treated with oral

corticosteroids, are also at increased risk of HZ

complications.

Keywords Rheumatoid arthritis � Herpes zoster �Postherpetic abdominal-wall pseudohernia �Postherpetic neuralgia

Herpes zoster is a cutaneous viral infection caused by the

reactivation of varicella-zoster virus (VZV) remaining

dormant in the dorsal root ganglia after resolution of a

primary VZV infection (chickenpox). The impaired

immune system due to aging, disease or immunosuppres-

sive therapy is the main factor for VZV reactivation. Pre-

vious studies suggested that patients with rheumatoid

arthritis (RA) are at increased risk of herpes zoster [1, 2].

Postherpetic neuralgia is the most common complication of

HZ with frequency of 9–34%, whereas postherpetic

abdominal-wall pseudohernia is a rare complication (0–2%)

[3–5].

Presented as a poster at the 17th EADV Congress, Paris, France

(September 2008).

H. P. Dobrev � L. G. Zisova

Department of Dermatology, Medical University,

Plovdiv 4000, Bulgaria

P. A. Atanassova (&)

Department of Neurology, Medical University,

15A V. Aprilov Blvd., Plovdiv 4000, Bulgaria

e-mail: pp_atanassova@yahoo.com; bdd11@yahoo.com

V. N. Sirakov

Department of Image Diagnostic, Radiology and Nuclear

Medicine, Medical University, Plovdiv 4000, Bulgaria

123

Rheumatol Int (2012) 32:1775–1777

DOI 10.1007/s00296-009-1360-2

Here, we report a unique case of two neurological

complications of herpes zoster in a patient with rheumatoid

arthritis. In particular, a 75-year-old woman was admitted

to the dermatology clinic on the occasion of neuralgia

following cutaneous herpes zoster appeared 6 weeks

before. She had a history of RA for 45 years and long-term

treatment with glucocorticoid, antimalarial, and non-

steroidal anti-inflammatory drugs.

Our patient presented with a typical joint deformity

(Fig. 1) and positive rheumatoid factor. The physical

examination revealed also confluent ulcers that began to fill

with granulation tissue, crusts, scars, and skin discoloration

in the area of the left T12-L2 dermatomes and reducible,

painless swelling of the left flank (size 20 cm 9 20 cm),

without palpable defect in the abdominal-wall (Fig. 2,

upper panel).

On neurological examination superficial abdominal

reflexes were diminished in the left side and hypesthesia of

the overlying skin was present. Needle electromyography

revealed denervational changes limited to the left-side

paraspinal muscles, corresponding to affected dermatomes

(T12-L2). Thoraco-abdominal computed tomography did

not reveal the presence of existing hernia or mass. There

was an abdominal distension and the left abdominal-wall

was thinner than the right side.

The patient was treated with oral preparation containing

benfotiamine and vitamins B6 and B12, carbamazepine,

amitriptyline, gabapentin, and local lidocaine. Skin rash

left with scarring and pigmentary changes and the

abdominal-wall swelling had completely resolved within

8 months (Fig. 2, lower panel). However, the pain per-

sisted for about 4 months longer.

Notably, the HZV infections complicated by cutaneous

dissemination, necrotizing fasciitis, encephalomyelitis, or

lower motor neuron paresis have been reported in patients

with RA [6]. Our case is the first observation of pos-

therpetic abdominal-wall pseudohernia associated with

RA. This rare motor complication appears to be self-lim-

ited with a good prognosis for recovery, whereas the pos-

therpetic neuralgia may require a combination of treatment

modalities for adequate pain relief [3, 4, 7]. Advancing age,

female sex, severe rash, and severe acute pain are consid-

ered as risk factors for development of postherpetic neu-

ralgia [3]. In addition, patients with RA (especially those

treated with oral corticosteroids) are also at increased risk

of chronic herpes zoster complications [6]. According to

Fig. 1 Joint deformity of hands

in a patient with rheumatoid

arthritis. a Dorsal view;

b Palmar view

Fig. 2 Lateral and frontal view of the abdomen in a patient with rheumatoid arthritis. Upper panel Herpetic rash; Lower panel Abdominal wall;

a 6 weeks after appearance; b 8 weeks; c 4 months; d 8 months

1776 Rheumatol Int (2012) 32:1775–1777

123

Yamauchi et al. [8], the high incidence of herpes zoster in

patients with RA is probably due to an impaired cellular

immunity.

Acknowledgment The authors thank Dr Borislav D. Dimitrov

(Italy) for his critical reading and useful comments provided during

the preparation of this case report.

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