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Hi. My name is Dr. Charles Argoff, Professor of Neurology and Director of the Comprehensive Pain Center at Albany Medical College and Albany Medical Center in Albany, New York. Today, I would like to discuss an interesting patient presentation that I hope will increase awareness of the importance of being vigilant about a diagnosis.
Simply having a diagnosis can significantly help patients with chronic pain understand what they are experiencing and even lessen their pain. In patients with fibromyalgia, for example, it certainly has been shown that being properly diagnosed leads to reduced pain. This has also pointed the way to further clinical trials in a particular area that I am about to discuss with you.
A 20-year-old college student came to see me [because of pain in her lower extremities]. She had been participating in significant athletic activities and developed bilateral compartment syndrome as a result of an injury. She was treated acutely by the orthopedic surgeons in the community and told that it would take time for her to heal. But after a reasonable amount of time, she continued to experience severe burning pain in both shins and soles, and the dorsal surfaces of her feet.
This pain was so nearly disabling for her that she could not physically function normally, although she has stayed in school. She has a great support system. She has no other medical problems. She was referred to me with a diagnosis of painful lower extremities and possible complex regional pain syndrome. She had not been extensively treated by anyone else and was lacking a firm diagnosis. Electrophysiologic studies were completely normal, and she was otherwise described as having a normal neurologic examination before coming to see me.
When I saw her, the pertinent findings included significant allodynia -- pain upon normally nonpainful stimulation. I use a pressure manometer to quantify that, and she experienced pain at thresholds below 4 kg/cm in her shins and calves bilaterally, and a subjective sense of severe burning.
She had undergone electrophysiologic studies performed by someone who I presumed to be competent with the procedure; she had intact reflexes and no other evidence of a large neurofiber problem. I advised her to undergo a skin biopsy -- a 3-mm skin biopsy per protocol as established by Johns Hopkins and other institutions -- and she agreed to this.
We sent her [biopsy] samples to a commercially certified laboratory. Analysis showed markedly reduced epidermal neurofiber density and findings that were consistent with a painful small-fiber neuropathy.
We are now in the process of looking for more specific diagnoses, because there can be associated neuropathies; for example, neuropathies that could be associated with various infections, vitamin deficiencies, or celiac disease, although she had no history of that. I am not expecting those [studies] to be abnormal. However, just being able to explain her diagnosis to her has given this young woman hope that there will be a way for her to manage this. She feels more comfortable knowing that there is a [neuropathologic] process associated with her complaints. She has returned to school. We may try a variety of different topical agents to help relieve her pain.
Time and time again, as a neurologist and pain specialist, I have seen how important it is to be vigilant about diagnosis. The take-home message here is that when evaluating someone who has peripheral extremity complaints, keep in mind that the skin and analysis of the skin is very, very important and skin biopsy can lead to [a diagnosis of] small-fiber neuropathy.
I'm Dr. Charles Argoff. Thank you for your attention. I hope this was helpful.
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