Ornery.org
  Front Page   |   About Ornery.org   |   World Watch   |   Guest Essays   |   Contact Us

The Ornery American Forum Post New Topic  Post A Reply
my profile login | register | search | faq | forum home

  next oldest topic   next newest topic
» The Ornery American Forum » General Comments » Playing House

 - UBBFriend: Email this page to someone!    
Author Topic: Playing House
LetterRip
Member
Member # 310

 - posted      Profile for LetterRip   Email LetterRip   Send New Private Message       Edit/Delete Post   Reply With Quote 
No, not the game that little kids play, but solving a cool medical mystery that has baffled a bunch of doctors by a clever insight. Will post the case history to let others guess (surely we have a few folks with medical background who'd like a crack at it [Smile] ), then if noone gets it in a day or so will post my proposed solution (and will update when my solution is confirmed/falsified).

Chronic cough

A non-smoking 60 year old caucasian woman has had a chronic non-productive cough for 3+ years, the cough ceases when lying down. Has had shortness of breath on exertion for perhaps 10 years (only recently realized during retrospection). Has a BMI of 31. Recently (one week ago) was hospitalized for an idiopathic bilateral pulmonary embolism (confirmed with CT scan) and is taking warfarin + heparin to treat. Has a familial history of cancer. Recent chest x-ray (two weeks prior to the PE diagnosis) was clean and recently tested negative for allergies. No known environmental exposures.

Other details

Has a personal history of severe iron deficiency anemia when younger. Has had varicose veins for 10+ years. Has edema (many years) in both legs, but particularly the left leg. Is currently taking Telerene (antidiuretic) and Novarec (Calcium Channel Blocker) for hypertension.

Previous treatments for the cough have been antibiotics without effect.

[ September 09, 2013, 03:43 PM: Message edited by: LetterRip ]

Posts: 8287 | Registered: Jan 2001  |  IP: Logged | Report this post to a Moderator
kmbboots
Member
Member # 6161

 - posted      Profile for kmbboots   Email kmbboots   Send New Private Message       Edit/Delete Post   Reply With Quote 
Asthma presents as a non-productive cough rather than a wheeze sometimes. Could also be irritation from post-nasal drip. Could also be irritation from acid reflux.
Posts: 2635 | Registered: Jul 2008  |  IP: Logged | Report this post to a Moderator
LetterRip
Member
Member # 310

 - posted      Profile for LetterRip   Email LetterRip   Send New Private Message       Edit/Delete Post   Reply With Quote 
kmboots,

the goal is based on the case history to narrow it to specific causal chain. So if you think it is asthma - why; if you think it is post-nasal drip - why; if you think it is acid reflux - why, or any of the other possible causes of chronic cough - why, and similarly why do you rule out other potential causes (you don't need to rule out everything just what can reasonably ruled out from the case history).

Posts: 8287 | Registered: Jan 2001  |  IP: Logged | Report this post to a Moderator
Grant
Member
Member # 1925

 - posted      Profile for Grant   Email Grant       Edit/Delete Post   Reply With Quote 
The cough is secondary to low grade pulmonary edema, secondary to hypertensive crisis or heart failure (bi-ventricle)(which also covers the edema), secondary to hypertension and cardiovascular disease(explains the varicose veins and pulmonary embolism), secondary to poor diet/lack of exercise (explains the obesity).

Give O2 NRB 15lpm, EKG 12 Lead, IV access, Lasix, transport to nearest appropriate medical facility.

Smoke a cigarette.

Repeat.

[ September 09, 2013, 07:55 PM: Message edited by: Grant ]

Posts: 3264 | Registered: Jul 2004  |  IP: Logged | Report this post to a Moderator
LetterRip
Member
Member # 310

 - posted      Profile for LetterRip   Email LetterRip   Send New Private Message       Edit/Delete Post   Reply With Quote 
Not all of the symptoms and case history are relevant to the chronic cough (or at least I don't think they are, my diagnosis isn't confirmed yet though her current doctor agrees with it and a treatment based on my diagnosis is being implemented - will let you know if/when confirmed or found to be wrong) so don't worry about addressing everything. This is a 60 year old woman, and they tend to be falling apart, so some stuff can be old age etc. [Smile] I included most of the same details in the case history that I had (although I've included some details that I figured out after I solved it that might make it easier to figure out, and have excluded some details that would have made it harder to solve).

