A 68-year-old woman comes to the office due to persistent right-sided chest pain. The patient has had burning pain on the right chest wall and back for the past several months. She has had no associated cough, dyspnea, or trauma but had a transient rash in the same region prior to the onset of symptoms. Medical history is notable for breast cancer treated with surgery and chemotherapy, as well as hypertension and type 2 diabetes mellitus. Temperature is 37.1 C (98.8 F), blood pressure is 130/80 mm Hg, and pulse is 82/min. Chest examination shows no skin rash, but there is a band-like area of hyperesthesia on the right side. Lung auscultation reveals prolonged expiration with no wheezes. Heart sounds are normal. Back examination shows no deformity or focal tenderness. Which of the following is the best next step in management of this patient?

Question

A 68-year-old woman comes to the office due to persistent right-sided chest pain.  The patient has had burning pain on the right chest wall and back for the past several months.  She has had no associated cough, dyspnea, or trauma but had a transient rash in the same region prior to the onset of symptoms.  Medical history is notable for breast cancer treated with surgery and chemotherapy, as well as hypertension and type 2 diabetes mellitus.  Temperature is 37.1 C (98.8 F), blood pressure is 130/80 mm Hg, and pulse is 82/min.  Chest examination shows no skin rash, but there is a band-like area of hyperesthesia on the right side.  Lung auscultation reveals prolonged expiration with no wheezes.  Heart sounds are normal.  Back examination shows no deformity or focal tenderness.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d54a_83ef_bc81_e30e5e52206c_MD0003_00 This patient had a self-limited rash on the trunk (likely herpes zoster) and now has continued burning pain and hyperesthesia in the area of the rash, suggesting postherpetic neuralgia (PHN). Acute zoster (shingles) is due to reactivation of the varicella zoster virus (VZV) and causes transient pain due to hemorrhagic inflammation of the sensory nerve. As viral replication diminishes, the skin lesions resolve and the pain typically fades; however, persistent pain for >4 months indicates PHN. PHN occurs in approximately 5% of patients with shingles. The risk is greatest in those with advanced age, severe initial pain, or severe rash. The pain may be constant or intermittent and is typically associated with allodynia (pain elicited by nonpainful stimuli [eg, light touch]). Physical examination often reveals sensory abnormalities (eg, anesthesia, hyperesthesia) in the affected dermatome. PHN often improves over time, but resolution may take years and the severity of pain usually warrants pharmacologic treatment. Anticonvulsants (primarily gabapentin and pregabalin) and tricyclic antidepressants (eg, amitriptyline) are the best-established drugs. Topical capsaicin and lidocaine are options for patients with mild to moderate pain. Opioids (eg, oxycodone) are also effective but are not preferred due to the expected duration of treatment and potential for dependence and abuse. (Choice B) Systemic glucocorticoids (eg, prednisone) may decrease the pain of acute shingles but are not useful in prevention or treatment of PHN. Rarely, intrathecal glucorticoid therapy may be considered for patients with severe, refractory PHN symptoms. (Choice C) MRI is useful to evaluate radiculopathy, which can cause burning pain in a dermatomal distribution but is significantly less common in the thoracic spine than in other spine segments. The diagnosis of PHN is based primarily on the temporal relation between the dermatomal rash and the subsequent pain; imaging is not usually helpful. (Choice D) Chest x-ray may identify a pleural effusion due to pleuritis or pleural metastases, which could cause chest pain. However, this patient has no cough, dyspnea, or examination findings (eg, asymmetrical breath sounds) to suggest an effusion, and her burning pain, hyperesthesia, and rash history are more consistent with PHN. VZV pneumonia (due to viral spread) can occur but typically presents at around the same time as the rash and is associated with respiratory symptoms. (Choice E) Antiviral therapy (eg, valacyclovir) can shorten the course of acute shingles and reduce the risk of PHN. However, PHN is not associated with ongoing viral replication, and antiviral therapy has no benefits. Educational objective: Postherpetic neuralgia is characterized by burning pain and hyperesthesia lasting >4 months following acute zoster. The risk is greatest in those with advanced age, severe initial pain, or severe rash. First-line treatment includes anticonvulsants (eg, gabapentin) and tricyclic antidepressants (eg, amitriptyline). References: Gabapentin for chronic neuropathic pain in adults. (http://www.ncbi.nlm.nih.gov/pubmed/28597471)

A 68-Year-Old Woman Comes to the Office Due to Persistent