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Cabsaicin for the trunent of pain in Guillain-Barr syndrome.

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Cabsaicin for the
Tr&unent of Pain in
Guillain-Barr6 Syndrome
Joel C. Morgenlander, MD, Barrie J. Hurwitz, MD,
and E. Wayne Massey, M D
Pain can be a prominent feature of Guillain-Barre syndrome
11). Aching low back pain, deep muscular soreness, and
burning or lancinating extremity pain have all been reported.
Therapeutic measures include narcotics 121, anticonvulsants
131, tricyclic antidepressants, and transcutaneous electrical
nerve stimulation 14). Recently, we successfully treated a
patient with topical capsaicin 0.075% because her pain did
not respond to more conventional analgesic therapy.
A 25-year-old woman was transferred to Duke University
Medical Center because of back pain, lower extremity dysesthesias, and progressive weakness. She had had bronchitis
three weeks prior to admission. Neurological examination
showed a facial diplegia, moderate neck and bilateral arm
weakness with severe bilateral leg weakness, and a stockingglove decrease in pinprick, temperature, and vibration perception. Reflexes were absent except for 1+ biceps reflexes.
Serological tests for hepatitis B antigen and human immunodeficiency virus were negative. Urine tests for porphyrins
and heavy metals were negative. Initial cerebrospinal fluid
examination was normal. Nerve conduction studies and electromyography confirmed a diffuse demyelinating sensorimotor neuropathy typical of Guillain-Barri. syndrome.
She was treated with plasmapheresis. Following admission
her weakness progressed to quadriplegia with ventilator dependence.
Her low back pain responded to local heat and nonsteroidal analgesics. She also complained of severe constant
aching and burning in her feet with paroxysms of a sharp,
stabbing pain. Her feet were hyperpathic and this limited her
ability to participate in physical therapy. Acetaminophen,
ibuprofen, piroxicam, amitriptyline, and carbamazepine therapy did not effectively reduce the pain. Minimal improvement was obtained with methadone at a dose of 5 mg every
6 hours. After two months of hospitalization, capsaicin
0.075% was applied topically every 6 hours to areas of hy-
perpathia. Initially these areas included the soles of her feet
and, over the following days, progressed to include both feet
and ankles. She first noticed relief after four days of treatment and continued to improve over the first week. The
superficial burning pain responded best to capsaicin, and a
deeper aching discomfort lessened minimally. Over the following two months, the capsaicin was stopped twice because
pain had decreased markedly; each time return of pain
prompted reinstitution of therapy. She is currently slowly
recovering strength.
Capsaicin, an ingredient in hot peppers, has effects
throughout the peripheral and central nervous systems r51.
These effects include depletion of substance P and other
neuromodulators from “capsaicin sensitive” neurons (including type C fibers), prolonged membrane depolarizdtion, and
block of axoplasmic transport of substance P E5, 61. These
factors contribute to decreased pain sensitivity in the area of
topical application. Studies have shown that capsaicin’s actions occur over hours to days, so delay in clinical response is
expected [6].Further investigations are warranted in the use
of capsaicin for the treatment of pain associated with GuillainBarr6 syndrome.
Divison of Neurology
Department of Medicine
Duke University Medical Center,
Durham. NC
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Arch Neurol 1984;41:511-514
2. Rosenfeld B, Bore1 C, Hanley D. Epidural morphine treatment
of pain in Guillain-Barri. syndrome. Arch Neurol 1986;43:
1194-1 196
3. Winspur I. Tegretol for pain in the Guillain-Barre syndrome.
Lancet 1970;637:85
4. McCarthy JA, Zigenfus RW. Transcutaneous nerve stimulation:
an adjunct in the pain management of Guillain-Barre syndrome.
Phys Ther 1978;58:23-24
5. Buck SH, Burks TF.The neuropharmacology of capsaicin: review of some recent observations. Pharmacol Rev 1986;38:179226
6. Fitzgerald M. Capsaicin and sensory neurones-a review. Pain
Annals of Neurology
Vol 28 N o 2 August 1990 199
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barry, pain, syndrome, guillain, cabsaicin, trunent
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