Tag Archives: Chronic Symptoms

THE DOCTORS 101 CHRONIC SYMPTOMS & CONDITIONS #59: Lyme Disease

Lyme disease is high on every hard-to-diagnose disease list, because it is relatively uncommon, and can produce a variety of disturbing symptoms often classified as psychosomatic.

It is caused by a deer tick bacterial injection of the Borrelia genus, which can progress to cause widespread problems. Not every tick bite will inject the bacterium, and ticks that have been attached for less than 12 to 24 hours are unlikely to have done so.

Risk factors include living in a wooded area, particularly on the east coast. With people fleeing the cities in the wake of Covid, exposure is more common.

The NYT columnist, Ross Douthat wrote a book about his travails: “patient heal thyself“. In this day and age of overworked  doctors, and with the huge variety of medical information available online, more and more people are going on a “medical odyssey”.

A painless red swelling, followed by an expanding area of red(erythema migrants), is often the best medical clue. Flu-like symptoms and enlargement of the lymph glands can accompany the “rash”. Tests are not positive for several weeks, and may be negative if and when the late symptoms of Lyme disease develop.

The earlier you get treated with a 10-day course antibiotics, the better. The problem is that not all tick bites produce infection, and so overtreatment is a real possibility.

Late symptoms can include fatigue, mental symptoms arthritis, liver problems and a variety of other symptoms. Like another bacterial disease, syphilis, lyme disease can be the great mimic.

Prevention is paramount. People living in endemic areas should wear long sleeves and pants when they go out into the woods, use insect repellent , and make sure their animals are kept tick-free.

A DWWR article on Nootkatone may be worth your time to read, since DEET and many other insecticides are toxic and have to be used with care.

Please refer to the following article by the Mayo clinic for more organized information.

-Dr. C.

THE DOCTORS 101 CHRONIC SYMPTOMS & CONDITIONS #56: LUPUS

Lupus, which used to be called lupus erythematosus because of its butterfly rash and light sensitivity, is an auto immune disease, along with celiac disease and several other autoimmune diseases, it is the great imitator. It can affect almost any organ system.

The great variety of symptoms, and relative rarity leads to a difficulty in establishing the diagnosis. Eventually, you may be lucky enough to  find someone who figures it out.

The butterfly rash over the bridge of the nose and cheeks is the most typical finding but it’s not present in all patients. Rheumatoid symptoms, including fatigue fever and joint involvement is common. Chest pain and shortness of breath can occur. Headache confusion and memory loss occurs. Involvement of the kidneys can also occur, it is often the involvement that is life-threatening. These are symptoms maywax and wane over a number of years.

The cause of lupus may involve a black background of infection, the medication, or even sunlight. As with most auto immune diseases, the actual cause is obscure.

Laboratory findings may include an anemia, kidney or liver involvement, and especially anti-nuclear antibody’s. Most people with lupus have a positive ANA test, but not all people with these positive tests have lupus. Other test maybe necessary.

Treatment is usually with Drugs which diminish the immune system. Targeting the B-lymphocytes specifically with rituximab or bulimumab may be helpful.

Lupus, the wolf, can be stealthy and severe. Patients often have to be their own advocate in order to get properly treated.

Please see the following mail clinic article for more information.

—Dr. C.

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THE DOCTORS 101 CHRONIC SYMPTOMS & CONDITIONS #55: ALOPECIA (HAIR LOSS)

Alopecia is the medical term for baldness. The word has an interesting linguistic  derivation, and comes from the Greek word Alopex, meaning fox. Foxes in Hippocrates time apparently were afflicted by hair loss from mange.

Men and women have different kinds of hair loss. In men, there is the receding hairline with age. As women age, there’s some thinning of the hair generally, and at the top of the head.

A special kind of hair loss that occurs in discrete areas is called alopecia areata. This is an auto immune disease, and is increased in frequency with people who have other autoimmune diseases. Hair loss can also be due to a fungal disease (ringworm) especially in children.

Cancer treatment can cause generalized hair loss, and we have all seen the bald children receiving cancer therapy, especially radiation.
Hair loss and regrowth comes in cycles. We all lose many hairs each day, but they regrow. When the cycle slows, there is a net loss of hair.

When I was in medical practice, my partner had early onset baldness, and was given hair transplants, which were effective. Treatments include minoxidil, which apparently increases the speed of hair cycles. An irritant, such as anthralin, will sometimes help Alopecia areaway by causing inflammation, apparently resetting  the immune reaction that’s causing the hair loss.

