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.