Archive for March 2015

Common Warts

“Thirty eight… and seven.”

“Nice.”

Such was the interaction between one of my older brothers and me when he would return for a visit from college.  I was eight years old and my brother always wanted to know how many warts I was up to and how many scars I had on my head; I had a tendency to have more than the usual number of both.

We’ll leave the scar issue alone, but what about warts?  Mine dotted my hands, knees and forearms.  Happily, at around age eleven, when I began to actually care about these mild disfigurements, they started to magically disappear. Finally, I was left with four rather large warts: three on the hands and one on my knee.  These persisted stubbornly for another year and showed no sign of leaving despite my various attempts at home surgery.

Then someone told me that I needed to cut a raw potato in half and rub it on the warts and then bury the potato.  I had some skepticism… especially about the need to bury the potato.  But, hey, if I was going to do this, I might as well do it right.  Grabbing a spud out of the five pound bag of potatoes, I halved it, rubbed it on each wart and buried it in the garden.  I can’t say I really expected much.  But in the next three weeks all four of those large warts that had been stubbornly present for four years disappeared.  And now I want you to buy some of my Dr. Smith’s Magic Potato Wart-Be-Gone. Ok, I’m just kidding about that last sentence.

The point is this: warts are fickle, weird things.  They are caused by a virus, the human papillomavirus (HPV). There are over a hundred different strains of HPV known and they cause common warts, flat warts, genital warts and plantar warts (on the bottom of the feet).  They are spread either by direct skin to skin contact or indirectly when a wart touches a surface and then the virus is picked up when someone else touches that surface afterwards.

That contagiousness is one of the reasons that up to 10-20% of school age children may have warts at any given time.  And they can be anything from one tiny wart to my thirty eight (or more) to large mats of warty tissue called mosaic warts.  They can occur at any age, but peak in the middle teens.  At some point, if you’re fortunate, your immune system kicks in and knocks out the warts.  But sometimes this seems to take forever, and since it’s caused by a virus, a person may get more and more of them.

So, what do you do about them?  There is a saying in medicine: when there are lots of different treatments for a problem that means none of them works extremely well (or everyone would just use the one extremely effective treatment).  Warts have lots and lots of treatments, starting with just ignoring them.  About 65% of warts go away on their own within two years.  But, as we’ve said, some begin to spread and grow and refuse to disappear quietly.  For these there is salicylic acid, a somewhat effective non-prescription treatment. There are numerous acid applications including blister beetle juice.  My go-to treatment is the application of liquid nitrogen.  Occasionally a single application is sufficient, but more often a few applications at three week intervals is needed.  Even more aggressive measures such as surgical excision or laser can be used, but this sometimes replaces a temporary wart with a permanent scar.  One other measure that deserves mention is the injection of a small amount of a material into the wart which triggers an immune response against the wart.

The list of alternative treatments is both endless, and somewhat humorous.  It includes adhesiotherapy (that would be applying duct tape to the warts daily), raw garlic, hypnosis, tea tree oil, propolis resin, hyperthermia (immersion in 113 degree water for 30-45 minutes 3 times weekly), cimetidine, and the list goes on.  Because warts will sometimes spontaneously go away at the urging of our immune system, many approaches that trigger an immune response may aid in the disappearance of warts.  That is probably even why the potato treatment may have helped my warts.

So if these rough little bumps start showing up on your epidermis, don’t blame frogs and toads; it’s those nasty microscopic viruses.  And if you don’t want to ignore them, you’ve got lots of options.  If you’re a little desperate, you might even start with a potato… and you may want to start treatment before you get to a count of thirty eight.

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Fever of Unknown Origin

“Over the last few weeks I just keep getting these night sweats.  I’m all achy and tired… I just don’t feel good.  I’ve checked my temperature and it’s gone over 101 degrees several times in the last few weeks.”  Mrs. Brown looked moderately ill, but after a physical exam the only abnormalities were her usual heart murmur, maybe a little louder than usual, and some mild tenderness around her low back.  Blood work came back mostly normal except for a slightly high level in her sedimentation rate (sed rate – a general marker for inflammation or infection in the body), and a borderline high white blood count (WBC), also usually an indicator of infection.

