Colonic

Downloaded from www.ajronline.org by 104.169.132.6 on 10/19/15 from IP address 104.169.132.6. Copyright ARRS. For personal use only; all rights reserved

LESLIE

S. MENUCK,1

Changes

FOLKE

of Herpes

BRAHME,1

JOHN

The lesions of herpes zoster of the colon were observed in three cases. Small polygonal mucosal blebs or small ulcerations involving a short segment of the colon and appearing in a reasonable time relationship with the cutaneous mani-

festations

either

in a corresponding

Colonic

changes

in herpes

zoster

are

uncommon.

Even

of this

and

entity

its differentiation

from

other

colonic

ab-

normalities in order to avoid more invasive diagnostic cedunes. Three cases of herpes zoster with colonic normalities are presented to illustrate the radiographic ifestations and the development of these changes. Case

AND

HOWARD

P. SHERR2

3

A 54-year-old male who had previously been in good health suddenly developed an acute onset of intense, deep pain in the left side of his abdomen. Blood was noted in the stool. An air contrast barium enema was performed 6 days after the onset of symptoms. In the descending colon a narrowed segment was found with some irregularity to the mucosa, felt to represent small ulcerations. Two weeks later the patient developed skin lesions typical of herpes zoster on the inner aspect of the left lower limb. By this time the abdominal symptoms of bleeding had resolved, and a second radiographic study of the colon demonstrated healing of the ulcerations with moderate residual narrowing of the involved segment. A follow-up examination 2 months later showed further resolution of the colonic changes (fig. 3).

or noncorresponding

lesions do not usually cause severe symptoms, to recognize the radiologic manifestations

AMBERG,1

Case

dermatome should enable diagnosis of this unusual condition. Recognition of this entity in the presence of these skin lesions should be obvious and therefore helpful in avoiding more aggressive and invasive diagnostic procedures.

though these it is important

Zoster

proabman-

Discussion

Herpes zoster order secondary pox

Reports

virus

of from

that

is an exanthematous neurocutaneous disto reactivation or reinfection by a large

also

three

gives

to five

rise to vanicella.

cases

per

1 ,000

It occurs

persons

at a rate

per

year.

The

Case 1

skin

A 43-year-old male had been in good health until he noted the sudden onset of nonspecific migratory abdominal pain which was

of the posterior root ganglion on extramedullary ganglion of the cranial nerve and along the peripheral sensory nerve distribution [1, 2]. the portal of entry of this virus has not been established, but observations of Cheatham [3] suggest that the gastrointestinal tract rather than the skin is initially invaded. The virus may then propagate from the myenteric plexus to the sympathetic ganglion by way of

followed

by a fullness

in the right lower quadrant.

There was no

diarrhea or hematochezia. Several weeks later, he developed skin lesions of herpes zoster involving a single dermatome along the inner aspect of the left thigh. On physical examination, there was a suggestion of night lower quadrant abdominal mass.

A barium

enema

was done which

disclosed

multiple,

sharply

changes

angular filling defects within the cecum. Examination of the remainder of the upper gastrointestinal tract and small bowel showed no abnormality. At colonoscopy, the cecum was not reached but

visceral

no abnormalities

chills,

were seen in the distal colon.

Two weeks

resolution of the skin lesion, a double contrast colonic was repeated and showed a normal cecum (fig. 1).

schizophrenic

female

had a previous

In the

after

examination

more

of the skin lesions, colonoscopy

only a very small residual polypoid abnormality repeat barium enema 2 weeks later disclosed (fig. 2). 1

Department

of Radiology,

San Diego, california 2

Am

Department

J Roentgenol

University

921 61 . Address

of Gastroenterology,

1 27

: 273-276,

Hospital, reprint University

1976

of California

the

posterior

of herpes

malaise

the

involved

by several follow are

pain

by way

dermatome

may

phase and

along

and

crusts,

simply

the

dry

up,

the

cutaneous which are

course

may then

of

hyper-

precede

days or weeks. The grouped, clear vesicles

unilaterally

form

roots

a prodromal

associated

eruptions

and with

inflammation

nerve

zosten,

with

These

respiratory

of one

or

either

become

or become

hemor-

ulcerate and then subsequently heal [1 ]. In paan altered immune state (usually patients on

or

tract,

or steroid leukemia),

medications skin eruptions

or

zoster generalisatus.” visceral manifestations gastrointestinal

tract,

patients with may be diffuse involving

genitourinary

the tract,

the liver, and serous membranes of the pleura and pentoneum have been described both in patients with an altered immune response and in patients who are otherwise healthy [2, 4-9]. The true incidence of these extracutaneous manifestations is unknown, probably because such

in the cecum. A a normal cecum

University

case

causing “herpes Extracutaneous

was done, showing

requests to Hospital.

