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(a) Uterine. MRI: Solid 18<span class="elsevierStyleHsp" style=""></span>cm uterine mass (blue arrow) with necrotic areas (white star). (b) Uterine. PET: Hypermetabolic uterine mass (black arterisk) (SUVmax 22). (c) Vaginal. MRI: Isointense vaginal lesion in T1, with a diameter of 24<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>21<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>33<span class="elsevierStyleHsp" style=""></span>mm (white arterisk). (d) Retroperitoneal. MRI: Cystic multiloculated mass with a solid area which extends through the retroperitoneum (left para-aortic side) from the renal area to the left inguinal region (white arrow). (e) Retroperitoneal. PET: Retroperitoneal lesion with low metabolic activity (white arrow) (SUVmax 1.9). (f) Pulmonar lymphangioleomyomatosis CT: Multiple fine wall cystic images in lung parenchyma of different sizes greater than 14<span class="elsevierStyleHsp" style=""></span>mm (small white arrows).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Inmaculada Nicolás, Pere Fusté, Adela Saco, Jaume Ordi, Aureli Torné" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Inmaculada" "apellidos" => "Nicolás" ] 1 => array:2 [ "nombre" => "Pere" "apellidos" => "Fusté" ] 2 => array:2 [ "nombre" => "Adela" "apellidos" => "Saco" ] 3 => array:2 [ "nombre" => "Jaume" "apellidos" => "Ordi" ] 4 => array:2 [ "nombre" => "Aureli" "apellidos" => "Torné" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0025775319300557" "doi" => "10.1016/j.medcli.2019.01.009" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775319300557?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S238702061930227X?idApp=UINPBA00004N" "url" => "/23870206/0000015300000002/v2_202004301535/S238702061930227X/v2_202004301535/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific letter</span>" "titulo" => "Herpes zoster multiplex: Report on one case" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "88" "paginaFinal" => "89" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Ana Varela-Veiga, Benigno Monteagudo, Óscar Suárez-Amor" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Ana" "apellidos" => "Varela-Veiga" "email" => array:1 [ 0 => "anavarelaveiga@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Benigno" "apellidos" => "Monteagudo" ] 2 => array:2 [ "nombre" => "Óscar" "apellidos" => "Suárez-Amor" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Complejo Hospitalario Universitario de Ferrol, Ferrol, A Coruña, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Herpes zóster multiplex: descripción de un caso" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 515 "Ancho" => 989 "Tamanyo" => 67989 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(a) Vesicular lesions with herpetiform distribution and erythematous fundus, located on the instep, extending towards the dorsum of the first toe of the right foot; (b) erythematous plaques with some bundles of fragile vesicular lesions, which in some cases have ruptured, leaving small erosions located in the right costal area.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Herpes zoster (HZ) occurs due to the reactivation of the varicella-zoster virus (VZV), which remains latent in the sensitive thoracic lymph nodes after primary infection. Its reactivation can be triggered by situations of immunosuppression, although it also occurs in immunocompetent patients. It usually affects a single dermatome, without exceeding the median line, although, more rarely, it can manifest as disseminated HZ. In terms of location, it typically affects the thoracic and facial area. However, concurrent involvement of 2 or more dermatomes, contiguous or not, ipsi or contralateral may occur, these findings being less common.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 67-year-old female patient, who underwent a heart transplant operation 18 months earlier, for which she received multiple immunosuppressive drugs, with a history of breast cancer undergoing mastectomy and chemoradiation therapy and a hysterectomy with double adnexectomy, without other findings of interest. She did not report any personal or family history of skin disorders.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was referred due to 1-week history of painful, vesicular-bullous lesions on a erythematous base located on the instep of the right foot, extending to the back of the big toe (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>a), corresponding to dermatome L4-L5, and right side (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>b), at the level of T11-T12-L1. She had received only topical antibiotic treatment, without evidence of clinical improvement. There was no fever, dysthermia or other systemic symptoms.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">In view of the lesions and the state of immunosuppression of the patient, the main suspicion was of HZ <span class="elsevierStyleItalic">multiplex</span>. Given these findings, copper sulphate at 1:1000 hot packs and 125<span class="elsevierStyleHsp" style=""></span>mg brivudine were prescribed daily for 7 days, with clear improvement until complete resolution.