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Postherpetic neuralgia in the elderly [ISRCTN32866390]. BMC Anesthesiology 2004; 4. Jung BF, Johnson RW, Griffin DRJ, Dworkin RH. Risk factors for postherpetic neuralgia in patients with herpes zoster. Neurology 2004; 62: 15451551. Alper BS, Lewis PR. Does treatment of acute herpes zoster prevent or shorten postherpetic neuralgia? J Fam Pract 2000; 49: 255264. Tyring S, Barbarash RA, Nahlik JE, Cunningham A, Marley J, Heng M et al. Famciclovi4 for the treatment of acute herpes zoster: effects on acute disease and postherpetic neuralgia. A randomized, double-blind, placebo-controlled trial. Collaborative Fwmciclovir Herpes Zoster Study Group. Ann Intern Med 1995; 123: 8996. Beutner KR, Friedman DJ, Forszpaniak C, Andersen PL, Wood MJ. Valaciclovir compared with acyclovir for improved therapy for herpes zoster in immunocompetent adults. Antimicrob Agents Chemother 1995; 39: 15461553. Cobo LM, Foulks GN, Liesegang T, Lass J, Sutphin JE, Wilhelmus K et al. Oral acyclovir in the treatment of acute herpes zoster ophthalmicus. Ophthalmology 1986; 93: 763770. Whitley RJ, Weiss H, Gnann JW Jr, Tyring S, Mertz GJ, Pappas PG et al. Acyclovir with and without prednisone for the treatment of herpes zoster. A randomized, placebo-controlled trial. The National Institute of Allergy and Infectious Diseases Collaborative Antiviral Study Group. Ann Intern Med 1996; 125: 376383. Bowsher D. The effects of pre-emptive treatment of postherpetic neuralgia with amitriptyline: a randomized, double-blind, placebo-controlled trial. J Pain Symptom Manage 1997; 13: 327331. Opstelten W, van Wijck AJ, Stolker RJ. Interventions to prevent postherpetic neuralgia: cutaneous and percutaneous techniques. Pain 2004; 107: 202206 and
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Case Report: The patient was a 21-year-old male who presented to the emergency room with a two-day history of fever, malaise, and epigastric pain. The patient had recently returned from Argentina and was concerned that he may have contracted an illness. He described the epigastric pain as a constant ache that radiated to the chest and was exacerbated by eating. He denied shortness of breath, nausea, vomiting, diarrhea, melena, or hematochezia. The patient was taking acetaminophen and ibuprofen for his presenting symptoms. He admitted to smoking a half pack of cigarettes a day and to drinking multiple alcoholic beverages three to four times a week. Previously, the patient had been in good health, and his past medical history was non-contributory. On physical examination, the patient's temperature was slightly elevated at 99.4 degrees. He appeared uncomfortable but in no acute distress. Palpation of the abdomen revealed generalized epigastric tenderness and some voluntary guarding. The exam was otherwise unremarkable. Diagnostic testing in the emergency room included a chest x-ray, abdominal ultrasound, and a routine complete blood count and comprehensive metabolic panel. The ultrasound revealed slight hepatomegaly. The chest x-ray and laboratory studies were normal. The emergency room physician made a presumptive diagnosis of Helicobacter pylori infection or gastroenteritis, which may have been exacerbated by alcohol consumption and cigarette smoking. She prescribed famotidine and advised the patient to take aluminum hydroxide magnesium hydroxide simethicone Maalox ; liquid as needed. She also instructed him to follow-up with his primary care provider the following day. Subsequently, the patient developed severe odynophagia. The pain radiating from the distal esophageal region to the epigastrium persisted, while his fever and malaise resolved. One day after the emergency room visit, the primary care provider obtained an immediate referral to a gastroenterologist. Based on the history, the gastroenterologist assigned a presumptive diagnosis of esophageal ulcer secondary to HSV or pill injury. She performed an esophagogastroduodenoscopy EGD ; with biopsies on the same day that the patient was evaluated. The EGD revealed esophagitis with multiple discrete coalesced ulcerations consistent with HSV. The gastroenterologist prescribed famciclovir, a "GI cocktail" and narcotic pain medication, to treat the patient. He recovered without complications. 65. A Case of Hyperbilirubinemia: A Search for the Less Obvious. M. Miller and M. Statler, Midwestern University Physician Assistant Program, Glendale, Arizona When a patient presents with jaundice, abdominal pain, and hyperbilirubinemia, the most common etiology is secondary to biliary obstruction. When no obvious source is found.
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