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: [email protected]; [email protected]
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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