糖尿病患因罹患帶狀疱疹相關疼痛接受硬膜外類固醇及局部麻醉劑治療後發生糖尿病酮症酸中毒之病例報告

Impending Diabetic Ketoacidosis after Epidural Steroid and Local Anesthetics Administration for Herpes Zoster with Deaff erentation Pain of a Diabetic Patient- a Case Report

帶狀施疹後神經痛（ Postherpetic Neuralgia）Herpes zoster （HZ）最常見的後遺症且是種難以消除的疼痛。而類固醇在帶狀疱疹相關疼痛及帶狀疱疹後神經痛的療效現在並無定論：先前曾有文獻提及於帶狀飽疹的急性期使用類固醇及局部麻醉劑於硬膜外腔內可減少止痛劑的使用、睡眠干擾時間縮短及提早恢復身體基本活動功能並且預防帶航飽疹後神經痛的發生。由於類固醇可能引起血糖控制的不穩定使得類固醇的使用在糖尿病患的使用是受限的。我們報告一位67歲女性糖尿病患使用硬膜外類固醇（40mg M祖咽。lone）及局部麻醉劑的方式來緩解帶狀疱疹所引起的相關疼痛（deaff帥ntation pain）以及預防帶狀疱疹後神經痛的發生：不幸的是，此痛患於接受治療後於八天後發生了糖尿病關症酸中毒。我們進一步了解並討論硬膜外類固醇使用於糖尿病患者上可能造成的生理變化，以期有助於硬膜外類固醇於違類病患（帶航疱疹相關疼痛及帶狀疱疹後神經痛）的治療與預防。

Postherpetic neuralgia (PHN) is the most complication of Herpes zoster (HZ) and one of the most intractable neuropathic pains. The use of corticosteroids with or without other concomitant therapy for HZ and PHN is not guaranteed. Previous studies showed that epidural injection of steroids and local anesthetics or/and antiviral therapy in acute phase of herpes zoster is a promising therapy for reductions in the use of analgesics, the time to uninterrupted sleep, the time to resumption of usual activities ,and prevention of PHN. However, Corticosteroid therapy is seldom used in patients at risk for corticosteroid-induced toxicity (e.g., patients with diabetes mellitus or gastritis) and makes a restriction for these patients. We present a case of 67-year-old female patient with the history of diabetes mellitus who presented with impending diabetic ketoacidosis (DKA) 8 days after receiving 40 mg triamcinolone into the epidural space for prevention of PHN and relief of HZ with deafferentation pain. Further investigations of metabolic and endocrine sequelae of epidural corticosteroid, association between diabetic patient and the use of epidural steroid and the strategies of treatment and prevention of postherpetic neuralgia will be beneficial for clinicians in helping this kind of patients who suffered from this problem.