Segmental zoster paresis (SZP) is a rare complication of herpes zoster (HZ) that results in focal weakness of the extremity in the myotome that corresponds to dermatomal involvement. We present a case of an 80year-old female with a resolving HZ rash on her left leg and buttocks that presented with left leg weakness for two weeks. The patient's rash preceded the left leg weakness by two weeks. The exam revealed erythematous macular and crusting lesions in the left L3/L4 distribution. The left thigh was flaccid with 1/5 knee extension strength with an absent patellar reflex. Lumbar spine magnetic resonance imaging (MRI) revealed enhancement of the left L4 roots, suggestive of inflammation or neuropathy. The patient was discharged on gabapentin, amitriptyline, and a two-week prednisone taper. In this case study, we present SZP, a rare complication that occurs in approximately 3% of HZ patients. The majority of SZP cases occur on the face or upper extremity, whereas our patient had SZP of the lower extremity. This case emphasizes the importance of maintaining a comprehensive differential diagnosis and highlights that SZP should be considered in patients who present with acute weakness in an extremity.
Chronic pruritus is a complex yet prevalent concern without a gold standard treatment. The mainstay therapy for chronic pruritus includes topical ointments such as corticosteroids, capsaicin, local anesthetics, antihistamines, and immunomodulators. There are many different subtypes of chronic pruritus, and each unique subtype may benefit from specialized treatments. This review article sheds light on the role of psychiatric, analgesic, and antiepileptic medications in chronic pruritus. We believe that further large-scale studies are needed to determine the true effectiveness of these medications in treating chronic pruritus.
Bile leaks are a rare occurrence most often seen as a complication of cholecystectomy. Other less common etiologies include endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTC), liver surgery, percutaneous drainage of liver abscesses, living donor hepatectomy, and non-iatrogenic abdominal trauma. In this case study, we present a 67-year-old female with morbid obesity who presented with abdominal pain and was diagnosed with a spontaneous bile leak. She had no history of recent surgery or abdominal trauma. CT revealed that the patient's gallbladder was located in the right lower quadrant, most likely due to mass effect from a large ventral hernia, and possible fluid collection extending from the gallbladder along the surface of the anterior inferior right hepatic lobe. Hepatobiliary iminodiacetic acid (HIDA) was performed due to a concern for cholecystitis. HIDA demonstrated a bile leak in the right upper abdomen of unknown etiology. Initially, there was a concern for gallbladder obstruction. Gastroenterology recommended magnetic resonance cholangiopancreatography (MRCP), however, MRCP was not possible due to the patient's body habitus. The patient had normal liver function tests, was tolerating oral intake, and her abdominal pain resolved, therefore, we became less suspicious of gallbladder obstruction. This case suggests that bile leak should be included in the differential diagnosis for abdominal pain even in patients who have not had recent abdominal surgery or procedures. This case also highlights the unique anatomical finding of a right lower quadrant gallbladder secondary to mass effect from a large ventral hernia.
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