Abdominal hernia following abdominal herpes zoster

PK Sharma, RK Gautam, C Basistha, RK Jain, HK Kar

 Department of Dermatology and S.T.D. Dr, K M, L, Hospital, New Delhi- 110001, India

Correspondence Address:
P K Sharma
E-4, CGHS Dispensary, Dr. Zakir Hussain Marg, Pundara Park, New Delhi- 110 003
India

Introduction

Cutaneous herpes zoster can sometimes af-flict motor neurons leading to motor paralysis. Acute weakness may effect some or all muscles of the corresponding or adjacent dermatome.[1],[2] ′The weak-ness can occur at levels above or below the cutane-ous rash.[2],[3] Paralysis has been attributed to the in-volvement of anterior horn cells, ventral roots, mo-tor axons within peripheral nerves and focal myosi-tis.[1],[3],[4],[5],[6] The involvement of the facial muscles and muscles innervated by the cervical and lumbosacral nerve roots are most commonly afflicted.[7],[8],[9] We re-port a rare case of abdominal hernia of T10, T11 abdominal segments following abdominal zoster at T11.

Case Report

A 55-year- old man suddenly developed a swelling in the middle of left side of abdomen 4 months back. This swelling maintained its size and shape since then. It increased on coughing, sneez-ing, defaecating and urinating. This was preceded a month before by pain and sudden appearance of vesicles over the swollen area. These vesicles extended from the back to just below the umbilicus on the left side.

The pain was constant and at times sharp shooting in character. Slowly, in 3 weeks time all the lesions healed and left behind scars. The pain also subsided along with it. No history of fever or injury to the back could be elicited. The patient did not have diabetes mellitus or hypertension.

Dermatological examination revealed multiple healed scars of varying sizes and shapes on the left side, over the T11 dermatome extending from the back to the midline anteriorly just below the umbili-cus. The T10 dermatome had no lesions. Sensa-tions of temperature, touch and pain were absent in the scar areas. They were either diminished or nor-mal in the non scar areas of T 11 dermatoma seg-ment. Abdominal reflex was absent in T10 and T11 segments.

A swelling of 20 cmx 10 cm was present in T10, T11 abdominal segment on the affected left side [Figure - 1]. The swelling was soft, non mobile, non tender with well defined sloping margins and reduced on pressure. Cough reflex was positive. Heamoglobin, total and differential leucocyte count, ESR, blood glu-cose, blood urea and serum electrolytes were nor-mal. The electromyogram of the paraspinal muscles of the affected T11 and the adjacent T10 segment, showed no neurogenic involvement electrophysiologi-cally.

Discussion

The latent period between the onset of rash of herpes zoster and paralysis varies between one to five weeks. In our patient it was 4 weeks. Right side dermatome and myotome involvement is twice as common as on the left.[2] The latter was affected in this patient at T11 dermatome. There was also sig-nificant sensory deficit present in this segment. The muscle weakness of T11 segment which led to ab-dominal hernia was clearly observed here. This ex-tended to involve the adjacent, upper T10 segment clinically and spared the lower T12 segment. Also, all the sensations were normal in this segment. Thus there was selective motor neuron involvement of the adjacent preceding segment. Whether this occurred at the level of spinal cord or not can only be a matter of speculation as the electromyogram of the T11 segment was normal.

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