Finasteride, which interferes with local testosterone production, can stimulate hair growth. I take Finasteride for prostate enlargement, and was surprised to hear about it’s effect on hair growth. Maybe that’s why I have such a bushy head of hair.

Please read the following at Mayo clinic article for a more organized discussion.

—Dr. C.

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THE DOCTORS 101 CHRONIC SYMPTOMS & CONDITIONS #53: GRAVES’ DISEASE

Graves’ disease is the most common cause of hyperthyroidism. Hyperthyroidism is an over activity of the thyroid gland, and can also be produced by an overgrowth in the gland called an adenoma.

The thyroid gland is an H-shaped structure sitting astride the wind pipe. If a physician palpates the front of your neck, she is most likely trying to see if she can feel the thyroid gland. Enlargement of the grand can interestingly be produced by either overactivity or under activity.

Graves’ disease is an auto immune disease, where the antibodies produced attach to the TSH receptor on the thyroid gland, stimulating overactivity.

Many  metabolic processes are regulated by the thyroid gland, and increased activity produces difficulties like insomnia, fast irregular heartbeat, shaking of the hands, heat intolerance, and irritability. Other symptoms are protrusion of the eyes, fatigue, muscle weakness, and unexplained weight loss.

The doctor suspects the disease because of the symptoms, and must do blood tests and perhaps imaging tests to make the diagnosis. Treatment consists of decreasing thyroid activity, either by radiation techniques, anti-thyroid chemicals, or surgery.

It is very difficult to reduce thyroid activity in exactly the right amount, so that thyroid administration will be necessary. This can be tricky, and requires several visits for adjustment.

The ultimate cause of Graves’ disease is unknown. The immediate cause is thyroid stimulating immunoglobulin. Graves is an auto immune disease, and is more common in people who suffer from other autoimmune diseases, such as type one diabetes, rheumatoid arthritis, or inflammatory bowel disease. The doctor will question you about some of these diseases.

Both causes of hyperthyroidism have occurred in friends of mine. The friend with the adenoma had an easier time with medication adjustment, and had no other problems. The one with the Graves’ disease has had a difficult time getting a proper dose of thyroid medication, and she has other problems with auto immunity. Women typically have more  autoimmune problems.

Interestingly, the commonest cause of low thyroid activity is also an autoimmune disease. Some of the symptoms of low thyroid are the opposite of excessive thyroid activity; sleeping is excessive, there is sensitivity to cold, unexplained weight gain, and sluggishness.

Check with the doctor if you have any of the symptoms mentioned.
There is a Cleveland clinic discussion of Graves’ disease following this article.

—Dr. C.

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THE DOCTORS 101 CHRONIC SYMPTOMS & CONDITIONS #52: RHEUMATOID ARTHRITIS

Painful, stiff joints are almost the rule as we get older, it seems. Both osteoarthritis and rheumatoid arthritis contribute to that eventuality. Osteoarthritis typically worsens as we get older, whereas rheumatoid arthritis starts in middle age.

Rheumatoid arthritis is much more severe than osteoarthritis, since it is an autoimmune condition with an episodic inflammatory component. A recent medical study of different blood substances found that the “metabolome” has many markers for exacerbation of rheumatoid arthritis.

The main test currently being used to show exacerbation is CRP, C-reactive protein. Rheumatoid factor tests, such as anti-CCP, are used to confirm the diagnosis.

Rheumatoid arthritis tends to involve the small joints of the hand, and osteoarthritis the larger joints, such as the hips and knees. I go a bit against the grain, having diagnosed osteoarthritis of my fingers and toes, more typical of RA, but, even at the age of 89, my large joints are still in good shape, even with a lot of walking. Since walking is thought to increase the perfusion of joint fluid to nourish the knee cartilages, perhaps I should say BECAUSE of walking. Running tends to wear the knees and hips out, because of high impact on the joints.

The inflammation of rheumatoid arthritis tends to wax and wane, but during an exacerbation can be quite incapacitating. The interleukin TNF seems instrumental in causing these flares, and antibodies directed towards TNF, such as etanercept, has been a helpful treatment. This injection is also given for other inflammatory, autoimmune conditions such as psoriasis, particularly psoriatic arthritis, and the inflammatory bowel diseases.

Almost half the people who have rheumatoid arthritis also experience signs and symptoms in other tissues, such as the skin, eyes, heart, and lungs. It is truly a systemic, autoimmune disease.

