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

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A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 4: Pain• Viral and non-viral infectious processes (mononeuritis multiplex, including polyneuritiscranialis, polyradiculopathy of the lower limbs, cauda equina syndrome and plexopathiescaused by CMV, herpes zoster, MAI)26 picas• Immune-mediated inflammatory demyelination (acute and chronic Guillain-Barrésyndrome)• A variety of medical conditions (diabetic neuropathy, post-herpetic neuralgia, entrapmentneuropathies)• Nutritional deficiencies (B 6 , B 12 )• Toxins (alcohol)• HIV-related therapies (e.g., ddI [didanosine], ddC [zalcitabine])Several antiretroviral drugs can cause painful toxic neuropathy, including the following:• ddI (didanosine), ddC (zalcitabine), d4T (stavudine)• Chemotherapy agents used to treat Kaposi’s sarcoma (vincristine)• A number of medications used in the treatment of PCP, MAI, and other HIV-associated10, 28, 29infectionsTable 4-4: Neuropathies in Patients with HIV/AIDSPredominantly SensoryNeuropathy (PSN) of AIDSIMMUNE-MEDIATED:• Inflammatory demyelinating polyneuropathies(IDPs)• Acute (Guillain-Barré syndrome)• Chronic (CIDP)INFECTIOUS:• Cytomegalovirus polyradiculopathy• Cytomegalovirus multiple mononeuropathy• Herpes zoster• Mycobacterial (MAI)TOXIC/NUTRITIONAL: • Alcohol, Vitamin deficiencies (B 6, B12)• Antiretrovirals: ddI (didanosine), ddC (zalcitabine),d4T (stavudine)• Anti-virals: foscarnet• PCP prophylaxis: dapsone• Anti-bacterial: metronidazole• Anti-mycobacterials: INH (isoniazid), rifampin,ethionamide• Anti-neoplastics: vincristine, vinblastineOTHER MEDICAL CONDITIONS: • Diabetic neuropathy• Post-herpetic neuralgia92U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau
A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 4: Pain• Predominantly Sensory Neuropathy (PSN) of AIDSThe most frequently encountered neuropathy is a symmetrical predominantly sensory painful peripheralneuropathy.26 picasThis is typically a late manifestation, occurring most often in patients with anAIDS-defining illness. 30 The prevalence of this neuropathy in hospice populations ranges from 19%17, 31, 32to 26%.The predominant symptom in about 60% of patients is pain in the soles of the feet. Paraesthesia isfrequent and usually involves the dorsum of the feet and soles. Most patients have signs of peripheralneuropathy (most commonly, absent or reduced ankle jerks and elevated thresholds to pain and30, 33,vibration sense); and, while the signs progress, the symptoms often remain confined to the feet.34Although the patients’ complaints are predominantly sensory, electrophysiological studies demonstrateboth sensory and motor involvement.IV• Immune-mediated NeuropathiesAcute Guillain-Barré syndrome has been described in association with seroconversion (group-Iinfection) but may occur at any time. Both acute and chronic inflammatory demyelinatingpolyneuropathies are predominantly motor-related, and sensory abnormalities are rare. 35Mononeuritis multiplex presents with sensory or motor deficits in the distribution of multiple spinal,cranial or peripheral nerves and may progress into a chronic inflammatory demyelinating35, 36polyneuropathy.• Infectious NeuropathiesPolyradiculopathies (associated with CMV infection) often present with radicular pain and followa distinct course. 37 The onset is usually subacute and the deficit initially confined to sacral andlumbar nerve roots. Both sensory and motor functions are involved, and there is usually early involvementof sphincters. Progression is relentless. 35Harrison and colleagues identified three variables related to herpes zoster pain: extent of lesionhealing; extension of lesion crusting; and the number of new vesicles. 38 According to their study, thesignificance of baseline pain due to herpes zoster was a predictor of return to daily life functioning.Furthermore, the significance of pain at presentation and at one month was a significant predictorof chronic pain. 38• Toxic/nutritional NeuropathiesToxic and nutritional neuropathies in patients with HIV disease have been reported with the following:29, 33• Alcohol• Vitamin deficiencies (B 6 , B 12 )• Antiretroviral drugs: ddI (didanosine), ddC (zalcitabine), d4T (stavudine)• Anti-virals: foscarnet• PCP prophylaxis: dapsone• Anti-bacterial drugs: metronidazole• Anti-mycobacterial drugs: INH, rifampin, ethionamide• Anti-neoplastics: vincristine, vinblastineU.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 93
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DedicationA Clinical Guide to Suppo
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Lynn A Jansen, RN, PhDAssistant Res
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TABLE OF CONTENTSPart IChapter 1Cha
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IChapter 1.26 picasHIV and Palliati
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IA Clinical Guide to Supportive and
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A Clinical Guide to Supportive and
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IIIChapter 3.Assessment of Physical
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Chapter 8.26 picasOral ProblemsDavi
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Chapter 9.26 picasDermatologic Prob
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Chapter 11.26 picas Substance Use P
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Chapter 14.26 picasCulture and Care
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Chapter 15.26 picasSpecial Populati
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Chapter 17.26 picasEthical IssuesLy
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Chapter 18.26 picasLegal and Financ
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Chapter 19.Palliative 26 picas Care
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Chapter 25.26 picas Prevention of S
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Chapter 26.26 picasResourcesMagda B
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DRUGS AND THERAPIES INDEXNOTES: Ent
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