Management of Herpes Zoster Infection Using a Combination of Allopathic and Herbal Medication: A Case Report

Herpes zoster (HZ) also known as shingles is the reactivation of varicella-zoster virus (VZV) that causes chickenpox. It usually occurs in adults after remaining dormant in the dorsal root ganglia or ganglia of the cranial nerves for several years. It typically manifests as vesicle crops in a dermatomal or "zosteriform" pattern, which shows vesicle, ulcer, and scab distribution that is unilateral, clustered, and linear in a dermatome that is supplied by a single nerve. Patients usually experience prodromal symptoms of deep, severe aching or burning pain. Medicinal treatment frequently includes antiviral drugs to decrease the severity of the lesion and steroidal drugs to reduce symptoms of inflammation. It is also a known fact that steroid has several adverse effects on patients due to which therapeutic drugs with lesser side effects may be given to patients such as herbal medications. This case presentation reports a patient with HZ viral infection who was successfully treated with a meticulous combination of conventional allopathic drugs with ayurvedic medication with a significant positive response to the medication.

Oral Herpes Zoster Infection Following COVID-19 Vaccination: A Report of Five Cases

Recently, two cases of oral herpes zoster (HZ) following COVID-19 vaccines were reported. It was suggested that COVID-19 vaccine-related oral HZ cases might be missed or misdiagnosed as stomatitis or isolated oral herpes. In this report, five cases of oral HZ following COVID-19 vaccinations are presented. Four cases were observed on the hard palate (V2), and one case was found on the mandible (V3). Four patients did not receive any treatment for their oral HZ, but one patient also had skin reactions on her right orbit and ear and was thus treated with an antiviral drug. As these cases were seen during such a short period of time and in one practice, the relationship with the COVID-19 vaccination appears to be related.

Hindlimb Somatosensory Information Influences Trunk Sensory and Motor Cortices to Support Trunk Stabilization

Sensorimotor integration in the trunk system is poorly understood despite its importance for functional recovery after neurological injury. To address this, a series of mapping studies were performed in the rat. First, the receptive fields (RFs) of cells recorded from thoracic dorsal root ganglia were identified. Second, the RFs of cells recorded from trunk primary sensory cortex (S1) were used to assess the extent and internal organization of trunk S1. Finally, the trunk motor cortex (M1) was mapped using intracortical microstimulation to assess coactivation of trunk muscles with hindlimb and forelimb muscles, and integration with S1. Projections from trunk S1 to trunk M1 were not anatomically organized, with relatively weak sensorimotor integration between trunk S1 and M1 compared to extensive integration between hindlimb S1/M1 and trunk M1. Assessment of response latency and anatomical tracing suggest that trunk M1 is abundantly guided by hindlimb somatosensory information that is derived primarily from the thalamus. Finally, neural recordings from awake animals during unexpected postural perturbations support sensorimotor integration between hindlimb S1 and trunk M1, providing insight into the role of the trunk system in postural control that is useful when studying recovery after injury.

A Narrative Review of the History of Skin Grafting in Burn Care

Thermal injuries have been a phenomenon intertwined with the human condition since the dawn of our species. Autologous skin translocation, also known as skin grafting, has played an important role in burn wound management and has a rich history of its own. In fact, some of the oldest known medical texts describe ancient methods of skin translocation. In this article, we examine how skin grafting has evolved from its origins of necessity in the ancient world to the well-calibrated tool utilized in modern medicine. The popularity of skin grafting has ebbed and flowed multiple times throughout history, often suppressed for cultural, religious, pseudo-scientific, or anecdotal reasons. It was not until the 1800s, that skin grafting was widely accepted as a safe and effective treatment for wound management, and shortly thereafter for burn injuries. In the nineteenth and twentieth centuries skin grafting advanced considerably, accelerated by exponential medical progress and the occurrence of man-made disasters and global warfare. The introduction of surgical instruments specifically designed for skin grafting gave surgeons more control over the depth and consistency of harvested tissues, vastly improving outcomes. The invention of powered surgical instruments, such as the electric dermatome, reduced technical barriers for many surgeons, allowing the practice of skin grafting to be extended ubiquitously from a small group of technically gifted reconstructive surgeons to nearly all interested sub-specialists. The subsequent development of biologic and synthetic skin substitutes have been spurred onward by the clinical challenges unique to burn care: recurrent graft failure, microbial wound colonization, and limited donor site availability. These improvements have laid the framework for more advanced forms of tissue engineering including micrografts, cultured skin grafts, aerosolized skin cell application, and stem-cell impregnated dermal matrices. In this article, we will explore the convoluted journey that modern skin grafting has taken and potential future directions the procedure may yet go.

