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Scientific letter
Herpes zoster multiplex: Report on one case
Herpes zóster multiplex: descripción de un caso
Ana Varela-Veiga
Corresponding author
anavarelaveiga@hotmail.com

Corresponding author.
, Benigno Monteagudo, Óscar Suárez-Amor
Servicio de Dermatología, Complejo Hospitalario Universitario de Ferrol, Ferrol, A Coruña, Spain
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">&#40;a&#41; Vesicular lesions with herpetiform distribution and erythematous fundus&#44; located on the instep&#44; extending towards the dorsum of the first toe of the right foot&#59; &#40;b&#41; erythematous plaques with some bundles of fragile vesicular lesions&#44; which in some cases have ruptured&#44; leaving small erosions located in the right costal area&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Herpes zoster &#40;HZ&#41; occurs due to the reactivation of the varicella-zoster virus &#40;VZV&#41;&#44; which remains latent in the sensitive thoracic lymph nodes after primary infection&#46; Its reactivation can be triggered by situations of immunosuppression&#44; although it also occurs in immunocompetent patients&#46; It usually affects a single dermatome&#44; without exceeding the median line&#44; although&#44; more rarely&#44; it can manifest as disseminated HZ&#46; In terms of location&#44; it typically affects the thoracic and facial area&#46; However&#44; concurrent involvement of 2 or more dermatomes&#44; contiguous or not&#44; ipsi or contralateral may occur&#44; these findings being less common&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 67-year-old female patient&#44; who underwent a heart transplant operation 18 months earlier&#44; for which she received multiple immunosuppressive drugs&#44; with a history of breast cancer undergoing mastectomy and chemoradiation therapy and a hysterectomy with double adnexectomy&#44; without other findings of interest&#46; She did not report any personal or family history of skin disorders&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was referred due to 1-week history of painful&#44; vesicular-bullous lesions on a erythematous base located on the instep of the right foot&#44; extending to the back of the big toe &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>a&#41;&#44; corresponding to dermatome L4-L5&#44; and right side &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>b&#41;&#44; at the level of T11-T12-L1&#46; She had received only topical antibiotic treatment&#44; without evidence of clinical improvement&#46; There was no fever&#44; dysthermia or other systemic symptoms&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">In view of the lesions and the state of immunosuppression of the patient&#44; the main suspicion was of HZ <span class="elsevierStyleItalic">multiplex</span>&#46; Given these findings&#44; copper sulphate at 1&#58;1000 hot packs and 125<span class="elsevierStyleHsp" style=""></span>mg brivudine were prescribed daily for 7 days&#44; with clear improvement until complete resolution&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Although uncommon&#44; HZ can manifest with the involvement of several dermatomes&#44; of unilateral or bilateral&#44; non-contiguous distribution&#44; with an incidence lower than 0&#46;1&#8211;0&#46;5&#37;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#44;2</span></a> of all the forms&#44; with only 42 cases of HZ <span class="elsevierStyleItalic">duplex</span> &#40;HZD&#44; involvement of 2 non-contiguous dermatomes&#41;&#44; <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> &#40;more than 2 non-contiguous dermatomes&#41; in the literature reviewed&#46; It is a more common entity in patients of advanced age or with malignant disease&#44; especially haematological&#44; although it has also been reported in children without immune alterations&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> It occurs more frequently in immunocompromised patients&#44; such as those transplanted undergoing immunosuppressive treatment&#44; this being the case of our patient&#44; or those with end-stage renal disease<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> or undergoing peritoneal dialysis&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Cases have also been reported in immunocompetent patients&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> The mechanism of reactivation of the virus in several dermatomes is unclear&#46; In most cases&#44; no systemic involvement or other complications have been demonstrated&#44; so it does not confer a worse prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> The most common sites are the thoracic &#40;50&#8211;60&#37;&#41; and the facial &#40;10&#8211;20&#37;&#41; regions&#44; with other locations being less frequent&#44; such as the instep and big toe of the right foot&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In addition&#44; VZV may develop other atypical skin manifestations&#44; such as gangrenous lesions&#44; ulcers or ecthyma lesions&#44; predominantly in immunosuppressed patients&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In 2015&#44; 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&#44; finding a higher prevalence in Asian individuals&#44; despite having a lower prevalence of seropositivity for VZV&#44; suggesting the possibility of genetic susceptibility&#46; Likewise&#44; a greater prevalence was observed in people over 50 years of age&#44; finding no differences regarding the typical form&#46; It was more common in women&#44;<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&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> As in other publications&#44; the importance of immunosuppression in its physiopathology is highlighted&#46;<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&#46; Regarding treatment&#44; the use of antivirals &#40;acyclovir&#44; valaciclovir&#44; famciclovir and brivudine&#41;&#44; especially during the first 72<span class="elsevierStyleHsp" style=""></span>h&#44; has shown benefit in reducing the intensity of pain in the acute phase&#44; although more studies would be necessary to clarify the preventive nature of postherpetic neuralgia and other complications&#46; In addition&#44; they contribute to a shorter healing process&#46; However&#44; it must be combined with strictly symptomatic treatment&#44; using regular analgesics&#44; gabapentin or opioids&#44; among others&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Therefore&#44; we report a new case of HZ <span class="elsevierStyleItalic">multiplex</span>&#44; located at the right costal level &#40;T11-12-L1&#41; and on the right foot &#40;L4-L5&#41;&#44; the latter also constituting an atypical location&#46;</p></span>"
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