Page 195 Guide to Pain Management in Low-Resource Settings

Chapter 24
Management of Postherpetic Neuralgia

Maged El-Ansary

Case report be called postherpetic neuralgia. Th is has a therapeutic
consequence because spontaneous remission of pain be-
As a general practitioner, you receive a 75-year-old male comes more unlikely after this period of time. Th erapeu-
patient with a history of diabetes mellitus. He has had tic eff orts should be increased if pain lasts longer than a
bronchogenic carcinoma and is currently on chemo- couple of weeks.
therapy. He has pain in the left side of the chest along the
distribution of the 5th, 6th, and 7th intercostal nerves.
What is your possible diagnosis? Is acute pain a predictor of an
Th e possibilities are myositis, coronary ischemia, outcome of postherpetic neuralgia?

left-sided pleurisy, fractured ribs, itching due to skin al-
Unfortunately, there are no accepted and validated fac-
lergy or drug eruption or other causes, such as the pre-
tors for predicting the severity and duration of pain af-
eruptive stage of acute herpes zoster.
ter herpes infections. Pain may be almost or completely
absent in patients who develop PHN. But for the elderly,
Why is postherpetic neuralgia as pain can start before the skin changes, hemorrhagic
diffi cult to treat? effl orescence and a location outside the trunk might in-

dicate a high-risk patient.
Postherpetic neuralgia (PHN) is known to be one of the
most resistant chronic pain problems. It is classifi ed as a
neuropathic pain state. Th e signifi cance is that the pain Are pain management and antiviral
is coming from nerve lesions due to viral infections at therapy suffi cient to treat a patient
the site of spinal nerve roots.
with herpes zoster?
Not only pain fi bers of the nerve but also sym-
pathetic and tactile fi bers, and in rare occasions motor It is wise to summarize acute herpes zoster as a sign of
fi bers, may be involved in the syndrome. Remember: an alarmingly low level of immunity. It should be known
you can only make a diagnosis if you undress your pa- that acute herpes zoster and PHN could indicate a wide
tient and look at the site of pain. range of underlying diseases. In many regions of the
world, the fi rst diseases to consider underlying shin-
When is pain after herpes zoster gles are immune-compromised diseases such as HIV/
called postherpetic neuralgia? AIDS and/or malnutrition. Early use of antiviral drugs
and pain treatment in the early stages of the acute her-
Most experts agree that pain lasting longer than 3 pes zoster will have an impact on the course of an acute
months after an acute herpes infection (“shingles”) should attack and the possibility of lowering the incidence of
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 183
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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recommendation by the editors, authors, or IASP in favor of other medical products or procedures that are not covered in the text.