Cutaneous Branch of the Obturator Nerve Extending to the Medial Ankle and Foot: A Report of Two Cadaveric Cases

The area of skin supplied by the cutaneous branch of the obturator nerve (CBO) is highly variable. Although most introductory anatomy texts describe the CBO as innervating only a portion of the medial thigh, there are numerous reports in the literature of CBOs passing the knee to innervate the proximal, middle, or even distal leg. There are no previous reports of CBOs extending to the ankle and foot. Herein we describe 2 cases of CBOs extending at least to the medial foot. Both cases were discovered incidentally, during routine cadaver dissections by osteopathic and podiatric medical students in the anatomy laboratory of Western University of Health Sciences in California. In both instances, the anomalously long CBOs shared several characteristics: (1) they arose as direct branches of the anterior division of the obturator nerve, not from the subsartorial plexus; (2) they coursed immediately posterior to the great saphenous vein from the distal thigh to the distal leg, only deviating away from the saphenous vein just above the medial malleolus; and (3) they terminated in radiating fibers to the posterior half of the medial ankle and foot. In both cases, the saphenous branch of the femoral nerve was present but restricted to the area anterior to the great saphenous vein. It is likely that the variant CBOs carried fibers of the L4 spinal nerve and thus provided cutaneous innervation to the medial foot and ankle, a function most commonly reserved for the saphenous branch of the femoral nerve distal to the knee. Saphenous neuropathy is a common postoperative complication of saphenous cutdowns for coronary artery bypass grafts, so the potential involvement of a long CBO can add additional complexity to regional anesthetic blocks for foot and ankle surgery and procedures such as vein harvesting for coronary artery bypass grafts.

Clinical differences between segmental nevus depigmentosus and segmental vitiligo

Segmental nevus depigmentosus and segmental vitiligo can be difficult to differentiate from each other. Differential diagnosis of these two diseases is important because they have significantly different prognoses and psychological effects. The purpose of this study is to identify clinical clues that may be helpful in differentiating these two diseases. We enrolled 63 patients with segmental nevus depigmentosus and 149 patients with segmental vitiligo. Sex, age of onset, sites involved, dermatomal distribution, margin of lesion and presence of poliosis were evaluated in both groups. The age of onset was less than 10 years in 96.8% of segmental nevus depigmentosus and 28.9% of segmental vitiligo cases. Trunk (36.5%) and cervical (38.1%) dermatomes were the most commonly involved in segmental nevus depigmentosus and face (67.1%) and trigeminal (64.4%) dermatomes in segmental vitiligo. The average number of dermatomes involved in truncal lesions was different in segmental nevus depigmentosus and segmental vitiligo (2.71 vs 1.62, P = 0.001). Segmental vitiligo on the face, neck and trunk appeared closer to the axis than segmental nevus depigmentosus (P < 0.001). Segmental nevus depigmentosus and segmental vitiligo showed significantly different margins (90.5% and 41.6% serrated, respectively; P < 0.001). We observed clinical differences between patients with segmental nevus depigmentosus and those with segmental vitiligo. Distribution (site, distance to axis, dermatome), vertical width, margin of lesion and presence of poliosis can be helpful in differentiating segmental nevus depigmentosus and segmental vitiligo.

Segmental innervation of the Göttingen minipig hind body. An electrophysiological study

The Göttingen minipig is being used increasingly in biomedical research. The anatomical structure of the porcine peripheral nervous system has been extensively characterized, but no equivalent to the dermatome map, which is so valuable in human neurophysiological research, has been created. We characterized the medullar segmental skin and muscle innervations of the minipig hind body, using neurophysiological methodology. Six adult minipigs underwent unilateral laminectomy from L2 to S3, exposing the nerve roots. The skin of the hind part of the body was divided into 36 predefined fields, based on anatomical landmarks for consistent reproducibility. We recorded the evoked potential in each exposed nerve root L2-S3 for cutaneous stimulation of each skin field, mapping the sensory innervation of the entire hind body. We subsequently recorded the motor response in seven predefined muscles during sequential stimulation of the L2-S3 nerve roots. We obtained a clear sensory evoked potential in the nerve roots during stimulation of the skin fields, allowing us to map the sensory innervation of the minipig hind body. Neurophysiological data from skin stimulation and muscle recordings enabled us to map the sensory innervation of the Göttingen minipig hind body and provide information about muscular innervation. The skin fields were sensory innervated by more than one root. The muscles each had one dominant root with minor contribution from neighboring roots. This is consistent with experimental data from human studies.

