Page 214 Guide to Pain Management in Low-Resource Settings

202 Glenda E. Gray et al.

Case report 4 (“postherpetic What complications of zoster are more
neuralgia”) common in immune-compromised individuals?
Extensive skin involvement, disseminated disease,
A 44-year-old HIV-positive man, compliant and stable pneumonitis, ocular involvement, meningoencepha-
on antiretroviral therapy for 3 years, complains of sud- litis, myelitis, and involvement of cranial nerves have
den-onset fatigue and severe pain in his left shoulder. been described.
He describes the pain as the worst pain he has ever felt,
with a burning quality, waking him up from his sleep,
Case report 5 (“cryptococcal
worse with movement of the left shoulder, causing him to
break out into a sweat and incapacitating him. He has meningitis”)
no history of trauma. He recalls experiencing a mild fl u-
An 18-year-old, pregnant, HIV-infected woman with
like illness 1 week ago. His daughter was ill recently with 6
baseline CD4 count of 38 × 10 /L and viral load
chicken pox. On examination of the skin, two vesicles are
>500,000 copies/mL has been receiving stavudine/la-
found at the tip of the left shoulder, and the pain extends
mivudine/nevirapine for 3 weeks. She now presents
unilaterally in a dermatomal distribution. Oral valacy-
with a 7-day history of headache, described as mild,
clovir, a combination paracetamol (acetaminophen)-co-
initially, but worsening with time, persistent, stabbing,
deine tablet, and ibuprofen, were initiated.
no longer responsive to paracetamol, exacerbated by
movement and associated with photophobia and vom-
What treatments may be used to alleviate the
pain and itchiness of zoster rash? iting. On examination, she is mildly pyrexial, fully
awake, alert and oriented but restless. Five papular
Th is condition is extremely painful, and analgesic use
skin lesions measuring 2 mm in diameter have been
should be liberal. Topical calamine lotion and water
noted below the lower right eyelid since prior to antiret-
dressings may help relieve the itchiness. Paracetamol,
roviral induction, which were thought to be molluscum
ibuprofen, and dihydrocodeine will be necessary as well.
contagiosum. She displays neither focal neurological
Secondary infection of the blisters may occur and may
defi cits nor papilledema. Serum cryptococcal antigen
exacerbate pain, and so should be treated with antibiot-
is positive, and cerebrospinal fl uid results are as fol-
ics and a topical agent such as chloramphenicol, tetra-
lows: opening pressure 20 cm H O, slightly turbid fl uid,
cycline, or gentian violet. Th ere is some evidence that 2
CSF-protein 0.5 g/L, CSF: serum glucose 40%, chloride
corticosteroid use with acyclovir decreases acute pain,
125 mmol/L, acellular, Gram stain negative, CSF-
but steroids should be used with caution, especially in
cryptococcal latex agglutination test positive, India ink
immune-compromised patients.
positive. Skin biopsy results culture Cryptococcus neo-
formans. Intravenous amphotericin B and oral dihy-
How can one manage the pain
of postherpetic neuralgia? drocodeine were given, and the patient reports complete
pain relief by the third day of treatment.
Amitryptiline and carbamazepine should be considered
for postherpetic neuralgia. Carbamazepine has drug in- Which signs will alert the clinician to raised
teractions with antiretrovirals and should be used with intracranial pressure in a patient with
caution. Consider the use of pregabalin, a new drug in cryptococcal meningitis?
the anticonvulsant class, for postherpetic neuralgia pa- Focal neurological defi cits. Transient loss in visual acu-
tients who are not responding to tricyclic antidepres- ity, diplopia, hearing loss, confusion, and papilledema.
sants, gabapentin, and other analgesics. Th e initial
dose of pregabalin is 75 mg b.i.d., but the dose may be How should one manage and treat patients with
increased to 150 mg b.i.d. after three days. Pregabalin raised intracranial pressure >25 cm H O?
2
would require dose adjustment if creatinine clearance To avoid herniation, prior to lumbar puncture, a CT
is below 60 mL/min. Dizziness and somnolence has or MRI scan of the brain should exclude mass eff ect.
been reported frequently with pregabalin, and we sug- Drainage of small amounts of cerebrospinal fl uid daily
gest care when coadministering the drug with efavi- for a maximum of 2 weeks, with monitoring of pres-
renz, which has similar side eff ects in the initial weeks sure, usually improves headache and other symptoms
of treatment. associated with cryptococcal meningitis. After 2 weeks,