For more information please consult the following mayo clinic article on rheumatoid arthritis.

—Dr. C.

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THE DOCTORS 101 CHRONIC SYMPTOMS & CONDITIONS #51: PSORIASIS (SKIN DISEASE)

Psoriasis is a common skin disease, thought to be in the auto immune category. One of the main elements supporting auto immunity is it’s frequent association with an arthritis, which can be severe.

Eczema (atopic dermatitis) is both a skin and an allergic disease, and looks a bit like psoriasis. In my practice I saw many patients with psoriasis, perhaps people confusing allergy and dermatology.

Both psoriasis and eczema have a red inflamed base, with many little silvery scales of skin on top. These patchy areas tend to be on the outside bends of the elbows and knees in psoriasis, contrasting with eczema, where the dermatitis is located on the inside of the bends. Eczema is a lot more itchy.

The cause of the skin lesions in psoriasis is thought to be due to an interleukin called TNF, which calls to the area a number of inflammatory cells which, in addition to the thickened skin area and excess of epithelial cells, leads to a characteristic appearance under the microscope; biopsies are uncommonly needed when there is doubt about the diagnosis.

In its severe form, psoriasis can be very disfiguring, irritating, painful or itchy, and life altering. You have probably seen advertisements on TV.
Psoriasis has accumulated many different treatments, since it has been recognized and treated over such a long period of time. The basis of many effective treatments is “shotgun” systemic  immunosuppression, which reduces the autoimmune inflammatory reaction, but with side effects.

Topical Cortisone cream is the cheapest reasonably effective treatment, and works for mild cases. More recent treatments are specifically aimed out the interleukins which cause the disease, like TNF.

Please refer to the mayo clinic article for more pictures, and discussion of treatment.

—Dr. C.

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THE DOCTORS 101 CHRONIC SYMPTOMS & CONDITIONS #48: URTICARIA (HIVES)

ALLERGY is a type of reaction that can vary from annoying to fatal. The question has always been: what possible utility to the body does the allergic reaction, which has survived evolution, provide? The best theory fingers parasitic infestations; not only can parasites cause allergic reactions, Indicate allergy by showing blood eosinophilia, but the allergic reaction seem to help us fight parasitic infestation, which was much more common in humanity’s  past, and in present day underdeveloped societies.

URTICARIA consists of a number of little welts or bumps that pop up on the skin and are very itchy. This reaction is caused by little darkly-staining cells called MAST CELLS, which release Histamine  and other irritants into the skin, causing hives. These mast cells are provoked into releasing their irritating cargo by IGE antibodies, the basis of true allergy.

Treatment consist of removing the cause, blocking the action of the IgE antibodies, or giving medication to block the action of the histamine( anti-histamines).

There are multiple common causes, several giving its name to a type of Urticaria. Pressure urticaria can be caused by a belt or tight fitting clothing pressing on the skin to cause the hives. Solar urticaria can be caused by sunlight.

Cold urticaria can be caused by exposure to very cold objects. Hives can also be caused stress, exercise, different foods(seafood and strawberries are the most famous), different drugs(penicillin and aspirin are the most famous), and scratching on the skin(dermatographia).

Hives can occur as a feature of ANAPHYLAXIS. If the IgE-mast cell reaction is extensive, the blood pressure can drop, internal organs can be affected, and emergency treatment must take place to prevent death.
My only experience with hives was after a bee sting, when I broke out with itchy bumps. I had desensitization with honeybee venom, although this is not always done these days. Be sure to check with your doctor if you have such a reaction, however.

The biggest recent improvement in treating people who are incapacitated with frequently recurring and long lasting hives is anti-IGE, an expensive but very effective injection.

If you have hives, be sure to keep a record of events that immediately preceded the hives, including foods, activities,, and exposures. Although the recommended Mayo clinic article that follows suggests that you see a dermatologist or an allergist, I would reverse that and suggest the allergist first.

—Dr. C.

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THE DOCTORS 101 CHRONIC SYMPTOMS & CONDITIONS #47: POST-TRAUMATIC STRESS DISORDER (PTSD)

PTSD, post traumatic stress disorder, has been increasingly recognized by the medical community, and was admitted to the status of a psychiatric disorder in 1980. It was first recognized as “shell shock” in combat soldiers.

The movie, “Patton”, featured one such case; abusive behavior of a soldier by Patton hit the newspapers, and he was sidelined for the start of “ operation overlord“. Since the majority of soldiers were not incapacitated , Patton thought the soldier was cowardly.

