LETTERS TO THE EDITOR
5. Ghez D, Calleja A, Protin C, et al; French Innovative
Leukemia Organization (FILO) CLL group. Early-
onset invasive aspergillosis and other fungal infec-
tions in patients treated with ibrutinib. Blood.
2018;131(17):1955-1959.
6. Chamilos G, Lionakis MS, Kontoyiannis DP. Call for
action: invasive fungal infections associated with
ibrutinib and other small molecule kinase inhibitors
targeting immune signaling pathways. Clin Infect Dis.
2018;66(1):140-148.
http://dx.doi.org/10.1016/j.mayocp.2019.02.002
Chronic and Complex
Myofascial Pain
Syndromes in Chronic
Abdominal Wall Pain
To the Editor: We appreciated
reading the recent article by Kamboj
and colleagues, entitled Chronic
Abdominal Wall Pain: A Common
Yet Overlooked Etiology of Chronic
Abdominal Pain.1 We were
impressed by the emphasis on a
careful physician examination and
the description of Carnett’s sign.
Overlooked, however, was a more
thorough discussion of the role of
myofascial pain as the most com-
mon etiology of abdominal wall
pain. Our experience has been that
myofascial pain involving the rectus
abdominis, obliques, and transver-
sus abdominis is a very common
cause of previously undiagnosed
chronic, distressing abdominal
pain, which frequently involved
extensive and costly imaging and
referrals.
We would refer practitioners to
Travell and Simons’ pioneering
work, Myofascial Pain and Dysfunc-
tion, which is still the best resource
for the diagnosis and treatment of
myofascial pain.2
Chronic and complex myofascial
pain syndromesdincluding myofas-
cial abdominal paindare commonly
seen in our multidisciplinary pain
clinic and are most successfully
managed with help from physical
Mayo Clin Proc. n May 2019;94(5):914-922
www.mayoclinicproceedings.org
therapists and chiropractors.
Although we frequently use
trigger-point injections (TPIs) with
very small amounts of local anes-
thetic to both help diagnose and
treat myofascial abdominal pain,
there is no evidence that the addi-
tion of corticosteroids is effective.
Recent studies support that dry-
needling techniques are also effec-
tive in treating myofascial trigger
points. Finally, great care needs to
be exercised when performing TPI
or dry needling in the abdomen,
where there is a risk of entering
the peritoneum or damaging under-
lying viscera.
George Comerci Jr., MD
Department of Internal Medicine
University of New Mexico
Albuquerque, NM
Brian M. Shelley, MD
Department of Family Medicine, University of
New Mexico
Albuquerque, NM
Benson R. Daitz, MD
Department of Family and Community Medicine
University of New Mexico
Albuquerque, NM
Potential Competing Interests: The authors
report no competing interests.
1. Kamboj A, Hoversten P, Oxentenko A. Chronic
abdominal wall pain: a common yet overlooked eti-
ology of chronic abdominal pain. Mayo Clin Proc.
2019;94(1):139-144.
2. Travell JG, Simons DG. Myofascial Pain and Dysfunc-
tion: The Trigger Point Manual. Baltimore, MD: Wil-
liams and Wilkins; 1992.
http://dx.doi.org/10.1016/j.mayocp.2019.03.002
In Reply: Chronic and
Complex Myofascial
Pain Syndromes in
Chronic Abdominal
Wall Pain
To the Editor: We appreciate the
Letter to the Editor by Comerci
and colleagues regarding our manu-
script, Chronic Abdominal Wall
Pain: A Common Yet Overlooked
Etiology of Chronic Abdominal
Pain.1 We believe that this provides
us with an opportunity to further
discuss the complex topics of
chronic abdominal wall pain
(CAWP) and myofascial pain.
Although our Concise Review on
CAWP was expansive, this format
did not allow for a detailed discus-
sion on what is known of its
pathophysiology.
In this review, we discuss CAWP
or anterior cutaneous nerve entrap-
ment syndrome.1 The most common
etiology of CAWP is entrapment of
the cutaneous branches of sensory
nerves that supply the abdominal
wall as they pass through the rectus
muscle.2-4 Myofascial pain refers to
a regional pain syndrome character-
ized by trigger points within mus-
cles.5,6 We agree with Comerci et al
that myofascial pain is a common
cause of chronic pain in the outpa-
tient setting. However, myofascial
trigger points, although a common
cause of chronic abdominal pain,
are a less common cause of CAWP.4,7
We also agree with Comerci et al
that patients with CAWP and myo-
fascial pain require a multimodal
approach, and treatment should be
guided by severity of symptoms.
For patients with mild symptoms,
the mainstay of treatment consists
of conservative measures including
reassurance, modification of activ-
ity, and physical therapy. Although
some patients may find chiroprac-
tors helpful for myofascial pain,
there is no evidence to support their
use for CAWP, and we have not
routinely sent patients to them in
our practice for this indication.8
For a patient with moderate to
severe symptoms, we recommend a
combination of conservation
917

measures and consideration of a
trigger-point injection (TPI) using
an anesthetic agent with or without
a glucocorticoid. Combination ther-
apy with an anesthetic and a gluco-
corticoid appears to be more
effective in sustained relief of pain
compared with an anesthetic alone,
even for CAWP secondary to myo-
fascial structures.9,10
As mentioned by Comerci et al,
we emphasize that TPIs are not
entirely benign and outline some of
the risks associated with this proced-
ure. There is a small risk of injecting
into the peritoneal cavity. Although
ultrasound may further decrease
this risk, physicians should weigh
the cost of this additional procedure
with the added safety benefit. Obese
patients may benefit from ultrasound
guidance, given their body habitus.
