A Case of Post-herpetic neuralgia uncontroled after Stellate Ganglion Block
A Case of Post-herpetic neuralgia uncontroled after Stellate Ganglion Block
Post-herpetic neuralgia(PHN) is a chronic pain syndrome associated with the reactivation of a primary infection with varicella zoster
virus(chinken pox), which leads to a chronic infection of dorsal root ganglia. The most common risk factor for shingles and its potential
sequela, PHN, is advanced age. For a significant number of patients, the pain following healing of shingles can persist for months to years.
If this pain, classified as PHN, persists longer than one month. PHN often leads to depression, disrupted sleep, decreased productivity, and
utilization of health care.
We treated a 60 year-old female patient who suffered pain and headache after Stellate Ganglion Blocks(SGB). In identifying points for
differentiation of syndrom(辨證), this subject was diagnosed as Yangmyeong Merdian wind-heat syndrom(陽明經風熱證) and was
administered Seungmagalgeuntanggamibang(modified Shengmagegen-tang, 升麻葛根湯加味方). To ease pain, Western medication was
administered as well. After fourteen days of treatment, pain and other symptoms improved.
II. case
1) patient : kim○○, female. 60 years old
2) diagnosis: (1) Post-herpetic neuralgia
(2) Diabetes Mellitus
3) chief complain : (1) headach (left lateral side, and forehead)
(2) itchy, eschar on the head where herpes erupt
(3) dry mouth
(4) anxiety (due to pain, always having a fear of pain)
(5) insomnia due to pain
4) on set : January. 8. 2003. → Progressed.
5) admission day : February. 6. 2003.
6) p/h : (1) DM (po-med) diagnosed in 1987.
7) f/h : nothing special
8) constitution : (1) fat, introversive charater, nervousness due to pain.
(2) no dringking, no smoking.
9) P/I : she had been hospitalized from 20030108 to 2030206 in a university hospital. During that time, she had a Stellate Ganglion Block three times and a treatement of po-med. But after Stellate Ganglion Block, she had experienced improving and progressing of the pain, but, in 20030201, the sypmtoms progressed severely, so in 20030206, she is transferred to Oriental Medicine hospital of Daejeon University. Dctor's note from the university hospital says that originaly the Stellate Ganglion Block have to be taken five times, but the patient complained of pain severey, therefore the other two times cannot be taken. And Demerol which is narcotic analgesic, is given, but the effect is not so good, so the docter gives pain killer which is lower than Demerol. Medicines cause her dizziness, so that it is hard to go toilet.
10) examination
(1) v/s : bp 140/90㎜Hg, bT 36.4℃, pulse 92/m, resperation 20/m, bst 158㎎/㎗
(2) EKG : WNL
(3) chet X-ray : WNL
(4) Lap test :
① WBC : 10,200/㎣, Platelet Count : 418,000/㎣
② u/t : suger ±
11) the first medical examination
(1) headach (left lateral side, and forehead): whenever pain comes up, she crys out with puring water over the head. (as mania)
(2) itchy, eschar on the head where herpes erupt
(3) dry mouth
(4) anxiety and insomain (due to pain, always having a fear of pain, and almost sitting in the coner of bed to pour water as soon as the pain comes up.
(5) 客症
① generalbody sign: headache, anxiety
② skin : white slightly, eschar on the head where herpes erupt
③ dry mouth, bitter taste in the mouth
④ digestion : usually it is ok, but after on set of this disease, anorexia occurs.
⑤ defecation : constipation, po-med
⑥ tongue: mild red of tongue, thin white fur in margin place of the tongue and mild yellow and thick fur in the center of tongue.
⑦ a pulse is floating and slippery
Treatment.
1) oriental Tx
① 2. 6 ~ 2. 7 : modified Long Dan Xie Gan Tang. 龍膽瀉肝湯加味
② 2. 8 ~ 2. 10 : Xian Fang he Shi Wei Tang. 仙方合十味敗毒湯
③ 2. 11 ~ 2. 19 : Sheng Ma Ge Gen Tang with Zhi Mu, Huang Bai, Man Jing Zi, and Bai Zhi. 升麻葛根湯加知母, 黃柏, 蔓荊
Form 20030206 to 20030219, 3貼 # (am 9:00, pm 2:00, 7:00) one hour after a meal.
(2) A –Tx
Gall bladder seng gyuk (膽勝格) stomach seng gyuk (胃勝格)
2. western medicine tx
(1) herpetic neuralgia : Neurotin 3T tid, Azeptin 2T bid, Hydrocobalamin 3T tid, Amitriptyline 3T tid
(2) DM : Amaryl 1T qd, Gliclazide 1T qd → 2T bid (2월 11일부터 증량됨)
(3) Constiaption : Magmil 1T qd
2. Clinical Consequence (Table 1. 2)
1) 2. 6 ~ 2. 7 (modified Long Dan Xie Gan Tang. 龍膽瀉肝湯加味):
at the time of admission, there is burning and picking pain, and itchy in the left lateral head. The pain occurs 6-10 times a day. The degree of pain is different from time to time. In severe case, she screaming with pouring cold water over the head and throwing something. She always has a fear of pain, so she would not lie down on the bed. At night, reccurent pain inhibits her sleep and she has a no desire to eat.
2) 2. 8 ~ 2. 10( Xian Fang he Shi Wei Tang. 仙方合十味敗毒湯) :
There is no improve, and whenere severe pain occurs, pain killer of Trodon 1 is injected (intramuscular. But the pain would not relieve.
3) 2. 11 ~ 2. 13 (Sheng Ma Ge Gen Tang with Zhi Mu, Huang Bai, Man Jing Zi, and Bai Zhi. 升麻葛根湯加知母, 黃柏, 蔓荊 :
Fron the after noon, febuary, 11, the frequency of pain occurring reduces to 3-4 times a day, and the degree of pain also decrease. But relatively, the itchy sign is increased. Since febuary, 13. There is no occurring of pain at night.
4) 2. 14 ~ 2. 19 : all of symptoms are improved, and intake also increases.
I was resident one in 2003. Actually I was still an intern and was about to take the job of resident. At that time, I was no confident in my skill in caring of patient. My first impression to the patient is that she looks like crazy person as mania. I want to escape from that situation. I did not know what to do. (you understand me at those times??). My superior doctor (resident 3) gave the formulas (prescriptions) : (modified Long Dan Xie Gan Tang. 龍膽瀉肝湯加味) and (Xian Fang he Shi Wei Tang. 仙方合十味敗毒湯). But unfortunately, the fomulas did not work. In spite of no improving, the patient and her family do not complain. Why not so? Of course, the pain was not improved, instead progressed even in the university hospital. So their expectation is not high. But anyway I am her chief doctor. I felt enormous stress, she sceamed out continuously a few times at night and her room is right front of doctors night duty room. I can hear her scream and complaining of an other doctors who are inhibited in sleep.
At that time, I decided to think the symptoms simply. The position of disease is in the head, in the upper burner. So I choose herbs that works in the head, high. And when a disease is in high, that should be dispersed. And pathogen is wind, damp, heat. So I choose Sheng Ma Ge Gen Tang with Zhi Mu, Huang Bai, Man Jing Zi, and Bai Zhi. It works. At that time I was realy happy to find that my thinking is not wrong.
In my opinion, Long Dan Xie Gan Tang and Xian Fang he Shi Wei Tang also treate wind, damp, and heat, but the position of pathogen is not matched with those formula. Those two formula little bit tend to work in the middle.