A 49-year-old female patient (weight: 60 kg; height: 1.63 meters) presented to the emergency department with a 5-day history of burning and electric pain of 10/10 intensity on a verbal analogue scale.
Pain is episodic, exacerbated by movement and does not improve with tramadol and diclofenac.
Physical examination revealed erythematous vesicular lesions with dermal distribution on the skin of the lumbar region and left glue.
The rest of the physical examination is normal.
She had a history of lumbar disc disease, hypertension and hypothyroidism on medical treatment.
The patient denied history of kidney disease.
The patient is evaluated by an infectious disease service who considers that it is a herpetic neuritis and decide, due to the severity of the condition, to hospitalize the patient.
During the first day and prior to the hydration protocol (500 ml of 0.9% saline solution), intravenous infusion of tramadol 10 mg/kg every 8 h (600 mg) is started.
Consultation to pain clinic was requested to start analgesic scheme with acetaminophen + codeine (500 + 30 mg orally every 6 h), morphine dose in case of severe pain (2150 mg per dose) and pregabalin (h).
The patient initially presents adequate analgesia without side effects, qualifying her pain in 4/10.
On the second day of hospitalization, the patient developed dizziness, nausea, emesis, somnolence and dysarthria.
It is considered that the clinical picture is a side effect to analgesics and it is decided to suspend acetaminophen with codeine and pregabalin.
Morphine doses of 2 mg are prescribed in case of severe pain after a state of consciousness evaluation.
On the third day of hospitalization, without receiving any dose of opioid, the patient persists with deterioration of her general condition, progressing to stupor, tachypnea, desaturation and respiratory distress.
Located to the Intensive Care Unit.
The clinical picture is compatible with acute pulmonary edema and renal failure with serum potassium in 5.7 mEq/L, BUN 50 mg/dl (admission value of 17.2), creatinine 5.01 mg/dl and metabolic acidosis blood gases.
Nephrology confirms the diagnosis of acute renal failure secondary to the administration of antiretroviral therapy, requiring hemodialysis.
The patient required a single hemodialysis session with improvement in the levels of nitrogen.
Analgesic management was continued with acetaminophen 500 mg and codeine 30 mg; the patient did not require new morphine doses.
She was discharged on the sixth day of hospitalization with controlled pain and normal renal function tests.