So, we were left with rather general symptoms, an unremarkable physical exam, and a couple of general abnormal lab findings, but no specific source for the infection.  Though it’s not always ideal, sometimes an initial course of a broad spectrum antibiotic is given to see if this clears the fever and other symptoms or whether a further work-up will be needed.  This was done with Mrs. Brown and she came back stating she felt much better and that the fever and night sweats had cleared.  Likewise her WBC and sed rate were nearly normal.  We told her to get back to us if the symptoms returned once she was off the antibiotic, and sure enough, they did.

Mrs. Brown generally fell into a category called fever of unknown origin (FUO).  Basically, FUO’s are described as a recurrent fever of 101 or greater over a course of 3 or more weeks with no obvious source despite an adequate workup to find one.  FUOs may be caused by infections (30-40%), tumors (20-30%), rheumatologic diseases like rheumatoid arthritis or lupus (10-20%), and numerous miscellaneous diseases (15-20%).  In studies, between 5 and 15% of FUO cases remain undiagnosed despite extensive studies.

Some of the specific causes of FUO’s include heart valve infections, tuberculosis, lupus, urinary tract infections, abscesses (sometimes on internal organs), bone infections, HIV, fungal infections, parasites, long-acting viruses, lymphoma, leukemia, solid tumors, fevers caused by medications, and a long list of even more uncommon causes.

When, as in Mrs. Brown’s case, the symptoms are rather general and vague, the workup can be difficult and the answer elusive.  Over time, Mrs. Brown complained more about her low back being particularly painful as her fever kept recurring and her sed rate continued to climb.  An x-ray and then an MRI of the lumbar (lower) spine showed an uncommon infection of a disc between two vertebrae, an infection called, discitis.  Likewise one of a few blood cultures that were drawn grew out a type of Strep bacteria.  Sometimes this type of bacteria first infects a heart valve, having gotten there through the blood stream from the mouth, perhaps after some dental work.  If so, the bacteria will damage the heart valve as well as traveling from there to other places in the body, like a disc in the spine.

At any rate, Mrs. Brown ended up needing intravenous antibiotics to clear this serious infection, and may need back surgery as well.  The bottom line is that some FUO’s turn out to be relatively minor viral infections while others are markers for much more serious illnesses.  Hopefully you’ll never experience weeks of unexplained fever, but if you do, best to get it investigated sooner rather than later.

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Trigeminal Neuralgia

“I keep getting this sharp stabbing pain from the corner of my mouth to the angle of my jaw.  It feels almost like a jabbing electric shock and it’s excruciating.  After that it starts getting better slowly over a few minutes.  But I keep wondering when the next one’s going to hit.”

My middle-aged patient was describing a somewhat uncommon, but extremely painful condition called trigeminal neuralgia (TN), or less commonly, tic douloureux (which just means “painful spasm”).

TN is a jolting jab of pain along one of the five branches of the trigeminal nerve.  The trigeminal nerve is the main nerve of sensation for the face.  Most of the time the cause of the nerve malfunction is unknown and there is no simple blood test or imaging study to diagnose this.  But the symptom is quite characteristic and usually makes the diagnosis clear.

TN has been described for well over 300 years and surgical treatments for it began over a century ago.  In fact a first century Greek physician, Aretaeus of Cappadocia is thought to have been referring to TN when he described a headache in which “spasms and distortions of the countenance took place.”

The frequency of TN is only about 1.5 cases per 10,000 people per year.  It occurs primarily in the middle-aged to elderly population, rarely occurring before age 40.  The relative rarity of TN is a good thing as it can become so severe in some cases that, if not treated, it has pushed patients to the brink of suicide.  The agonizing jabs of pain can occur anywhere from once every couple of days to hundreds of times per day.  Most commonly they shoot from the corner of the mouth to the angle of the jaw.  But they can also shoot from the area around the upper canine teeth toward the eyebrow.

So, what can be done about this agonizing malady if it strikes?  Fortunately, there are some fairly effective treatments.  For starters, certain medicines like Tegretol, gabapentin and Lyrica have shown benefit.  Other meds can be used as add-ons if needed.  These can give desperately needed relief.  The course of TN is quite variable.  So sometimes, if one of these meds can help in the short run, the pains dissipate over a few months and the person can go off the meds and do well.  But in a majority of cases the pain returns at some point and it is not uncommon for the meds to begin to lose their effectiveness.

In more stubborn cases, certain surgical procedures can be effective, such as a procedure where pressure is taken off of the afflicting nerve branch.  Obviously TN is no picnic to go through.  But at least there are a few fairly effective options that weren’t around when Aretaeus observed his patient with “spasms and distortions of the countenance.”

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