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Although uncommon, HZ can manifest with the involvement of several dermatomes, of unilateral or bilateral, non-contiguous distribution, with an incidence lower than 0.1–0.5%<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a> of all the forms, with only 42 cases of HZ <span class="elsevierStyleItalic">duplex</span> (HZD, involvement of 2 non-contiguous dermatomes), <span class="elsevierStyleItalic">bilateralis</span> or <span class="elsevierStyleItalic">unilateralis</span> having been reported so far and less than 10 cases of HZ <span class="elsevierStyleItalic">multiplex</span> (more than 2 non-contiguous dermatomes) in the literature reviewed. It is a more common entity in patients of advanced age or with malignant disease, especially haematological, although it has also been reported in children without immune alterations.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> It occurs more frequently in immunocompromised patients, such as those transplanted undergoing immunosuppressive treatment, this being the case of our patient, or those with end-stage renal disease<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> or undergoing peritoneal dialysis.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Cases have also been reported in immunocompetent patients.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> The mechanism of reactivation of the virus in several dermatomes is unclear. In most cases, no systemic involvement or other complications have been demonstrated, so it does not confer a worse prognosis.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> The most common sites are the thoracic (50–60%) and the facial (10–20%) regions, with other locations being less frequent, such as the instep and big toe of the right foot.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In addition, VZV may develop other atypical skin manifestations, such as gangrenous lesions, ulcers or ecthyma lesions, predominantly in immunosuppressed patients.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In 2015, a study was published<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> in which 36 cases were reviewed in order to determine the risk factors for HZD, finding a higher prevalence in Asian individuals, despite having a lower prevalence of seropositivity for VZV, suggesting the possibility of genetic susceptibility. Likewise, a greater prevalence was observed in people over 50 years of age, finding no differences regarding the typical form. It was more common in women,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> being related to a closer and prolonged contact with children whose ages were susceptible to varicella.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> As in other publications, the importance of immunosuppression in its physiopathology is highlighted.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The diagnosis is basically clinical and complementary examinations are usually not necessary. Regarding treatment, the use of antivirals (acyclovir, valaciclovir, famciclovir and brivudine), especially during the first 72<span class="elsevierStyleHsp" style=""></span>h, has shown benefit in reducing the intensity of pain in the acute phase, although more studies would be necessary to clarify the preventive nature of postherpetic neuralgia and other complications. In addition, they contribute to a shorter healing process. However, it must be combined with strictly symptomatic treatment, using regular analgesics, gabapentin or opioids, among others.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Therefore, we report a new case of HZ <span class="elsevierStyleItalic">multiplex</span>, located at the right costal level (T11-12-L1) and on the right foot (L4-L5), the latter also constituting an atypical location.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Varela-Veiga A, Monteagudo B, Suárez-Amor Ó. Herpes Zóster Multiplex: a propósito de un caso. Med Clin (Barc). 2019;153:88–89.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 515 "Ancho" => 989 "Tamanyo" => 67989 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(a) Vesicular lesions with herpetiform distribution and erythematous fundus, located on the instep, extending towards the dorsum of the first toe of the right foot; (b) erythematous plaques with some bundles of fragile vesicular lesions, which in some cases have ruptured, leaving small erosions located in the right costal area.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Herpes zoster duplex bilateralis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C.H. 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Endo" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Dermatol Online J" "fecha" => "2013" "volumen" => "19" "paginaInicial" => "13" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24021372" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Zoster duplex: a clinical report and etiologic analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "F. Zhang" 1 => "J. Zhou" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Int J Clin Exp Med" "fecha" => "2015" "volumen" => "8" "paginaInicial" => "11020" "paginaFinal" => "11025" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26379899" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015300000002/v2_202004301535/S2387020619302335/v2_202004301535/en/main.assets" "Apartado" => array:4 [ "identificador" => "43311" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015300000002/v2_202004301535/S2387020619302335/v2_202004301535/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020619302335?idApp=UINPBA00004N" ]
