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A 72-year-old man comes to the clinic complaining of 3 days of severe back pain. He was seen yesterday in the emergency department and was sent home with acetaminophen and advised to avoid any strenuous activity. Despite following this advice, he continues to have back pain, and now wishes to have a second opinion. The pain is located in the right lower lumbar region and is described as a sharp, stabbing pain. The pain is constant and not worsened with movement or recumbency. He denies any known trauma or strain, but does describe some recent low-grade fevers that have resolved with acetaminophen, and diffuse myalgias in the days preceding his back pain. The patient is concerned, for although he has a history of severe osteoporosis, he has never had any lumbar pain before. His medical history, in addition to osteoporosis, includes noninsulin-dependent diabetes mellitus diagnosed 2 years ago and glaucoma. Vital signs are: temperature 38.3 C (101.0 F), blood pressure 138/88 mm Hg, pulse 98/min, and respirations 20/min. Examination of the patient™s back reveals no focal tenderness (though the patient is in obvious pain), but does show three to four small, grouped vesicles in the right paraspinal lumbar region. The patient is surprised by the lesions and is fairly certain that they were not present the previous day. Which of the following is the most appropriate treatment at this time?
A. Admission for intravenous antibiotics
B. High-dose ibuprofen around the clock
C. Oral acyclovir and oral prednisone
D. Oral famciclovir and desipramine
E. Rest, ice, supportive therapy, and reassurance
Posts: 3,675,937
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Posts: 3,675,937
Threads: 734,344
Joined: Sep 2021
Reputation:
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Posts: 3,675,937
Threads: 734,344
Joined: Sep 2021
Reputation:
5
Posts: 3,675,937
Threads: 734,344
Joined: Sep 2021
Reputation:
5
The correct answer is D. This patient has herpes zoster, which can manifest as back pain, rash, and fever. The pain, often severe and described as œsharp and stabbing or œburning, can precede the skin lesions and can persist long after the lesions have healed, a condition known as postherpetic neuralgia. The treatment of choice for such patients is an antiviral agent, such as acyclovir, famciclovir, or valacyclovir, administered within 72 hours of the rash. Patients with significant pain also should be started on an agent that can minimize neuropathic pain, such as a tricyclic antidepressant (TCA). Desipramine has the lowest incidence of side effects among the TCAs. If the patient does not have any relative contraindications to steroids, such as diabetes, osteoporosis, or glaucoma, then oral steroids in addition to antivirals and TCAs are recommended (choice C) to reduce the duration of active zoster.
There is no indication for intravenous antibiotics (choice A). This patient™s fever is a common manifestation of a reactivation of dormant varicella-zoster virus that requires antivirals, not antibiotics.
High-dose ibuprofen (choice B) is poorly effective at controlling neuropathic pain. As this patient™s back pain is more likely neuropathic than inflammatory (which would be seen, for example, with trauma, strain, or repetitive use injuries), this medication choice is unlikely to be helpful. Further, high-dose nonsteroidal anti-inflammatory medications need to be used cautiously in elderly patients, given the risk for gastritis and renal damage.
Rest, ice, supportive therapy, and reassurance (choice E) will not adequately treat this patient™s pain. Further, untreated, this patient is more likely to develop postherpetic neuralgia, which can be extremely difficult to treat.
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