A n 80-year-old man visited our clinic with a two-day history of multiple painful, erythematous eruptions of the skin that had evolved into blisters with a linear distribution over his left flank. We diagnosed herpes zoster involving the left T11-12 dermatomes and prescribed oral famciclovir. The eruptions dried and healed in two weeks but were followed by a painless , reducible bulge, measuring 15 × 10 cm, in the left flank (Figure 1A). The bulge became more prominent when the patient stood or coughed. Abdominal sonography showed no evidence of an intra-abdominal mass. Electromyog-raphy was consistent with denervation limited to the left lumbar paraspinal muscles (T11-12 myotomes). We diagnosed a postherpetic pseudo-hernia. After 10 weeks, the bulge had completely resolved (Figure 1B). Herpes zoster is caused by reactivation of varicella-zoster virus, which usually involves a solitary posterior root ganglion and sensory nerve fibres. Its symptoms include pain, itchi-ness, sensitivity of the skin and rash in affected dermatomes. 1 Clinically significant motor deficit is rare, although subtle involvement of the paraspinal muscles has been described in up to 35% of instances of thoracic herpes zoster. 2 The pathogenesis may be related to direct spread of virus to anterior horn cells, ventral roots or both. Motor deficits related to infection with varicella-zoster virus have also been described in the distributions of cranial nerves (e.g., Ramsay Hunt syndrome caused by herpes zoster affecting the geniculate ganglion), peripheral motor nerves (paralysis of limbs) and visceral nerves (dys-function of the bladder). Most patients with pseudohernia after herpes zoster will recover in one year, without substantial sequelae. 3 References 1. Gilden DH, Kleinschmidt-DeMasters BK, LaGuardia JJ, et al. Neurologic complications of the reactivation of varicella-zoster virus. N Engl J Med 2000;342:635-45. 2. Cioni R, Giannini F, Passero S, et al. An electromyographic evaluation of motor complications in thoracic herpes zoster. Figure 1: (A) A reducible, painless hernia-like bulge, measuring 15 × 10 cm, two weeks after the onset of her-pes zoster in an 80-year-old man. (B) Complete resolution of the abdominal bulge after 10 weeks A B Clinical images are chosen because they are particularly intriguing, classic or dramatic. Submissions of clear, appropriately labelled high-resolution images must be accompanied by a figure caption and the patient's written consent for publication. A brief explanation (250 words maximum) of the educational significance of the images with minimal references is required.

No abstract

Postherpetic neuralgia is a common complication, 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 dermatomes and reducible, painless swelling of the left flank, 20 × 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.

Ethosuximide is a drug used for the treatment of absence seizures. Its prolonged application leads to gastrointestinal (GI) disturbances. The purpose of the present study was to determine the severity and nature of the disturbances, as well as the influence exerted upon them by neostigmine methylsulfate and metoclopramide. The drug-induced alterations, occurring in the rat GI tract, were registered by X-ray contrast examination. In vitro experiments were carried out on isolated GI smooth muscle (SM) preparations. The latter revealed that the drug hyperpolarized the SM tissues and inhibited their contractile activity. X-rays of ethosuximide-treated rats showed GI hypotonia, disturbed peristalsis and decreased evacuation activity. The inhibition of the GI functions was associated with hyperpolarization of SM and a reduction in Ca²⁺ influx, ensuring spontaneous contractile activity. The application of neostigmine methylsulfate significantly removed ethosuximide-induced functional GI disturbances in rats treated for 15 days with ethosuximide.

AbstractHyoscine and drotaverine effectiveness was compared for the purposes of achieving optimum distension following insufflation in CT colonography. The in vitro effects of hyoscine and drotaverine on tone and contractility of SM preparations isolated from different areas of human colon were studied by isometric registration of contractile activity. Both medications have a relaxing effect on SM preparations and inhibit their spontaneous contractions. The drotaverine-induced effects were reliably more marked than the hyoscine-induced ones. CT colonography was performed in 70 patients who were injected with equal doses of either hyoscine (n=32) or drotaverine (n=38). The degree of drug-induced distension in both groups was determined by measuring the lumen of the colon on a 2D reconstruction. In most colon areas the width of the distended lumen was greater in the drotaverine-treated patients. We concluded that drotaverine can be used as a means to facilitate colonic distension.