involve

segmental

communicantes.

and

distributed

antimetabolite lymphoma

hemolytic

with

dermatomes.

purulent rhagic tients

anemia with a probable drug-related leukopenia. A barium enema was obtained because of the anemia. Multiple small filling defects with angular margins were found in the cecum.

After clearing

usual

over

usually

of

vesicular lesions of herpes zoster developed along the T8 dermatome on the left. Except for the cutaneous lesions, the physical examination was unremarkable. Her hematocnit was 1 8%, and a white blood cell count was 1 ,400. Hematologic evaluation sug-

anemia and a Coombs-positive

and

skin changes lesions which history

associated

rami

fever,

esthesias

eczema of the arms, legs, and back which had been treated with steroids over a long period of time. Five weeks prior to admission, her appetite diminished. This lasted for 2 weeks, at which time the

gested an iron deficiency

nerves

of the white

Case 2 This 57-year-old

are

at San

Diego,

and

Veterans

Administration

L S. Menuck at the Veterans Administration Hospital. University of California at San Diego, La Jolla, California

273

Hospital, 92037.

3350

La Jolla

Village

Drive,

MENUCK

Downloaded from www.ajronline.org by 104.169.132.6 on 10/19/15 from IP address 104.169.132.6. Copyright ARRS. For personal use only; all rights reserved

274

Fig. 1 -case normal

cecum.

Fig. showing

2.-Case total

i . A, Double

2. A, resolution

contrast

Double

barium

contrast

of cecal

enema

barium defects

filling

enema

showing

multiple

showing

polygonal

sharply

angular

ET

AL.

filling

defects

polygonal

within

filling

defects

findings are usually asymptomatic on unrecognized. Since the disease is self limited in most instances, biopsy material is usually not obtained. The presence of gastrointestinal

cosal ulceration. respond to the

tract

case

involvement

stration within

the

inflammatory The onset skin

ganglion

been

substantiated

inclusion cells

of

and epithelial of the colonic

manifestations

precede weeks

has

of intranuclear

myentenic

the

plexus

itself and

in

cells within the mucosa [2]. lesions may coincide with the 1 and

2), though

(as in case 3) or follow

them

by as long

Resolution

demon-

of the virus

in cases

[9].

(as

the

by

bodies

of

the

colonic

lesions

they

may

as several may

lag

behind

the

3),

skin

have virus

or

only

intranuclear

have

other been

absent been

zoster

Repeat

1 month

later

examination

if there

will

two rare

(zosten

inclusion

depend

cases cases

has

been

bodies

there

may

the

within

later

mucon(as in

was

no real

skin

lesions

herpete)

by

showing

3 weeks

where

sine

established

gastrointestinal segment [2, The radiographic appearance herpes

B,

especially

in our

totally has

cecum.

examination

The segment of involved colon associated cutaneous denmatome

There

been

diagnosis

of

changes,

although

correlation.

B, Repeat

cecum.

finding the

and

the

of the involved

10].

on the

of the stage

lesions of the

in the disease

colonic at the

Downloaded from www.ajronline.org by 104.169.132.6 on 10/19/15 from IP address 104.169.132.6. Copyright ARRS. For personal use only; all rights reserved

HERPES

ZOSTER

OF

THE

275

COLON

: Fig.

3.-case

2 months

3. A, Double contrast

later

showing

time

of the barium

filling

defects

some

barium enema showing narrowing of involved

residual

examination. with

sharp

The

small

angular

short focal segment.

discrete

margins

narrowing

polygonal correspond

morphologically to the vesicular phase of the cutaneous lesions. This appearance was noted in two of our cases and also in the case reported by Khilnani and Keller [ii]. The presence of minute ulcerations in a short segment of the colon as seen in case 3 is felt to represent progression from the vesicular to the ulcerative phase. Similar small ulcerating lesions were found at autopsy in the case presented by Khilnani and Keller [ii], even though filling defects had been seen on the previous barium study 6 days earlier; again,

this

was

felt

to correspond

to the

progression

of the

disease from the vesicular to the ulcerative stage. presence of focal narrowing as observed by Figiel Figiel [12] and by Wyburn-Mason [9] was also seen in case

3. This

narrowing

probably

following

represents the

a stage

resolution

of the

of interim small

The and later

residual

ulcerations.

