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Unilateral abdominal bulge with sharp pain

Published:February 24, 2017DOI:https://doi.org/10.1016/j.ejim.2017.02.015

      1. Indication

      A 64-year-old man presented with sharp pain and progressive bulging in his right lower quadrant of the abdomen for three days (Fig. 1). He was smoker and he underwent appendicectomy about 50 years ago. There were no visible skin lesions, no paresthesia, and no bowel changes. The bulge increased in size with increased abdominal pressure, it seemed to be caused by abdominal paralysis. The remainder of the physical exam was normal. The patient did not have diabetes mellitus, and neither abdominal computed tomography nor spinal magnetic resonance imaging revealed abnormalities. One week later, the patient developed three vesicular and encrusted rashes in the area innervated by the ninth thoracic nerve.
      Fig. 1
      Fig. 1The bulge in right lower quadrant of the abdomen.

      2. What is the diagnosis?

      2.1 Diagnosis

      Segmental herpes zoster (HZ) abdominal paralysis was strongly suspected, and he was treated with valacyclovir for 1 week. Paired HZ-specific IgG antibody titers showed no significant increase. His abdominal pain disappeared after 2 months, and his abdominal paralysis gradually improved.
      The incidence of motor neuropathy in association with HZ is 0.9%. Only 1 of 40 patients with HZ abdominal paresis in previous studies developed paralysis before the rash, similar to our patient [
      • Chernev I.
      • Dado D.
      Segmental zoster abdominal paresis (zoster pseudohernia): a review of the literature.
      ,
      • Rexinger E.L.
      Herpes zoster presenting as soft abdominal mass with obstipation.
      ]. Exclusion of abdominal hernia, diabetic mononeuropathy, and spinal diseases is also important for accurate diagnosis of segmental HZ abdominal paralysis. Normal level of HZ-specific IgG could not deny the diagnosis of HZ because its sensitivity was 76% [
      • Breuer J.D.
      • Schmid S.
      • Gershon A.A.
      Use and limitations of varicella-zoster virus-specific serological testing to evaluate breakthrough disease in vaccinees and to screen for susceptibility to varicella.
      ].
      It is imperative to consider segmental HZ abdominal paralysis as a possible cause of unilateral abdominal bulging.

      Conflict of interest

      The authors declare no conflict of interest.

      References

        • Chernev I.
        • Dado D.
        Segmental zoster abdominal paresis (zoster pseudohernia): a review of the literature.
        Am J Phys Med Rehabil. 2013; 5: 786-790
        • Rexinger E.L.
        Herpes zoster presenting as soft abdominal mass with obstipation.
        Cutis. 1983; 31: 489
        • Breuer J.D.
        • Schmid S.
        • Gershon A.A.
        Use and limitations of varicella-zoster virus-specific serological testing to evaluate breakthrough disease in vaccinees and to screen for susceptibility to varicella.
        J Infect Dis. 2008; 197: S147-S151