Presented at the 2013 AAPM Annual Meeting « Back

Critical Illness Polyneuropathy with Refractory Pain: An Unusual Case Presentation

Jon Mader, MD, jonmader@gmail.com¹, Sanaz N. Soltani, MD², Tamara Kollarova, MD³, (1) Tufts Medical Center, Malden, Massachusetts, (2) Geisinger Medical Center, Danville, Pennsylvania (3) Tufts Medical Center, Boston, Massachusetts

Introduction: Critical Illness Polyneuropathy (CIP) is a complication that often affects both motor and sensory axons of peripheral nerves. Risk factors include multi-organ system failure, sepsis, and prolonged ICU courses. Clinical features may comprise of flaccid weakness, loss of reflexes, and impaired sensation. Typically, paraesthesias and pain are not a component of CIP. Case Report: A 53-year-old male presented to our rehabilitation facility after revision of left sided femoral-popliteal bypass complicated by a prolonged ICU course resulting in bilateral foot drop. Evaluation revealed diminished sensation with complete paralysis of ankle plantar-flexion, dorsiflexion, and inversion/eversion of both feet. Lab workup and imaging were unrevealing. EMG showed profound sensorimotor axonal polyneuropathy and denervation. Given his recent ICU course, EMG findings, and otherwise unremarkable lab/imaging workup he was diagnosed with CIP. With the onset of physical therapy he began complaining of intense 8/10 burning pain in both feet. Pain was refractory to treatments with Gabapentin and Pregabalin. Minor improvement was seen with long-acting and short-acting opioids. Ultimately, pain showed dramatic improvement with initiation of Duloxetine in combination with a long acting opioid, topical Capsasin rub, and Tramadol. Conclusions: There is no known literature that could be found by this author illustrating pain management recommendations for CIP. This may be due to the fact that pain and paraesthesias are not typically associated with this condition. The most effective analgesic treatment in this unusual presentation was a combination of Duloxetine, long acting opioids, and Tramadol. References: 1) Hermans G, De Jonghe B, Bruyninckx F, Van der Berghe G: Clinical review: critical illness polyneuropathy and myopathy. Critical Care 2008, 12:238 2) Vijayan J, Alexander M. Critical illness neuropathy. Indian J Crit Care Med 2005;9:32-4 3) Visser, L. H, Critical illness polyneuropathy and myopathy: clinical features, risk factors and prognosis. European Journal of Neurology 2006; 13: 1203–1212 4) Bolton CF, Gilbert JJ, Hahn AF, et al. Polyneuropathy in critically ill patients. J Neurol Neurosurg Psychiatry 1984;47:1223–31.

Funding: None