Page 210 Guide to Pain Management in Low-Resource Settings

198 Glenda E. Gray et al.

important to look at the package inserts of the antiret- be an NSAID, for example diclofenac suppositories, but
roviral drugs that are being prescribed to assess side ef- children who are in this amount of pain will most likely
fects and drug interactions. need admission for intravenous (i.v.) fl uids and parenter-
al analgesia in addition to i.v. fl uconazole.
What is the most likely cause of swallowing One week later, the mother reports that that her
disorder, and how can you manage it?
child shows weakness, but the oral sores have resolved
Esophageal candidiasis is the most likely diagnosis and and there are no new complaints. Th e child’s baseline
should be suspected on the basis of a history of diffi cul- blood work reveals no contraindications to antiretroviral
ty in feeding and the presence of extensive thrush into therapy, so she is started on stavudine, lamivudine, and
the oropharynx. lopinavir/ritonavir.
While mild oral candidiasis may respond well to
topical therapy, the effi cacy of Mycostatin drops is large- Case report 1 (cont.)
ly dependent on the length of time that the medication
remains in contact with the lesions. It is important to Four weeks after initiating HAART, the mother com-
explain to mothers that they need to try and remove plains that her baby has developed a lump under her
the thick plaques that form and then apply the drops di- right arm but is otherwise well. Examination reveals a
rectly to the lesions (giving the drops as one would give 4-cm mobile mass in her right axilla. Th e baby is clearly
a syrup). Allowing the baby to swallow it quickly will miserable and cries on examination of the lesion. A new
prove ineff ective. Th is procedure should be repeated at workup to exclude TB is started, but a working diagno-
least 4 times per day. Alternatively, one could prescribe sis of BCG-related immune reconstitution infl ammatory
a gel formulation like Daktarin oral gel, which will ad- syndrome (IRIS) is made.
here to the aff ected areas. Th e TB workup proves negative, so a decision is
Severe oral candidiasis and esophageal candi- made to await the results of specimen culture before con-
diasis will not respond to topical therapy. Th is is often a sidering TB treatment. Th e node continues to enlarge,
severely painful condition, and it is often present in in- causing further discomfort to the baby, and eventually it
fants and toddlers, causing loss of appetite or diffi culty becomes red, hot, and fl uctuant. Th e child is referred to
in feeding. Systemic therapy is required, and the fi rst- the pediatric surgery department for incision and drain-
line drug of choice is fl uconazole. Th e decision needs age of the node, and a course of oral prednisone is started.
to be made whether the child will need to receive fl uco Th e surgeons then duly perform an incision and drain-
needs to nazole intravenously, thus requiring hospital age (I&D) in the outpatient department. Th e baby is se-
admission and possible separation from her mother, or dated with valerian syrup and is also given a dose of
whether the child can tolerate it orally. A child who is paracetamol (acetaminophen) prior to the procedure. Six-
still taking in some oral feeds will often be able to tol- hourly paracetamol is prescribed for analgesia at home.
erate treatment orally. Of course, esophageal candidiasis Th e node improves, somewhat, following I&D
is a CDC (Centers for Disease Control and Prevention) and prednisone, but two new areas of fl uctuation develop
category C (“severely symptomatic”) diagnosis, and later on. Th e lesions are aspirated in the consulting rooms
highly active antiretroviral therapy (HAART) is also an under the same sedation and analgesia as before. Th e re-
important part of the treatment. sults of the sputum test and fi ne needle aspiration (FNA)
As mentioned above, this condition can be ex- fi nally show that the sputum is negative for TB, and the
tremely painful, and analgesia should also be prescribed FNA reveals Mycobacterium bovis as the causative agent.
for this patient. According to the WHO analgesic ladder, No TB treatment is started, HAART is continued, and
one could begin with oral paracetamol (acetaminophen) the baby receives a total of 6 weeks of prednisone. No
syrup if the patient is able to take oral medication or else further procedures are required, and the node improves
paracetamol suppositories. Th is drug can be safely and slowly over time, with resolution after 1 year of HAART.
easily administered 6-hourly in children. It is often useful
to advise the mothers to try to give the dose 30 minutes What other options were available for
before a scheduled feed so that the maximum effi cacy is manag the initial axillary abscess?
reached at the feed time, reducing pain on swallowing. 1) Conservative. Th is is not an advisable option
If this therapy proves inadequate, the next step would as the pus will need to be drained, and if a controlled