[ September 09, 2013, 08:06 PM: Message edited by: LetterRip ]

Posts: 8287 | Registered: Jan 2001  |  IP: Logged | Report this post to a Moderator
Grant
Member
Member # 1925

 - posted      Profile for Grant   Email Grant       Edit/Delete Post   Reply With Quote 
Pulmonary hypertension.
Posts: 3264 | Registered: Jul 2004  |  IP: Logged | Report this post to a Moderator
LetterRip
Member
Member # 310

 - posted      Profile for LetterRip   Email LetterRip   Send New Private Message       Edit/Delete Post   Reply With Quote 
The cause for almost all of the symptoms I suspect, is actually her medication - specifically the calcium channel blocker (CCB) for treating hypertension.

Which were started on about 12 years ago. Once I realized the connection, further questioning revealed that most of the chronic symptoms had in fact started shortly after the starting on the meds.

The cough is from CCB causing mild GERD (acid reflux) causing chronic cough. GERD presents sometimes with its only symptom as a cough. The bit that I forgot to include that made it easier to solve was that there is no history of heart burn or other classic signs of acid reflux, thus having that in the case history would lead most doctors to dismiss GERD as a likely culprit.

A challenge here is that cough only presents in 1-6% of cases of usage of CCBs, and the literature hasn't made the connection of the CCB->GERD->cough; only ACE->nasal drip->cough. Indeed the one article about hypertension meds I read that mentioned CCBs and cough dismissed them as similar to placebo.

Another way we can identify the acid reflux is from the fact that the cough subsides upon lying down - the reason is that there is a reflex to close the stomach sphincter which blocks the reflux (this doesn't always work, so some people it becomes worse upon lying down). Post nasal drip becomes worse when lying down so could probably be ruled out (afterwards I learned she had been given flonaze to treat post nasal drip to see if it would help, and without effect).

We can also probably trace other issues to the CCBs

1) Edema - CCBs increase capillary permeability causing leg edema/ankle swelling

2) Shortness of breath - CCBs can cause shortness of breath (she had assumed she was just 'out of shape')

3) Obesity - CCBs can cause a lack of energy and weight gain

4) The spider veins (doh! mistated in the case history as varicose veins - sorry) might be due to the weight gain and reduced activity level due to the CCBs.

So she switched to an ARB (Angiotensin II Receptor Blocker) and we should know within 3-6 weeks if the CCB was the cause of the cough.

The idopathic PE appears to be unrelated. Although CCBs can cause an increase in clotting through a non-vitamin K dependent pathway. I suspect multiple factors - she had traveled recently via a long flight; recently ceased taking an NSAID - another thing not realized in the literature is that sudden cessation of any blood thinning agent can cause 'rebound' clotting (body is trying to maintain clotting homeostatis so when you cease theregular usage of NSAIDs, warfarin, etc. it overshoots). Ultrasound of heart, legs, etc. didn't reveal a source of the clots, no cancers found either, no markers in blood tests or liver tests. Also the PE had very odd presentation - only sign was an 'exercise burn' on extremely mild exertion (putting on a shirt) and greater than her usual shortness of breath. More testing will be done once she has finished taking the anticlotting drug course.

Posts: 8287 | Registered: Jan 2001  |  IP: Logged | Report this post to a Moderator
LetterRip
Member
Member # 310

 - posted      Profile for LetterRip   Email LetterRip   Send New Private Message       Edit/Delete Post   Reply With Quote 
So, update -

1) a week after the medication change the cough is almost gone (90-95% reduction in occurence).

2) shortness of breath is definitely improved - back to at least pre blod clot levels, but not as good as I want (although admittedly has only been two weeks and the clots are being treated with the thinners also - so not sure how much, if any, of the reduction can be attributed to the CCBs).

The Edema doesn't seem to have improved much.

The other symptoms will take a long time to resolve so can't be used to evaluate.

I'd say the cough having almost gone away is adequate confirmation.


I also learned of a new symptom - charlie horses/muscle spasms - also chronic; and using a potassium supplement to treat (ineffectively).

This points me to a potentially ultimate underlying cause of magnesium deficiency.

Interestingly magnesium acts as a 'natural calcium channel blocker' - but without some of the side effects of artificial calcium blockers.

Mangesium deficiency->Potassium Deficiency->muscle cramping

Magnesium deficiency->Potassium Deficiency->edema

With low magnesium, the body will eliminate the potassium in the urine, thus making the potassium supplement ineffective for treating muscle cramps.

