A Case Narrative on Left Shoulder Hand Syndrome

 

Arya Lekshmi. U.S.¹, Hima Santhosh¹, Anusree Raj R.S.²

¹5^th Year Pharm D, Department of Pharmacy Practice, Ezhuthachan College of Pharmaceutical Sciences.

²Assistant Professor, Department of Pharmacy Practice, Ezhuthachan College of Pharmaceutical Sciences.

 

ABSTRACT:

Background: The case report deals with Shoulder-hand syndrome which is relatively a rare clinical entity  classified as a type 1 complex regional pain syndrome  and it shows manifestations like a painful 'frozen shoulder' with disability, swelling, vasomotor or dystrophic changes in the homolateral hand. The pathophysiology of this syndrome isn't well understood but may involve a predominant sympathetic factor affecting the neural and vascular supply to the affected parts. Symptoms include pain, swelling, redness, noticeable changes in temperature and hypersensitivity (particularly to cold and touch).
Case Presentation: A 52 year old female patient was admitted in general medicine department with complaints of neck pain for 1½ years, edema in both legs and restriction in movement of the left shoulder. She had a medical history of diabetes and hypertension. Conclusion: Early diagnosis and treatment is most effective and can completely reverse the disease progression. The current therapy mainly focusses on alleviating the signs and symptoms of the disease rather than actual cure.

 

 

 

BACKGROUND:

Shoulder-hand syndrome, also referred to asreflex sympathetic dystrophy, sudeck’s atrophy or causalgia, is a relatively rare clinical entity which is classified as a type 1 complex regional pain syndrome  and it shows manifestations like a painful 'frozen shoulder' with disability, swelling, vasomotor or dystrophic changes in the homolateral hand^1,2. Mostlythis complex pain syndrome develops after myocardial infarction, hemiplegia and painful conditions of neck and shoulder, such as trauma, tumors, cervical discogenic or intraforaminal diseases and shoulder calcific tendinopathy. And in rare cases it can also be seen associated with herpetic infections, tumors of brain and lungs, thoracoplasty and with certain drugs like phenobarbitone and isoniazid.

 

The exact pathophysiology of this syndrome isn't well understood but may involve a predominant sympathetic factor affecting the neural and vascular supply to the affected parts³.

 

The symptoms may vary over time and also shows inter individual variability. The primary symptoms include pain, swelling, redness, noticeable changes in temperature and hypersensitivity (particularly to cold and touch). As the time progresses, the affected limb can become cold and pale which may then undergo skin and nail changes as well as muscle spasms and tightening. Thus the condition becomes irreversible. The diagnosis of shoulder-hand syndrome in most cases is clinical, but imaging studies, particularly bone scintigraphy, can be useful to differentiate it from other disorders⁴.Treatment is likely to be most effective when started early in the course of the illness and even complete remission is possible.

 

CASE REPORT:

A 52-year-old female patient was admitted in general medicine department with complaints of neck pain for 1½ years, edema in both legs and restriction in movement of the left shoulder. She had a medical history of diabetes and hypertension. For diabetes she was under the treatment with T. Glycomet -500 mg (Metformin). Hypertension was managed by T.Telista -40 mg (Telmisartan) .The patient was advised to take CT scan of brain, MR Imaging of cervical spine, ECG, ECHO.

Table 1 : CT scan of brain plain study and mr imaging of cervical spine, ECHO

 

 

 

 

 

 

 

 

Table 2 : Echo report and summaray of ECHO ECG

 

Table 3: ECG report and ECG summaray

 

The report shows normal ECG and ECHO and changes in the CT brain and MRI of cervical spine.

 

Laboratory investigations of the patients were as follows and shows elevation in the lymphocytes (35.7%), ESR(36 mm/hr.), RBS(321mg/dl). FBS of the patient were as follows 327 mg/dl on first day,108 mg/dl on second day, 140mg/dl on third day,85 mg/dl on fourth day and 180mg/dl on last day of the hospital stay. Pharamacological treatment provided to the patient are Inj. Renerve plus for nerve pain which is a combination of methylcobalamin(1000mcg), niacinamide (100mg) and pyridoineHcl (100 mg) in 100 ml Normal saline, T.torsemide(20 mg) for edema  once daily in the morning, T.Glycomet (Metformin) and Inj.H.Actrapid (20 units s/c) for treatment of diabetes. T.Telista (Telmisartan-40 mg) for treatment of hypertension, T.Gabapentin (100 mg) is given for nerve pain, T.Zerodol S(Aceclofenac-100 mg+Serratiopeptidase- 15 mg) for treatment of pain and inflammation.T.lesuride (Levosulphride-25 MG) was given to the patient in the last two days of hospital stay as the patient experience gastric irritation.

 

CONCLUSION:

Multiple opinions remain with respect to an optimal treatment option for the shoulder hand syndrome even though much has been recommended literally⁵. Early diagnosis and treatment is most effective and can completely reverse the disease progression. The current therapy mainly focusses on alleviating the signs and symptoms of the disease rather than actual cure. A multifaceted approach integrating pharmacotherapy, physiotherapy and psychological therapy is most beneficial.

 

REFERENCE:

1.     Ghai B, Dureja G. Complex regional pain syndrome: A review. J Postgrad Med [serial online] 2004 [cited 2022 Jul 18]; 50:300-7. Available from: https://www.jpgmonline.com/text.asp?2004/50/4/300/13655

2.     Steinbrocker O., Argyros, T.G. (1958). The shoulder-hand syndrome: present status as a diagnostic and therapeutic entity. The Medical clinics of North America, 42(6), 1533–1553. https://doi.org/10.1016/s0025-7125(16)34203-1

3.     Massarotti M., Ciocia G., Ceriani R. et al. Metastatic gastric cancer presenting with shoulder-hand syndrome: a case report. J Med Case Reports 2, 240 (2008). https://doi.org/10.1186/1752-1947-2-240

4.     Low P.A., Amadio P.C., Wilson P.R., McManis P.G., Willner C.L. (1994). Laboratory findings in reflex sympathetic dystrophy: a preliminary report. The Clinical Journal of Pain, 10(3), 235–239. https://doi.org/10.1097/00002508-199409000-00010

5.     Johnson EW, Pannozzo AN. Management of Shoulder-Hand Syndrome. JAMA. 1966;195(2):108–110. http://doi:10.1001/jama.1966.03100020096023

 

Accepted on 18.07.2022           © RJPT All right reserved

Research J. Pharm. and Tech 2023; 16(3):1118-1120.