The differential diagnosis of the herpetic changes in the colon will depend on whether the vesicular or ulcerative phase is present and on the extent of the colonic involvement.

These

vesicular

appearance from true angular and straight

lesions

have

a somewhat

polyps in that the with a polygonal

different

margins are quite appearance. The

with

mucosal

pattern

irregularity

is similar

in mid

descending

to colonic

B, Repeat

colon.

urticaria

examination

as described

by

Berk

and Millman [1 3]. The focal segmental involvement and the angular polygonal appearance of the lesions will differentiate

colonic

herpes

from

any of the polyposis differentiation

inflammatory

syndromes,

from

lymphoma

size and

shape

lymphoid

The

allows

finding

of

(The

important

since

in incidence of herpes The lack of uniformity

one

nodular

on

lymphoma.

is especially

there is a significant increase in patients with lymphoma). from

pseudopolyposis

including

to differentiate

zoster in the

colonic

herpes

hyperplasia.

a narrowed

segment

with

small

ulcera-

tions short

is similar to that of a segmental colitis, although length of the lesion and the clinical history would

quite

atypical.

Segmental

diagnostic

possibility,

presence printing as well lesions

of [14].

(2)

The

marked rapid

will

temporal

present usually

correlation

in time making

cases, on

with

(1

the

is another

anticipate

the

edema

with

thumb

of the

small

lesions

to the typical the diagnosis

the )

colon

would

disappearance

three depend

of the one

submucosal

as their relationship will be helpful in

zoster. As in the herpes

more

infarction though

the be

diagnosis

radiographic

cutaneous

cutaneous of herpes

of colonic appearance,

lesions,

and

MENUCK

276

(3)

the inference

of the same

that

the colonic

and

cutaneous

lesions

are

ET AL.

7.

Reifferscheed Zentralbl

etiology.

Chir

M : Herpes 74

: 931 -934,

Zoster

und

paralytischer

lleus.

1949

Schirduan M, Dietze HH : Ober einen blinisch und pathologisch-anatomisch ungew#{244}hnlichen Herpes Zoster Multiplex mit eigenartigen Ileitis. Arch Dermatol Syphilis 1 94 : 366-375, 1952 9. Wybunn-Mason A : Visceral lesions in herpes zoster. Br Med J

8.

Downloaded from www.ajronline.org by 104.169.132.6 on 10/19/15 from IP address 104.169.132.6. Copyright ARRS. For personal use only; all rights reserved

REFERENCES 1 . Domonkos Dermatology, 2. Lever WF, Philadelphia,

AN : Andrew’s Diseases of the Skin; 6th ed, Philadelphia, Saunders, 1971 Schaambung G : Histopathology of Skin, Lippincott, 1975

Clinical

5th

ed.

1 :678-681,

3. Cheatham WJ : Relationship of heretofore unrecognized lesions to pathogenes’is of herpes zoster. Am J Pathol 29 : 401-41 1, 1953 4. Curtin

AG : Herpes

zoster

and its relation

tions and diseases, especially

to internal

inflammaAm J

of the serous membranes.

MedSci73:264-268, 1902 5, Darget A : Deux cas d’herpes zosten de en vessie. Nephrol (Paris) 27 : 229-231 , 1929 6. Eisenbad M: Chickenpox with visceral involvement. Med 12: 740-746. 1952

J

1 1.

1 2.

13.

Urol

Am

1 0.

J

14.

1957

Lewis GW : Zosten sine herpete. Br MedJ 2 : 41 8-421, 1958 Khilnani MT. Keller AJ : Roentgen and pathological changes the gastrointestinal tract in herpes zoster generalisata. SinaiJ Med NY 38 : 303-31 0, 1 971 Figiel SJ, Figiel LS : Herpes zoster with ileus simulating testinal obstruction. Am J Med 23 : 999-1 002, 1957 Benk AN, Millman SJ : Urticania of colon. Radiology 99:539540, 1971 Manshak A, Maklansky D, Calem SH : Segmental infarction the colon. AmJ Dig Dis 1 0 : 86, 1965

in Mt in-

of