Magnesium deficiency->Increased Arterial Tone->hypertension

Magnesium deficiency->Reduced Insulin Sensitivity ->weight gain

Magnesium deficiency-> Bronchial Smooth Muscle Tone ->Shortness of breath

Magnesium deficiency->Increased CRP->clotting

Low magnesium levels can cause an increase in C Reactive Protein levels - which increases the risk of thrombi.

I still think the idiopathic PE is multicausal but it is interesting that something that could be the underlying cause of the hypertension and cramping can also increase risk of thrombi.

Anywho, next step is to see if magnesium supplementation reduces/eliminates any of the other symptoms.

Posts: 8287 | Registered: Jan 2001  |  IP: Logged | Report this post to a Moderator
scifibum
Member
Member # 945

 - posted      Profile for scifibum   Email scifibum   Send New Private Message       Edit/Delete Post   Reply With Quote 
What's your relationship to the patient? Any worries about liability?
Posts: 6847 | Registered: Mar 2003  |  IP: Logged | Report this post to a Moderator
seekingprometheus
Member
Member # 3043

 - posted      Profile for seekingprometheus   Email seekingprometheus   Send New Private Message       Edit/Delete Post   Reply With Quote 
Could be Lupus.

[Wink]

Posts: 3654 | Registered: Sep 2006  |  IP: Logged | Report this post to a Moderator
LetterRip
Member
Member # 310

 - posted      Profile for LetterRip   Email LetterRip   Send New Private Message       Edit/Delete Post   Reply With Quote 
scifibum,

my mom [Smile] So not too worried about liability. My family is all people who don't complain, and since I tended to only see my folks during the winter holidays the stuff I did know about I assumed was seasonally induced (cough) or simply 'old age' stuff - hadn't bothered to try and fit the puzzle pieces together (especially given that most of the pieces were missing).

Only with the recent idiopathic PE did I learn about the various other issues.

Posts: 8287 | Registered: Jan 2001  |  IP: Logged | Report this post to a Moderator
LetterRip
Member
Member # 310

 - posted      Profile for LetterRip   Email LetterRip   Send New Private Message       Edit/Delete Post   Reply With Quote 
Interestingly, since she likely has adequate dietary intake and we combine the magnesium hypothesis with the history of anemia - we can tie them in a neat little bow by hypothesizing that the underlying cause is low stomach pH.
Posts: 8287 | Registered: Jan 2001  |  IP: Logged | Report this post to a Moderator
Pete at Home
Member
Member # 429

 - posted      Profile for Pete at Home   Email Pete at Home   Send New Private Message       Edit/Delete Post   Reply With Quote 
Beats me. Closest thing that I have to medical credentials, the neighbor girl that I used to play doctor with when I was three and a half, grew up to be a real doctor.
Posts: 44193 | Registered: Jun 2001  |  IP: Logged | Report this post to a Moderator
OpsanusTau
Member
Member # 2350

 - posted      Profile for OpsanusTau   Email OpsanusTau   Send New Private Message       Edit/Delete Post   Reply With Quote 
There should be no concern about liability - the worry would be practicing medicine without a license, but since it seems like LR has been talking to a doctor and the doctor is practicing medicine with a license, any liability issue would be shouldered by the doctor. And that is why doctors carry professional liability insurance.

[Smile]

Posts: 3791 | Registered: Mar 2005  |  IP: Logged | Report this post to a Moderator
scifibum
Member
Member # 945

 - posted      Profile for scifibum   Email scifibum   Send New Private Message       Edit/Delete Post   Reply With Quote 
Wouldn't practicing medicine without a license incur some liability? But yeah, I missed that there was a licensed MD involved.
Posts: 6847 | Registered: Mar 2003  |  IP: Logged | Report this post to a Moderator
OpsanusTau
Member
Member # 2350

 - posted      Profile for OpsanusTau   Email OpsanusTau   Send New Private Message       Edit/Delete Post   Reply With Quote 
Well, yes, I suppose it probably would incur liability if harm was caused - in addition to the jail time and fines regardless of whether anything bad happens.
Posts: 3791 | Registered: Mar 2005  |  IP: Logged | Report this post to a Moderator
LetterRip
Member
Member # 310

 - posted      Profile for LetterRip   Email LetterRip   Send New Private Message       Edit/Delete Post   Reply With Quote 
Ah it looks like the primary culprit for the clots might be a side effect of Hydroco/APAP (Hydrocodone with Acetaminophen). This isn't an effect identified in the literature explicitly.

