Women's chronic pain syndrome

Examples

Woman 33 years old

April 2009

CC: pelvic pain

Hpi: the patient describes a several years picture of history of pelvic pain associated with pain during sexual intercourse

Diag: R102 pelvic and perineal pain

August 2010

CC: lumbar pain

Hpi: complains about pain in lower back for the last year

Diag: M545 unspecified lumbago

March 2012

CC: pain in legs

Hpi: she relates pain in lower limbs for the last two years exacerbated with physical exercise

Diag: M796 pain in limb

April 2012

CC: pain in legs and dyspnea

Hpi: patient with history of pain in lower limbs

Diag: F419 anxiety depressive disorder

July 2013

CC: abdominal pain

Hpi: woman patient who complains of abdominal pain for last decade

Diag: F339 affective disorder unspecified

Woman 52 years old

Nov/ 2009

CC: my waist hurts

Hpi: pain in waist and hips for a year

Diag: M139 unspecified arthritis

January 2010

CC: all my joints hurt

Hpi: relates polyarticular pain during last past year

Diag: F419 anxiety depressive disorder

April 2011

CC: my neck and shoulder hurt

Hip: cervical pain radiated to shoulder and left arm

Diag: M542 cervicalgia

May 2012

CC: my feet hurt

Hpi: the patient relates pain in lower limbs for the last year

Diag: M255 joint pain

Woman 43 years old

October 2012

CC: abdominal pain- joints pain

Hpi: pain in hip joints and lower limbs

Diag: M104- M139 abdominal pain- arthritis

October 2012

CC: all my joints hurt

Hpi: the patient relates pain in her joints for several years, associated with pain in muscles

Diag: M609- M139- myositis-arthritis

Nov 2012

CC: dizziness- polyarthralgia

Hpi: the patient relates dizziness, and general discomfort, polyarthralgia for several years

Diag: F419 anxiety disorder

Dec 2012

CC: I am sick

Hpi: malaise for last ten years, with pelvic pain

Diag: R103 abdominal pain- F311 depressive disorder

March 2013

CC: my body hurts

Hpi: relates pain in muscles and joints- patient is referred to internal medicine in order treat fibromyalgia

April 2013

CC: polyarticular pain

Diag: M069 rheumatoid arthritis

January 2014

CC: general discomfort dizziness, headache

Diag: R51X

Common Wrong Diagnoses

This group of patients usually is diagnosed with Fibromyalgia, Unspecific Arthritis, Unspecific Myositis, Hypochondria, Anxiety- depressive disorder, and chronic fatigue syndrome.

These patients receive medication according to the diagnosis, but they do not get better.

We have taken a large group of patients with this symptomatology, and we have found history of consultation for other causes different of pain. Most of other consultations are related with respiratory infections.

We could diagram the history of these patients in the next graphic:

Are the acute respiratory infections isolated events? Or are these acute episodes related in some way?

Anamnesis

In this group of patients we have found a long history of respiratory diseases like chronic sinusitis, chronic tonsillitis, chronic otitis, turbinate hypertrophy, nasal congestion, chronic rhinitis.

Findings on physical examination

Chronic sinusitis 70%

Chronic tonsillitis 40%

Chronic otitis 20%

Turbinate hypertrophy 20%

Nasal congestion 20%

Chronic rhinitis 45%

Musculoskeletal Tenderness on palpation: 100%

Tenderness on renal fossae palpation 90%

Tenderness on bimanual pelvic palpation 90%.

According to these findings in the anamnesis and on physical examination, we might conclude that acute respiratory episodes are not isolated events, but they are manifestations of an underlying chronic respiratory infection according to the next diagram:

What is the relationship between the clinic pain picture described in this group of patients and the chronic respiratory infection?

The explanation could be in the immune response by the immunologic system

The presence of an acute infectious process causes the immune system to catch the infection (antigen) by antibodies (IgM, IgD, and IgG). Antigens and antibodies form immune complexes.

Antigens bound to antibodies in immune complexes through an acute infectious process are normally cleared by various cellular mechanisms (reticuloendothelial system). But what happens when we have a chronic infection? We have an overwhelmed reticuloendothelial system and an overload of immune complexes.

Immune complexes deposit on different tissues: joint structures, musculoskeletal system, renal basal membrane, endothelium of small vessels.

Immune disorders develop when immune complexes deposit pathologically in different organs, initiating inflammatory cascades which led to organ damaged/disease. Immune complexes are deposited on the articular surfaces, musculoskeletal system, renal glomerular basement membranes and vascular basement membranes and produce immune mediated inflammation, activation of humoral or cellular effectors mechanisms, activation of complement, release of vasoactive peptides, release of chemotactic factors, neutrophil accumulation, and release of lysosomal enzymes, with subsequent inflammation of vascular basement membranes, inflammation of joint surfaces, inflammation of the musculoskeletal system, inflammation of renal glomerular basement membrane, inflammation of pelvic structures, cell injury, tissue injury, tissue remodeling.

What we have in this group of patients is a chronic inflammation which we have decided to name: WOMEN"S CHRONIC PAIN SYNDROME. A disease with a clear picture of signs and symptoms. A disease with a clear pathophysiology: Immune complexes disease. A disease with clear target organs: joints, kidney (glomerular basal membrane) musculoskeletal system, basal membranes of small vessels.

This is an immune complexes disease described from clinical observation

Laboratory aspects

These patients usually run with lab tests like rheumatoid factor, X-rays, antinuclear antibodies, all of them negative.

Positive lab test could be CIC (circulating immune complexes), high levels of immunoglobulins (IgG), C-reactive protein (CRP) levels, or erythrocyte sedimentation rate (ESR).

References

Harrison, Principles of Internal Medicine, McGraw-Hill, Inc. p. 451. 1977

Manual Merck, Inmunología y Alergia, cap. 2., novena edición Española 1994

Roitt, Iván. Inmunología Fundamentos, séptima edición 1994, Editorial Medica Panamericana, cap. 6., cap. 7., cap. 10.

Presentations

• (I) Acute pain management symposium, Harvard medical school     (Boston ma. sept de 2013).

• (II) 24th meeting of American academy of pain management, (Orlando Fla. Sept. de 2013). 

• (III) IV congreso de medicina del dolor y cuidados paliativos, (Guayaquil, ecuador, mayo de 2013).

• (IV) Academia de medicina de Medellín (Med. enero de 2014).

• (V)  health conference, (Chicago, ill. July de 2014)

Autor:

Jaime Arango Hurtado

Medicine Doctor

Magister in epidemiology

University of Antioquia

Colombia- South America

Clinical chronic pain picture in women"s population

Pelvic pain, headache, musculoskeletal pain, lumbar pain, back pain, polyarticular pain, and malaise.