Page 191 Guide to Pain Management in Low-Resource Settings

Chapter 23

Painful Diabetic Neuropathy

Gaman Mohammed

Case report 1 (“neuroarthropathy”) insulin that she could also obtain at her local hospital
and was given an antibiotic with a good Gram-positive
Zipporah, a 54-year-old woman, who has had type 2 di- and -negative eff ect. She was advised to have her daily
abetes for 12 years and is on oral hypoglycemic agents, dressing done at her local clinic and not use hydrogen
came to the offi ce complaining about a history of leg peroxide solution on her injury. She was started on sim-
pains, especially at night. She regularly walks to the lo- ple analgesics (paracetamol/acetaminophen) in combi-
cal market where she sells vegetables. She has noticed nation with a weak opioid, tramadol. During follow-up
swelling on her legs over the last few months, but has no review, she was started on amitriptyline at a low dose
history of pain or trauma to the feet. Her husband Tom of 25 mg after she complained of burning sensations, es-
noted blisters on her feet a day after she had worn a new pecially at night. She was also given crutches and was
pair of sandals bought at her local market. Zipporah advised to mobilize, with partial weight bearing, for a
hadn’t felt any discomfort while wearing these sandals. month as she mentioned she had to attend to her duties
Th e blisters had burst, revealing cuts over the feet, and at the market.
her husband convinced her to seek medical attention af-
ter she unsuccessfully tried using home remedies such as Case report 2 (60-year-old
bandaging the wound with an old cloth and cleaning the diabetic male on oral
wound with salt solution.
hypoglycemic medication)
Tests revealed an elevated random blood sugar
of 15 mmol with an HbA of 11%. On visual examination Yusuf, a 60-year-old man from a coastal city, has had
she had bilateral foot edema with a septic lesion over diabetes for 6 years. He gave a history of severe burn-
both feet. Her foot pulses were present but feeble, prob- ing sensations in his feet at night, which was relieved by
ably as result of the edema. She had reduced vibration placing his feet in a bucket of water. He didn’t seek medi-
perception and pressure sensation in both feet. X-rays cal treatment for his ailment until he noted a painful
were suggestive of destruction of the talus and calcaneus swelling of his toes of the right leg, although he did not
bones in her feet. remember having had an injury to the foot. Examination
On discussion with Zipporah, she was advised revealed that the right foot was infected, and the infec-
that in view of her current poor glycemic control and foot tion had spread to the interdigital spaces. He also had
infections, insulin therapy had to be recommended to decreased vibration and pressure sensation, as tested by
control the blood sugar. She was started on twice-daily using a 10-g monofi lament and a tuning fork.
Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. Patel. IASP, Seattle, © 2010. No responsibility is assumed by IASP 179
for any injury and/or damage to persons or property as a matter of product liability, negligence, or from any use of any methods, products, instruction, or
ideas contained in the material herein. Because of the rapid advances in the medical sciences, the publisher recommends that there should be independent
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