Brazilian Journal of Pain
https://brjp.org.br/article/doi/10.5935/2595-0118.20220041-en
Brazilian Journal of Pain
Case Report

Epidural morphine for chronic pain in a patient with peripheral neuropathy and DRESS syndrome. Case report

Morfina peridural para tratamento de dor crônica em paciente com polineuropatia periférica e síndrome DRESS. Relato de caso

Julie Azevedo Araújo Valente; Bárbara Caroline Siqueira; Marcelo de Jesus Martins; Antonio Argolo Sampaio Filho

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Abstract

BACKGROUND AND OBJECTIVES: Peripheral neuropathy is a rare condition with many etiologies. Common symptoms are numbness, paresthesia, weakness and neuropathic pain. Treatment consists in frst-line agents such as anticonvulsants and some antidepressants. Te aim of this study was to report a case of chronic pain refractory to several therapies in a patient with absolute contraindication to the use of all anticonvulsants and antidepressants drugs.

CASE REPORT: Female patient, a 40-year-old treated for trigeminal neuralgia with decompression that developed chronic occipital pain refractory to radiofrequency and onset of transient and bilateral T4 sensory and motor polyneuropathy after viral meningitis. In addition, she showed a severe pharmacodermy (Drug Rash with Eosinophilia and Systemic Symptoms- DRESS Syndrome) after using carbamazepine and other anticonvulsants, as well as allergy to all analgesics and opioids except morphine. Epidural puncture with insertion of a catheter was performed aiming at a 5-day test through intermittent epidural morphine bolus to assess the possibility of morphine pump implantation.

CONCLUSION: The test was successful and the patient referred to the neurosurgery team. At the 6-month follow-up after the insertion of the morphine intrathecal pump, the strategy has proven to be efective in controlling pain secondary to polyneuropathy.

HIGHLIGHTS

  • A case report of a patient with a rare and potentially fatal allergic condition, the DRESS Syndrome, and refractory peripheral neuropathy;
  • Morphine via epidural and later subarachnoid was used with satisfactory pain control, a treatment that is not considered first-line;
  • Discussion of the mechanism of action of epidural and subarachnoid opioids in neuropathies.

Keywords

Analgesia, Drug hypersensitivity, Epidural, Morphine, Peripheral nervous system diseases, Syndrome, Trigeminal neuralgia

Resumo

JUSTIFICATIVA E OBJETIVOS: Neuropatia periférica é uma condição rara, de etiologia multifatorial. Dormência, parestesia, redução de força muscular e dor neuropática são sintomas comuns. O tratamento consiste em uso de anticonvulsivantes e antidepressivos. O objetivo deste estudo foi relatar o caso de dor crônica refratária a diversas terapias de uma paciente com contraindicação absoluta para uso de todos os fármacos anticonvulsivantes e antidepressivos.

RELATO DO CASO: Paciente do sexo feminino, 40 anos, com história de neuralgia do trigêmeo abordada previamente com cirurgia, com cefaleia occipital crônica refratária à radiofrequência e polineuropatia bilateral T4 sensorial e motora após meningite viral. No curso do tratamento, apresentou grave farmacodermia (Drug Rash with Eosinophilia and Systemic Symptoms - Síndrome DRESS) após o uso de carbamazepina e outros anticonvulsivantes, além de reação alérgica a todos analgésicos e opioides, exceto morfina. Optou-se por analgesia teste por via peridural, durante 5 dias, com bolus intermitentes e diários de morfina para avaliação de possibilidade de implante de bomba de morfina.

CONCLUSÃO: O teste foi considerado bem-sucedido e a paciente encaminhada para neurocirurgia. No seguimento de 6 meses após implante de bomba por via subaracnoidea, esta estratégia se mostrou eficaz no controle da dor secundária à polineuropatia.

DESTAQUES

  • Trata-se de relato de caso de uma paciente portadora de quadro alérgico raro e potencialmente fatal, a Síndrome DRESS, e neuropatia periférica refratária; 
  • Morfina por via peridural e posteriormente por via subaracnoidea foi utilizada com controle satisfatório da dor, um tratamento não considerado de primeira linha;
  • Discussão sobre o mecanismo de ação de opioides por via peridural e subaracnoidea em neuropatias. 

Palavras-chave

Analgesia, Hipersensibilidade, Morfina, Neuralgia do trigêmeo, Peridural, Polineuropatias, Trigeminal neuralgia

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Submitted date:
01/25/2022

Accepted date:
09/13/2022

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