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

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 4: PainOropharyngeal PainOral cavity and throat pain is very common, accounting for approximately 20% of the pain syndromesencountered26 picasin one study. 8 Common sources of oral cavity pain are candidiasis; necrotizing gingivitis;and dental abscesses and ulcerations caused by herpes simplex virus (HSV), cytomegalovirus(CMV), Epstein-Barr virus (EBV), atypical and typical mycobacterial infection, cryptococcal infection,or histoplasmosis. Frequently no infectious agent can be identified and these painful recurrentaphthous ulcers (RAU) are a clinically challenging problem. 10 RAU can be controlled with topicalsteroids (mixed with Orabase), systemic steroids, and/or thalidomide. Up to 75% of patients withcutaneous Kaposi’s sarcoma (KS) also have intraoral lesions, most commonly on the palate, althoughthese seldom cause pain. 10 Finally, zalcitabine (ddC) can cause a painful stomatitis. For more information,see Chapter 8: Oral Problems.IVEsophageal PainMany HIV/AIDS patients experience dysphagia or odynophagia, most commonly caused by esophagealcandidiasis. Ulcerative esophagitis, which can be quite painful, is usually a result of CMV infectionbut can be idiopathic. Thalidomide has been used successfully in this case.Infectious causes of esophagitis include: HIV itself, papovavirus, herpes simplex, Epstein-Barr virus,mycobacteria, Cryptosporidium and Pneumocystis carinii. Kaposi’s sarcoma and lymphoma bothhave been reported to invade the esophagus resulting in dysphagia, pain and ulceration. 10 Zidovudineand zalcitibine (ddC) have been implicated in esophagitis as have been non-steroidal medications.Abdominal PainThe abdomen is the primary site of pain in 12-25% of patients with HIV disease. 6, 8, 22 Infectious causesof abdominal pain predominate, and include: cryptosporidiosis, shigella, salmonella andCampylobacter enteritis, CMV ileitis and mycobacterial infection (MAI).Perforation of the small and large intestine secondary to CMV infection has been described. 22 Repeatedintussusception of the small intestine has been seen in association with Campylobacterinfection. 23 Lymphoma in the gastrointestinal (GI) tract can present with abdominal pain and intestinalobstruction. 10, 24 Other causes of abdominal pain in HIV positive patients 10 include ileus,organomegaly, spontaneous aseptic peritonitis, toxic shock, herpes zoster, and Fitzhugh-Curtis syndrome(perihepatitis in association with tubal gonococcal or chlamydia infection).Many antiretroviral agents are responsible for GI symptoms but lactic acidosis, a rare but seriouscomplication of some HAART regimens, can present with abdominal pain. Didanosine (ddI),zalcitabine (ddC) and stavudine (d4T) can cause pancreatitis (see below) and patients taking indinivirare at increased risk for nephrolithiasis.Biliary Tract and Pancreatic PainCholecystitis is a painful condition that may occur in HIV-infected patients as a result of opportunisticinfection, with CMV and cryptosporidiosis being the most common infectious agents. Pain fromextrahepatic biliary tract obstruction secondary to KS or MAI infection has been reported. 10 Sclerosingcholangitis (CMV, cryptosporidiosis) can cause right upper quadrant or epigastric pain, andopportunistic liver infections (CMV, MAI, fungal infections) as well as drug-induced hepatic toxicities(ddI, pentamidine, ritonavir and nevarapine) are sources of hepatitis and abdominal or rightU.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 89