Looking in the literature I find an article that explains how COX inhibitors can cause cardiovascular events.

quote:
Both selective and nonselective NSAIDs reduce prostacyclin formation in the infarcted heart; they accomplish this by tipping the balance of prostacyclin/thromboxane in favor of thromboxane, a prothrombotic eicosanoid. The relative increase in thromboxane, coupled with a diminution in prostacyclin in infarcted heart muscle, can lead to the development of thrombotic cardiovascular events. This may be prevented by the addition of a nitric oxide donor to NSAIDs.
http://content.onlinejacc.org/article.aspx?articleid=1127718

So increased thromboxane -> thrombosis -> Pulmonary Embolism

This article shows that magnesium deficiency also increases thromboxane

quote:
We conclude that dietary-induced magnesium deficiency 1) increases thromboxane urinary concentration and 2) enhances angiotensin-induced aldosterone synthesis.
http://www.ncbi.nlm.nih.gov/pubmed/8505087

So this reinforces my hypothesis of magnesium deficiency and provides a very nice mechanism that explains the timing of onset for the Idiopathic PE.

Something I haven't seen mentioned in the literature is a suggestion of dietary restriction of arachidonic acid (AA) if taking NSAIDs or other COX inhibitors. It would seem to me that AA + NSAID might significantly increase thromboxane and thus risk of embolism. Combine that with a magnesium deficiency (which due to reduced stomach acidity with aging is fairly common among the elderly) and this seems like a significant risk of stroke; PE; heart attack etc. via drugs recommended to reduce risk of those factors...

Posts: 8287 | Registered: Jan 2001  |  IP: Logged | Report this post to a Moderator
LetterRip
Member
Member # 310

 - posted      Profile for LetterRip   Email LetterRip   Send New Private Message       Edit/Delete Post   Reply With Quote 
To clarify, the first article was on 'selective COX-2' inhibitors, so my writing was a bit sloppy (since COX-1 inhibitors reduce thromboxane).

However ,

quote:
Acetaminophen (paracetamol) is a selective cyclooxygenase-2 inhibitor in man.
http://www.ncbi.nlm.nih.gov/pubmed/17884974

So while the clarification is necessary, it doesn't detract from my theory.

Posts: 8287 | Registered: Jan 2001  |  IP: Logged | Report this post to a Moderator
LetterRip
Member
Member # 310

 - posted      Profile for LetterRip   Email LetterRip   Send New Private Message       Edit/Delete Post   Reply With Quote 
The cough is now 100% gone.

She talked to her doctor late last week - unfortunately I didn't know she had the appointment so didn't see the doctor with her (it is impressive how garbled information gets even going through just one person). Doctor is doing a blood test for magnesium deficiency, and in the meantime did start her on a daily 200 mg magnesium supplement.

Posts: 8287 | Registered: Jan 2001  |  IP: Logged | Report this post to a Moderator
LetterRip
Member
Member # 310

 - posted      Profile for LetterRip   Email LetterRip   Send New Private Message       Edit/Delete Post   Reply With Quote 
Dr. did a blood test for magnesium and it came back in the 'normal range'.

Unfortunately, blood tests for deficiency can only confirm a deficiency, they can't rule it out, something which most doctors are apparently unaware of.

quote:
"The underestimated problem of using serum magnesium measurements to exclude magnesium deficiency in adults; a health warning is needed for "normal" results."
http://www.ncbi.nlm.nih.gov/pubmed/20170394

Symptoms of magnesium deficiency are dependent on total body stores and can test normal for serum magnesium.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1855626/

The gold standard is a magnesium loading test

http://www.ncbi.nlm.nih.gov/pubmed/8171268

Posts: 8287 | Registered: Jan 2001  |  IP: Logged | Report this post to a Moderator
   

Quick Reply
Message:

HTML is not enabled.
UBB Code™ is enabled.
UBB Code™ Images not permitted.
Instant Graemlins
   


Post New Topic  Post A Reply Close Topic   Feature Topic   Move Topic   Delete Topic next oldest topic   next newest topic
 - Printer-friendly view of this topic
Hop To:


Contact Us | Ornery.org Front Page

Powered by Infopop Corporation
UBB.classic™ 6.7.1