The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 4: Painupper quadrant pain. 25 Viral hepatitis (especially hepatitis B or C) is an increasingly common coinfectionand cause of hepatic pain.Pancreatitis,26 picasan extremely painful condition, is often related to adverse effects of HIV-related therapies,in particular didanosine (ddI), stavudine (d4T) and dideoxycytidine (ddC). Intravenous pentamidineis also associated with pancreatitis. Other causes of pancreatitis include CMV infection, MAIinfection, cryptococcal lymphoma and KS.Anorectal PainPainful anorectal diseases are often caused by perirectal abscesses, CMV proctitis, fissure-in-ano,and HPV and HSV infection.Chest Pain SyndromesChest pain is a common complaint in patients with HIV disease, comprising approximately 13%of the pain syndromes encountered in a sample of ambulatory AIDS patients. 6 Sources of chest painin patients with HIV disease are similar to those encountered in the general population, i.e., cardiac,esophageal, lung and pleura, and chest wall. However, the etiologies may be somewhat unique, i.e.,opportunistic infections and cancers. The index of suspicion for coronary artery disease, even inyoung patients with no other risk factors, must be high if the patient is being treated with HAART.In immunosuppressed patients, infectious causes of chest pain should be considered, particularly inthe presence of fever and some localizing sign such as dysphagia, dyspnea, or cough. Infectiouscauses of chest pain include the following:• Pneumocystis pneumonia (with or without a pneumothorax)• Esophagitis (CMV, candidiasis, herpes simplex)• Pleuritis/pericarditis (viral, bacterial, tuberculous)• Post-herpetic neuralgiaOpportunistic cancers (KS, lymphoma) invading the esophagus, pericardium, chest wall, lung andpleura may also be sources of chest pain. Rarely, pulmonary embolus or bacterial endocarditis may bethe cause of chest pain.For more information, see Chapter 6: Pulmonary Symptoms.Neurological Pain SyndromesPain syndromes originating in the nervous system include headache, painful peripheral neuropathies,radiculopathies, and myelopathies.The HIV virus is highly neurotropic, invading central and peripheral nervous system structures earlyin the course of HIV disease. Consequently, many complications of HIV/AIDS and opportunisticinfections result in neurological pain, and many commonly used HIV/AIDS medications can also beimplicated in neurological pain.Rarely, cerebrovascular events (e.g., thalamic stroke) occurring in hypercoagulable states can resultin central pain syndromes.90U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau