Hip pain as initial presentation for varicella-zoster infection in an adolescent male.

Hip pain and varicella infections are common diagnoses affecting children and adolescents. Hip pain in childhood can be a challenging presenting complaint for the pediatrician or orthopedic physician. The differential diagnosis is broad, and ranges from benign conditions, such as transient synovitis and muscle strains, to more serious infections or malignancies. Acute hip pain is usually referred to an orthopedic surgeon, and the principal concern is to distinguish infection of the hip joint or pelvis from an irritable hip or musculoskeletal pain. The Varicella-zoster virus, a member of the herpes virus family, often presents as a generalized, pruritic, vesicular rash. The primary infection is commonly known as chickenpox. The prevalence of varicella infections has decreased significantly over the past decade with use of the varicella vaccine. Reactivation of varicella infection, or herpes zoster, in patients younger than 20 years is seen in only 68 per 100,000 people. Hip pain as the presenting symptom for onset of a herpes zoster infection is rare. This article presents a case of herpes zoster infection with initial presentation of hip pain in a 13-year-old boy. This case highlights the difficulty in diagnosing atraumatic joint pain in the pediatric population. The clinical importance of a thoughtful differential diagnosis, and the necessity of close follow-up by a pediatrician and/or orthopedic surgeon until there is a confirmed diagnosis cannot be overstated.

Recurrent lumbosacral herpes simplex in two men.

Two cases of recurrent lumbosacral herpes simplex without concomitant genital lesions are reported. Both patients presented with vesicular lesions on the middle of the lower back and on the left thigh, respectively, and had positive serum antibody to herpes simplex virus type 2 and negative antibody to HIV. The lesions healed completely within 1 week by oral administration of acyclovir.

Diagnostic aspects for epidemic hemorrhagic fever in legal medical autopsy: report of 2 cases and review.

Epidemic hemorrhagic fever (EHF) is known also as hemorrhagic fever with renal syndrome (HFRS). Hantaviruses, a notorious cause of EHF is spreaded by rodents or biting insects, can cause epidemic hemorrhagic fever. This report describes two rare medico-legal autopsy cases died from epidemic hemorrhagic fever. The victims were two male individuals aged 34 years and 29 years. The medico-legal autopsies were requested for alleged medical negligence. In both cases, autopsy reveals lesions to kidneys and lungs with multiple organ hemorrhage and edema, indicative of the generalized capillary damage. On admission to hospital, both patients had the symptom of fever, lumbago, renal failure and recent outdoor activities. The laboratory diagnosis results indicating multiple organ dysfunction syndrome are also important for certificating of EHF. Though the ELISA-based detection of virus-specific IgM antibody which has the highest titers between 8 and 25d after onset of disease is positive in the 34-year-old case and negative in 29-year-old case, the pathological findings and clinical laboratory analysis suggested the both victims died of EHF. In addition, immunohistochemistry analysis for Hantavirus antigen in lung or in tubular cells and PCR having been used increasingly in recent years contribute to the diagnosis of Hantavirus infection.

Severity of skin lesions of herpes zoster at the worst phase rather than age and involved region most influences the duration of acute herpetic pain.

Duration of acute herpetic pain (AHP) in 1431 patients for whom treatment was begun within 14 days after the onset of herpes zoster (HZ) was analyzed with respect to age, involved region, and severity of skin lesions. All patients were treated with repeated sympathetic nerve blocks until their pain was almost nil. Severity of the skin lesions at the worst phase was defined as mild when they covered less than one-quarter of the primary dermatome, as severe when they covered more than three-quarters of the primary dermatome, and moderate if they were between mild and severe. Without taking into account the severity of skin lesions, the duration of AHP for those aged 60 years or over and for those with trigeminal involvement was significantly longer than for patients aged under 40 years (P < 0.01 and P < 0.001) and for patients with thoracic (P < 0.001) and lumbosacral (P < 0.01) involvement, respectively. However, duration of AHP was significantly longer with increase in the severity of skin lesions in all age groups (the mild group versus the moderate group, P < 0.01 and P < 0.001; the moderate group versus the severe group, P < 0.01 and P < 0.001). The mean duration of AHP for patients aged 60 years or over with mild skin lesions ranged from 17.4 to 22.9 days, while that for patients aged 30-59 years with severe skin lesions ranged from 37.2 to 50.1 days. In addition, duration of AHP was significantly longer with increase in the severity of skin lesions in all regions (the mild group versus the moderate group, P < 0.01 and P < 0.001; the moderate group versus the severe group, P < 0.05 and P < 0.001). The mean duration of AHP for those with trigeminal involvement with mild skin lesions was 19.5 days, while the range was from 51.3 to 55.0 days for patients with severe skin lesions involving regions other than the trigeminal area. The frequency of severe skin lesions was significantly higher (P < 0.001) in patients aged 60 years or over and in those with trigeminal involvement. Multiple stepwise regression analysis revealed that the most important factors influencing the duration of AHP were the severity of skin lesions of HZ at the worst phase (r = 0.412), age (r = 0.277) and the involved region (r = -0.101). Thus, AHP in the elderly and in cases of trigeminal involvement is longer because of higher frequencies of severe HZ in the elderly and in trigeminal involvement rather than "being aged' and "trigeminal involvement' itself. We propose that one needs to analyze the results of treatment of AHP with respect to the severity of skin lesions at the worst phase.

Another case of virologically confirmed zoster sine herpete, with electrophysiologic correlation.

A third virologically-confirmed case of thoracic-distribution zoster sine herpete is reported. Electromyography (EMG) of paraspinal muscles demonstrated frequent fibrillation potentials restricted to chronically painful thoracic root segments. Treatment with intravenous acyclovir and oral famciclovir were ineffective. These findings suggest the usefulness of EMG of muscles corresponding to painful dermatomes, combined with virologic studies, to support the diagnosis of zoster sine herpete.