Bilateral herpes zoster in a patient with end-stage kidney disease

Herpes zoster (HZ) is caused by the reactivation of a latent varicella-zoster virus (VZV) infection within the cranial or dorsal root ganglia. The cutaneous lesions of HZ are typically limited to a single dermatome, while non-contiguous HZ involving two or more dermatomes is a very rare clinical entity. In this report, we describe a case of HZ involving the left and right side of the abdomen corresponding to the T11 dermatome in a 63-year-old man on chronic peritoneal dialysis. The characteristic cutaneous manifestation encouraged us to ascribe the disease to HZ duplex bilateralis, and the patient was given a single dose of oral valacyclovir and achieved a favorable outcome. The therapeutic concerns regarding the reactivation of VZV in patients with end-stage kidney disease are also discussed.

Zosteriform impetigo: Wolf's isotopic response in a cutaneous immunocompromised district

Background:

Impetigo can result from Staphylococcus aureus (S. aureus). Wolf’s isotopic response is the occurrence of a new cutaneous disorder at the site of a previously healed disease. A cutaneous immunocompromised district is an area of skin that is more vulnerable than the rest of the individual’s body.

Purpose:

To describe a man with impetigo localized to a unilateral dermatome and review the clinical features of other patients with zosteriform Staphylococcus aureus cutaneous infection.

Methods:

PubMed was used to search the following terms, separately and in combination: cutaneous, dermatome, dermatomal, district, herpes, immunocompromised, impetigo, infection, isotopic, response, skin, staphylococcal, Staphylococcus aureus, Wolf, zoster, zosteriform. All papers were reviewed and relevant manuscripts, along with their reference citations, were evaluated.

Results:

Crusted, eroded and intact, erythematous papules and nodules acutely presented localized to the mandibular branch of the left trigeminal nerve on the face of a 66-year-old man; he did not recall a prior episode of varicella-zoster virus infection in that area. A bacterial culture isolated methicillin-susceptible S. aureus. Viral cultures and direct fluorescent absorption studies were negative for herpes simplex and herpes zoster virus. All of the lesions resolved after oral treatment with cefdinir. Impetigo and/or furunculosis in a zosteriform distribution have also been described in 3 additional patients. The bacterial culture showed either methicillin-susceptible or methicillin-resistant S. aureus; the skin infection resolved after treatment with oral antibiotics; however one man experienced 2 recurrences in the same area.

Conclusions:

Zosteriform cutaneous staphylococcal impetigo may be an example of Wolf’s isotopic response in a cutaneous immunocompromised district

Active Shingles Infection as Detected on (18)F-FDG PET/CT

We present the case of a 56-year-old male with a history of recurrent follicular lymphoma undergoing chemotherapy with multiple (18)F-FDG PET-CT studies at an outside facility. He developed a painful erythematous, pruritic rash in the left back requiring a visit to the emergency room. He was diagnosed and treated for Varicella zoster infection. He then presented to our imaging center 2 months later for a follow up (18)F-FDG PET/CT study. Imaging demonstrated a cutaneous band of increased metabolic activity in the upper back following a dermatomal distribution. This was confirmed to be in the same area as the treated Varicella zoster eruption. A subsequent follow up (18)F-FDG PET-CT scan 4 months later to confirm tumor resolution demonstrated the abnormal band of uptake in the back had resolved. This case illustrates the significance of being aware of this entity and to distinguish it from metastasis, especially in patients with a known history of malignancy.

Proposed catalog of the neuroanatomy and the stratified anatomy for the 361 acupuncture points of 14 channels

BACKGROUND

In spite of the extensive research on acupuncture mechanisms, no comprehensive and systematic peer-reviewed reference list of the stratified anatomical and the neuroanatomical features of all 361 acupuncture points exists. This study creates a reference list of the neuroanatomy and the stratified anatomy for each of the 361 acupuncture points on the 14 classical channels and for 34 extra points.

METHODS

Each acupuncture point was individually assessed to relate the point's location to anatomical and neuroanatomical features. The design of the catalogue is intended to be useful for any style of acupuncture or Oriental medicine treatment modality. The stratified anatomy was divided into shallow, intermediate and deep insertion. A separate stratified anatomy was presented for different needle angles and directions.

RESULTS

The following are identified for each point: additional specifications for point location, the stratified anatomy, motor innervation, cutaneous nerve and sensory innervation, dermatomes, Langer's lines, and somatotopic organization in the primary sensory and motor cortices. Acupuncture points for each muscle, dermatome and myotome are also reported.

CONCLUSION

This reference list can aid clinicians, practitioners and researchers in furthering the understanding and accurate practice of acupuncture. Additional research on the anatomical variability around acupuncture points, the frequency of needle contact with an anatomical structure in a clinical setting, and conformational imaging should be done to verify this catalogue.