Finally, we discuss bleeding risks
with use of antiplatelets and anticoa-
gulation, management of which
requires shared assessment and risk
stratification.
Overall, we agree with Comerci
et al that myofascial pain may be the
underlying etiology or a contributing
factor in certain cases of CAWP.
However, distinguishing this from
anterior cutaneous nerve entrapment
is clinically very challenging, and
management strategies, as outlined
above, are currently considered stan-
dard of care in clinical practice.
Amrit K. Kamboj, MD
Patrick Hoversten, MD
Amy S. Oxentenko, MD
Mayo Clinic
Rochester, MN
Potential Competing Interests: The authors
report no competing interests.
1. Kamboj AK, Hoversten P, Oxentenko AS. Chronic
abdominal wall pain: a common yet overlooked
etiology of chronic abdominal pain. Mayo Clin
Proc. 2019;94(1):139-144.
2. Sweetser S. Abdominal wall pain: a common clin-
ical problem. Mayo Clin Proc. 2019;94(2):347-355.
918
3. Shian B, Larson ST. Abdominal wall pain: clinical
evaluation, differential diagnosis, and yreatment.
Am Fam Physician. 2018;98(7):429-436.
4. Srinivasan R, Greenbaum DS. Chronic abdominal
wall pain: a frequently overlooked problem. Prac-
tical approach to diagnosis and management. Am
J Gastroenterol. 2002;97(4):824-830.
5. Yap E-C. Myofascial pain: an overview. Ann Acad
Med Singapore. 2007;36(1):43-48.
6. Skootsky SA, Jaeger B, Oye RK. Prevalence of
myofascial pain in general internal medicine prac-
tice. West J Med. 1989;151(2):157-160.
7. van Assen T, de Jager-Kievit JWAJ, Scheltinga MR,
Roumen RMH. Chronic abdominal wall pain mis-
diagnosed as functional abdominal pain. J Am
Board Fam Med. 2013;26(6):738-744.
8. Ernst E. Chiropractic treatment for gastrointestinal
problems: a systematic review of clinical trials. Can
J Gastroenterol. 2011;25(1):39-40.
9. Niraj G. Pathophysiology and management of
abdominal myofascial pain syndrome (AMPS): a
three-year prospective audit of a management
pathway in 120 patients. Pain Med. 2018;19(11):
2256-2266.
10. Koop H, Koprdova S, Schürmann C. Chronic
abdominal wall pain. Dtsch Arztebl Int. 2016;
113(4):51-57.
http://dx.doi.org/10.1016/j.mayocp.2019.03.003
Acute Myocardial
Infarction During
Pregnancy and the
Puerperium:
Experiences and
Challenges From
Southern India
To the Editor: The article on acute
myocardial infarction (AMI) during
pregnancy and the puerperium by
Smilowitz et al1 is informative and
useful for physicians and obstetri-
cians to consider this rare fatal
entity. Some of our clinical experi-
ences, and the challenges faced
from southern India, are shared
here.
Although the occurrence of AMI
during pregnancy and puerperium
is rare,2,3 we have recorded 12 cases
of AMI over a period of 13 years of
emergency medical practice from
2005 to 2018 among approximately
19,500 pregnancies (average of
MAYO CLINIC PROCEEDINGS
1500 per annum) in 3 different hos-
pitals located in 2 cities in the Tamil
Nadu state of India. The incidence
of AMI during pregnancy and puer-
perium is 62 per 100,000 cases.
The age of the women varied
from 23 to 44 years with a median
of 37 years, and all of them had one
or more risk factors for AMI such as
advanced maternal age, obesity,
hypertension, and type 2 diabetes
mellitus. Two patients had used oral
contraceptive pills, and none of
them were smokers or other tobacco
users. There was no family history
of coronary artery disease. None of
the patients had congenital or
acquired heart diseases, deep venous
thrombosis, pulmonary embolism,
hyperuricemia, dyslipidemia, auto-
immune diseases, infections, anti-
phospholipid antibody syndrome,
or abnormalities of protein C and
protein S or factor VII and V. Symp-
toms or signs reported among these
patients were breathlessness, chest
pain, restlessness, and hypotension
in 10, 8, 8, and 7 cases, respectively.
Among the 12 patients, 7 were
in their third trimester (34-36
weeks), and 5 were in the first
week of their puerperium. Also, 8
patients (66.6%) had undergone
in vitro fertilization (IVF) and were
receiving hormone supplementa-
tion. The hours of presentation to
the hospital varied among the pa-
tients, with 8 arriving between 12
to 24 hours after onset of symptoms
and the rest within 4 hours. All of
these patients had electrocardio-
graphic (ECG) abnormalities such
as ST-segment elevation (in 5 pa-
tients), ST-segment depression (in
3 patients), T-wave inversion (in 2
patients), and Q waves (in 2 pa-
tients). None of the patients had
previous ECGs for comparison. In
all 12 patients, the troponin level
was elevated up to 2-fold, and
Mayo Clin Proc. n May 2019;94(5):914-922
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