As an allergist, I was sent one case of PTSD; Believe it or not, the referring physician thought it might be an “allergy”, so little was it understood.

Now, memory consolidation  is considered to be one of its dimensions. An incompletely consolidated memory allows flashbacks to be considered the real thing.

PTSD is partly under genetic control, since identical twins are more more likely to experience the condition. Anxiety and other psychiatric problems such as depression and substance abuse  can be associated. Women are more likely to experience it. Individuals with low cortisol, elevated norepinephrine or a small amygdala or more likely to develop PTSD. Even children can be involved if they have been abused physically.

Any kind of a frightening experience, especially sexual, can be a cause.
Symptoms can include recurrent distressing memories, flashbacks, or nightmares of the traumatic event, or emotional distress and anxiety on exposure to a similar experience.

Treatment can include medication for depression, but  benzodiazepines should be avoided. Cognitive behavioral therapy has enjoyed some success, but treatment is generally difficult. Please consult the attached Cleveland clinic article for more information.

–Dr. C

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THE DOCTORS 101 CHRONIC SYMPTOMS & CONDITIONS #38: HEMATURIA

Pink urine! You can imagine my shock. What could it be? I exercise more than 1½ hours a day. Could it be myoglobin? I put beets in my daily osterizer “shake”: could the color be from the anthocyanins from beets?

I took a urine specimen to the lab, and the color turned out to be from Hemoglobin, the most likely cause all along. There were lots of red blood cells in my urine and the test strip was strongly positive for Hemoglobin. I called a urologist, who said I needed a Urine culture for infection, and a “CT Urogram”, to check for cancer, kidney stones and other problems.

You should always check with your doctor with Hematuria, and I am no exception. My Urology appointment was in 1 week. I got a urine culture, Cell cytology (for cancer), a CT Urogram, and a urine culture before the visit. I wanted to save time by scheduling a Cystoscopy at the time of the first visit, but couldn’t arrange it.

I went for the appointment. They took a blood pressure, but didn’t check my urine, which I thought was negligent. I had been regularly checking my urine for blood by a test strip, and it was negative. The appointment lasted only minutes. My old urologist always checked my urine on every visit, regardless of whether it was a regular check or to consult for a problem. If I were a Urologist, you can be sure I would have my microscope ready, have the nurse collect the urine, spin it down, and put the sediment under the microscope for me to check.

When I was in medical practice as an allergist, I would have my nurse check any sputum the patient produced smeared on a slide, stained and dried. Microscopic examination of urine and sputum takes only seconds and yields lots of information. In my opinion, 50 years of Insurance surveillance and governmental regulations, including restrictions on lab work done in the doctor’s office and Hippa privacy laws, have handicapped Doctors and are partly responsible for the costly, dysfunctional system that is modern medicine.

Sorry for the Sermons. Visible blood in the urine-Gross Hematuria- requires that you see your Doctor and find the cause of that blood. Please see the 2 appended Mayo Clinic articles for more detail.

–Dr. C.

THE DOCTORS 101 CHRONIC SYMPTOMS & CONDITIONS #37: EYE IRRITATION

‘Something is in my eye” is a feeling that everyone has had, and it doesn’t take much to create that sensation. A speck of dust, a grain of sand, a gnat or an ill-behaved eyelash will do it. Most of the time your eye will tear up and the offender is washed away.

As I get older, this sensation is more frequent. I look at my eyes in the mirror, and there is no one-sided redness, displaced lash or anything else I can see. When I saw the doctor for my cataract surgery a couple of years ago, he took a sample of my tears, and found a deficit in the fatty component. He recommended twice daily, five minute warming of my eyes, but I stopped doing it after a while.

I have so many picky little things I do that this extra time didn’t see worth it. I know that my eyes are dry, which is common in older people, and often use “Refresh-plus” individual, preservative-free ampoules, which seems definitely worth the trouble. It makes my eyes feel better, alleviates the gritty sensation, and even clarifies my vision. I have also resumed warming my eyes with a clean washcloth, moistened with hot water, when I take my shower.

I fancy that I am stimulating my meibomian glands like the eye surgeon intended, to increase the lipid content of my tears. I’ll keep you posted. There are a number of other disorders which can cause the eye symptom, as the accompanying article indicates. Be sure that if the discomfort is more than trivial, or the affected eye is red, or if vision is affected, that you consult your eye doctor, or at least your primary care Physician.

Dr. C.

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