COVID后疼痛综合征（二）

 英语晨读 ·

山东省立医院疼痛科英语晨读已经坚持10余年的时间了，每天交班前15分钟都会精选一篇英文文献进行阅读和翻译。一是可以保持工作后的英语阅读习惯，二是可以学习前沿的疼痛相关知识。我们会将晨读内容与大家分享，助力疼痛学习。

本次文献选自Fiala K, Martens J, Abd-Elsayed A. Post-COVID Pain Syndromes. Curr Pain Headache Rep. 2022 May;26(5):379-383. 本次学习由阎芳副主任医师主讲。

Discussion

Long-lasting Testicular Pain

There is growing evidence that a rare long-term complication of SARS-CoV-2 infection is testicular pain. Case reports by Marca et al. and Kim et al. document instances of atypical abdominal and long-term testicular pain in patients following infection with SARS-CoV-2. It has been proposed that the presence of high concentrations of angiotensin converting enzyme 2 (ACE2) in kidney and testicular tissue may help to explain the prevalence of long-term testicular pain in COVID-19 patients. SARS-CoV-2 appears to have a strong affinity for ACE2 receptors, serving as a pathway for viral entrance into human cells. Given high expression of ACE2 in spermatogonia, Sertoli cells, and Leydig cells, it is possible that SARS-CoV-2 binding to ACE2 receptors in testis may induce inflammation and facilitate testicular damage and orchitis in infected patients.

讨论

长期睾丸疼痛

越来越多的证据表明，新冠病毒感染的一种罕见的长期并发症是睾丸疼痛。Marca等人和Kim等人的病例报告记录了感染新冠后患者出现不典型腹部和长期睾丸疼痛的案例。有人提出，肾脏和睾丸组织中存在高浓度的血管紧张素转换酶2（ACE2），这可能有助于解释新冠肺炎患者长期睾丸疼痛的发生。新冠病毒似乎对ACE2受体具有很强的亲和力，ACE2受体可以作为病毒进入人体细胞的通道。鉴于精原细胞、支持细胞和睾丸间质细胞中ACE2的高表达，新冠病毒与睾丸中ACE2受体的结合可能会诱导炎症，并促进感染患者的睾丸损伤和睾丸炎。

While viral interaction with ACE2 in the testicular tissue may explain the mechanism in atypical testicular pain in some cases, it has been noted in other studies that the SAR-CoV-2 virus was not found to be present in the semen or testicular tissue. A case study by Paoli et al. demonstrated that viral mRNA was not present in a patient’s semen or urine that had tested positive for the virus through a nasopharyngeal swab. While there was not mRNA found in the urine, semen, or testicular tissue — a study by Holtmann and colleagues found there to be a decrease in quality of sperm with a moderate COVID infection. Another study from Corona et al. suggests that COVID-19-associated orchitis-like syndrome could be the result of vasculitis due to abnormalities in coagulation and segmental vascularization of the testis.

虽然在某些情况下，病毒与睾丸组织中ACE2的相互作用可以解释非典型睾丸疼痛的机制，但我们也在其他研究中注意到，新冠病毒未被发现存在于精液或睾丸组织中。Paoli等人的一项个案研究表明，通过鼻咽拭子检测病毒呈阳性的患者，其精液或尿液中不存在病毒mRNA。虽然在尿液、精液或睾丸组织中没有发现病毒mRNA，但Holtmann及其同事的一项研究发现，中度新冠感染会导致精子质量下降。Corona等人的另一项研究表明，新冠病毒相关的睾丸炎样综合征可能是由于睾丸凝血和分段血管化异常引起的血管炎所致。

Given these discrepancies in findings regarding a potential mechanism for pain, it is reasonable to assume that there may be a variety of mechanisms for long-lasting testicular pain in post-COVID patients and clinicians should focus on treating symptoms and identifying patients who are at risk for these post-COVID effects. Due to the increase in COVID-19-related testicular pain as a long-term consequence, there is a need to find a proper treatment plan for these patients. Generally, to treat testicular pain, it is recommended to use ice to reduce swelling or take acetaminophen/ibuprofen; however, further study should be conducted to assess and determine the best treatment plan for COVID-19-related testicular pain. Furthermore, risk factors should be identified for the development of testicular pain with COVID-19 to better prevent its occurrence.

鉴于关于病毒导致潜在疼痛机制的研究结果存在上述差异，我们有理由假设新冠肺炎后患者长期睾丸疼痛可能存在多种机制，临床医生应专注于治疗相关症状，并识别有可能受到新冠肺炎长期并发症影响的患者。由于新冠肺炎相关长期睾丸疼痛的患者数量越来越多，我们需要为这些患者找到合适的治疗方案。一般来说，要治疗睾丸疼痛，建议使用冰块消肿或服用对乙酰氨基酚/布洛芬；然而，还需要进行进一步的研究，以评估和确定新冠肺炎相关睾丸疼痛的最佳治疗方案。此外，应确定新冠肺炎引起睾丸疼痛的危险因素，以更好地预防其发生。

At the University of Wisconsin-Madison Pain Clinic, there have been several cases of post-COVID testicular pain. These cases at UW Pain Clinics can be added to this emerging field of interest analyzing long-lasting long-term testicular pain in patients following infection with SARS-CoV-2.

在威斯康星大学麦迪逊分校疼痛门诊，我们也诊治了几例新冠肺炎后睾丸疼痛的病例。我们的这些病例可以纳入这一新兴领域的研究，用于分析新冠病毒感染后患者的长期睾丸疼痛。

Chronic Pain

Similar to long-term testicular pain, chronic pain is another atypical symptom following COVID-19 that should be investigated further. Chronic pain is of particular concern for COVID patients who have been admitted to the hospital, particularly the ICU, for their care. Investigations into risk factors for long-standing pain have identified potential risk factors and mechanisms to explain the phenomenon in patients who have been seen in a hospital setting for coronavirus disease . Potential risk factors include acute pain, prolonged ventilation, prolonged immobility, neuromuscular blockade, repeating proning, and neurological insult. Additionally, patient age and overall physical condition likely contribute to patient risk for chronic pain post-infection. Elderly patients and patients with more underlying disorders, particularly hypertension, have been shown to be at a greater risk for chronic pain following treatment for coronavirus . It has been proposed that patient weakness may contribute to rapid deconditioning and joint-related pain, which may help to explain why chronic shoulder pain has been particularly prevalent in patients who were seen in the ICU for coronavirus treatment.

慢性疼痛

与长期睾丸疼痛类似，慢性疼痛是继新冠肺炎之后的另一个非典型症状，应进一步研究。慢性疼痛是对于入院治疗的COVID患者应特别关注的问题，特别是入住ICU的患者。已有研究针对入院治疗新冠肺炎的患者新冠后长期疼痛的风险因素进行了相关调查，并确定了潜在的风险因素和机制，以解释新冠后慢性疼痛的发生机制。潜在的危险因素包括急性疼痛、长时间人工通气、长时间制动、神经肌肉阻断、反复俯卧位和神经损伤。此外，患者的年龄和整体身体状况可能是导致患者感染后出现慢性疼痛的风险因素。老年患者和患有更多潜在疾病（尤其是高血压）的患者在冠状肺炎治疗后，患慢性疼痛的风险更大。有人提出，患者体质虚弱可能会导致快速去适应作用和关节相关疼痛，这可能有助于解释为什么慢性肩痛在ICU接受新冠肺炎相关治疗的患者中特别普遍。