A 26-year-old man, who weighed 48 kg and was 183 cm, was presented to a local respiratory department in Shenzhen, China, after 4 days of fever (up to 38.8 C) and right chest pain, which was accompanied by headache, myalgia, and weakness without cough, sputum, night sweats, weight loss, cutaneous rash, diarrhea, or arthralgia. Other vital signs were within normal limits. The patient had a history of antituberculosis treatment with first-line drugs initiated in 2018 and achieved treatment success in 2019, leaving a cyst in the right upper lung lobe. There were no recent vaccinations or histories of chronic illness, except for 20 years of chronic hepatitis B with normal liver function. On physical examination, the patient appeared thin but did not have cachexia. Breath sounds in the right lung were weakened, but rales were not heard. Routine blood test results were within normal limits. Sputum and blood cultures were negative. A computed tomography (CT) scan of chest of patient showed an enlargement of the cyst, the emergence of a liquid plane in it, and patchy lesions around it. Antibiotic treatment was ineffective, and he was transferred to thoracic surgery and underwent resection of the right upper lope. However, this was not alleviated after the surgery. Further antibiotic treatment and subsequent second surgery to repair the lung were failed to control the fever, but a substantial surgery wound was left on the right chest wall that would not self-heal.
Pleural effusions were emerged after the surgery, and GeneXpert Mycobacterium tuberculosis/resistance to rifampicin (MTB/RIF) showed positive TB-DNA and resistance to rifampicin. The rapid molecular test was failed because of paucibacillary samples of sputum and pleural effusion. The patient came to a specialized tuberculosis hospital and received a regimen of bedaquiline, linezolid, moxifloxacin, cycloserine, and clofazimine against RR/MDR/RR-TB. Thereafter, MTB culture from bronchoalveolar lavage (BAL) and pleural effusion were positive, and the minimum inhibitory concentration (MIC) showed resistance to FQs, isoniazid, rifampicin, pyrazinamide, and ethambutol and susceptibility to bedaquiline, linezolid, cycloserine, clofazimine, protionamide, and second-line injections, which met the definition of pre-XDR-TB. Thus, we substituted moxifloxacin for protionamide. In addition to chemotherapy, the patient needed to change the dressing daily on the surgical wound of the right chest wall and was waiting for a suitable time to undergo the right chest wall repair.
After 4 months of MDR/RR-TB treatment, the patient complained of numbness and pain in the lower limbs and progressive worsening, without anemia, leukopenia/neutropenia, thrombocytopenia, diarrhea, or visual problems. The drug that was likely responsible for PN was linezolid. Notably, other markers of linezolid toxicity, such as bone marrow suppression, were absent. B vitamin complexes containing vitamin B6, B1, and mecobalamin; painkillers, such as pregabalin, gabapentin, and tramadol; and a subsequent reduction in the linezolid dose to 300 mg daily for weeks were ineffective in relieving the pain. By 6 months, symptoms of the patient had progressed and worsened, and the pain had spread to his legs. In his own subjective opinion, the feeling was acute, frequent disabling, and burning pain, and he also felt numbness in his legs every day, especially in the lower extremities. Continuous insomnia during the day and night was almost unbearable. His electromyography showed that the sensory conductivity of the bilateral superficial gastrocnemius muscle nerves was decelerated and that the sensory nerve action potential (SNAP) amplitude was low so that the conductivity function of the bilateral superficial gastrocnemius muscle nerves was slightly affected. Half a month later, he was diagnosed with PN, and analgesic drugs were added to alleviate the symptoms. However, the problem could not be solved.
As a last resort and after being fully informed, the patient accepted acupuncture treatment once a day at the Acupuncture and Physiotherapy Department 18 times during hospitalization. We assessed the pain pre-, post-, and during the treatment. The intensity of pain was measured with the short form of the McGill Pain Questionnaire (SF-MPQ), which includes three items. This questionnaire included the pain rating index (PRI), visual analog scale (VAS), and present pain intensity (PPI). The PRI is used to evaluate pain sensation and emotion, with scores of 0 (no pain), 1 (mild pain), 2 (moderate pain), and 3 (severe pain). The PPI and VAS in SF-MPQ were also used to assess overall pain status.
When evaluating item 1, we asked the patient each question and marked the corresponding level of pain according to the patient's response. For item 2, the length of the line segment in the figure was 10 cm, and the scale was determined in mm. The patient was asked to mark corresponding points on the line segment with a pen according to his own pain feeling. For item 3, we marked the corresponding score according to the subjective feelings of the patient. Finally, the PRI, VAS, and PPI were evaluated. The higher the score was, the more severe the pain was.
A senior acupuncturist performed the therapeutic acupuncture sessions. The patient was first placed in a comfortable supine position. The acupuncture technique used to treat LIPN pain is in accordance with the "Zang-fu" and meridian system involved in the disease. The point locations for the acupuncture session are those used when treating painful conditions in the lower limbs. The main points were located in the meridians of the lower limb, such as the stomach, spleen, and kidney, for lower limb pain and the nourishing yin point and acupuncture points for the relief of pain. Subsequently, the acupuncturist used the Bilateral Zusanli (ST 36), Sanyinjiao (SP 6), Taixi (KI 3), Yongquan (KI 1), and Bafeng (EX-LE10) points (Figure 1).
The acupuncturist used 0.30 x 25 mm and 0.18 x 13 mm sterile acupuncture needles (Huacheng, Beijing Keyuan Medical Device Manufactory Co., Ltd., Beijing, China). The depth of acupuncture at ST 36, SP 6, and KI 3 was 0.5-0.8 cun and that of the other points was 0.3-0.5 cun. After the insertion, the needles were manipulated to achieve Deqi, and the needles at SP 6 and KI 3 were connected to electroacupuncture equipment for 30 min, as shown in Figure 1. The waveform was selected as a continuous wave. Stimulation intensity was determined by the patient's endurance. The acupuncturist added TCM fumigating treatment to promote blood circulation during the acupuncture sessions.
After 18 rounds of treatment, the patient felt much better, indicating an important pain reduction and improved physical function, particularly in the lower limbs. There were significant changes in the scores of the SF-MPQ (PRI decreased from 19 to 7, VAS decreased from 9 to 4, and PPI decreased from 5 to 2; Figure 2). After nearly 3 weeks of treatment, he reported significant improvement in every aspect of his pain, numbness, insomnia, distress, and the reduction in painkiller intake. Thus, linezolid was increased to a dose of 600 mg daily and endured by the patient. After discharge, the patient no longer received acupuncture treatment but continued to adhere to the TCM fumigation treatment.
The PRI, VAS, and PPI scores remained low before a slight increase at 8 months after pre-XDR-TB treatment, while pleural effusion in the left chest had occurred and was drained. After a 3-month remission period until the 10th month, the patient was hospitalized again with an LIPN problem. The PRI score was increased from 8 to 11, the VAS score was increased from 2 to 5, and the PPI score was decreased from 3 to 2. After 10 acupuncture treatments and TCM fumigation, the PRI was decreased from 11 to 5, the VAS score was decreased from 5 to 4, and the PPI score did not change. The patient's lower limb pain and other symptoms were not significantly relieved, and he could not tolerate linezolid anymore; therefore, it was discontinued. Trends in pain assessment over the course of treatment are shown in Figure 2.