Page 212 Guide to Pain Management in Low-Resource Settings

200 Glenda E. Gray et al.

saw that she was losing weight rapidly over a period of Th ree days later, her temperature has settled, her consti-
a few months, they decided she needed to be tested for tutional symptoms have improved, her abdominal pain
HIV as well. At the local clinic Abigail and her aunt had is much better, and she is back to her usual self and able
pre-test counseling together as it was felt she was mature to be discharged home.
enough to understand the implications of the test and to
give consent herself. When the results were available they What are some possible contributing factors
to her pain?
were given to Abigail alone without her aunt present. No
post-test counseling was done, and Abigail was simply 1) Intra-abdominal pathology: splenic tuberculosis.
told that she needed to go to the clinic as she was HIV It is also likely that with splenic involvement, there was
positive and needed treatment. also further lymphatic involvement. Tuberculosis of
At the fi rst visit, Abigail, is clearly disturbed by the mesenteric lymph nodes could cause partial bowel
the diagnosis. She is a bright child who obviously under- obstruction, resulting in the signs of peritonitis found
stands the meaning of the diagnosis and is hence some- on examination.
what reserved and noticeably scared—worried about 2) “Referred” pain. After 4 weeks of coughing and in
her future, scared of rejection, her whole life upturned. the face of disease-induced malnutrition, the patient’s
She has had a chronic cough for more than 4 weeks and diaphragm and accessory respiratory muscles have been
is wasted, listless, and in respiratory distress, with a sorely overexerted. Her abdomen may be tender due to
temperature of 40°C. A chest X-ray reveals a bilateral the prolonged muscular strain.
patchy infi ltrate. She clearly requires hospital admis- 3) “Psychological” pain. Children, particularly
sion but is reluctant as she is afraid of leaving the care younger children, often present with generalized or
of her aunts and of being abandoned in the hospital. Her nonspecifi c abdominal pain without any apparent pa-
aunts reassure her of their love, and the doctor assures thology. Th e pain may often simply be a sign of emo-
her that it is necessary and in her best interest, and she tional distress (although, of course, physical pathology
fi nally agrees. must fi rst be excluded). Caution must be exercised to
She is admitted with a diagnosis of community- diff erentiate real pain and peritonism from psychologi-
acquired pneumonia and is started on intravenous an- cal pain. Often by distracting the patient with conver-
tibiotics. Her CD4 count is 4. On admission it is also sation and questions or, for younger children, toys or
noted that she has severe abdominal pain. Th e ward doc- mobiles, you will be able to elicit whether or not the
tors note that the pain is generalized, with some appar- pain is real. Real pain will cause a grimace and even an
ent rebound tenderness, and order an abdominal X-ray interruption in the conversation. Peritonism will result
and serum lipase level. Th ey start her on tilidine drops in obvious rebound tenderness in spite of the distrac-
(an oral opioid analgesic) to be given 6-hourly. Investiga- tion. Purely psychological pain (or even feigned pain)
tions prove normal, but her tenderness does not seem to will result in no obvious signs of tenderness during the
improve. In the meantime, her condition appears to be examination while the child is distracted.
worsening. She appears weaker and more tired than ever.
Due to her deteriorating condition, Abigail is What are some possible reasons for the
deterioration in the patient’s condition?
seen by a palliative care specialist. She recommends
that the tilidine be changed to paracetamol (acetamino- 1) Incorrect diagnosis with worsening of her oppor-
phen) and codeine (a weak opioid with much less seda- tunistic infection. Th is child had several symptoms that
tive eff ect.) She also arranges for Abigail to be seen by her should have alerted the clinicians to the strong possibil-
team’s psychologist when she is more lucid. In the mean- ity of tuberculosis. She had a chronic productive cough,
time her temperature and symptoms are still not con- an unresponsive fever, and signifi cant weight loss with
trolled, despite various diff erent intravenous antibiotics suspicious chest radiograph changes. With a CD4 count
including tazobactam, amikacin, and even imipenem. of 4, the likelihood of TB and especially disseminated
Sputum results are delayed due to a backlog at the labo- TB was very strong.
ratory, and the cause for abdominal tenderness still has 2) New nosocomial (i.e., hospital-acquired) infec-
not been found. An abdominal ultrasound is ordered, tion. While this is often the cause of deterioration in
which shows splenic microabscesses. She is diagnosed severely immunocompromised in-hospital patients, it
with disseminated TB and started on TB treatment. was unlikely in view of the lack of positive specimen