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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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Rock-Paper-Scissors

In the game of Rock-Paper-Scissors each choice has the possibility of winning.  In the pursuit of health, patients often want to play a similar game of Diet-Exercise-Medication.

Patients, one of which I am known to be from time to time, like to eat.  They like to eat food that tastes good and makes them happy.  So our choice of diet tends to be unintentionally lax and undisciplined.  However, we most often claim that our poor health and obesity is due to not exercising enough.  It’s a pretty easy target to pick on because virtually everyone feels like they could exercise more.  Even athletes admit they could shoot for a higher goal.  We do all that while failing to recognize how far off a good dietary plan we really are.  The thought is that EXERCISE BEATS DIET.  If only we could exercise more, we’d be healthy.

Well, as exercise gets better and better but health actually becomes worse and worse, patients and physicians start turning to medications hoping to forestall what appears to be inevitable.  We try this new cholesterol drug and ask about that new diabetes drug which, generally speaking, are fantastic advancements in the pharmaceutical arts.  We become so very thankful for technological achievements that allow us to bolster our failing body.  I’m eternally grateful to Salvino D’Armante who allowed me to see my beautiful wife from across the room by inventing corrective lenses around 1285 A.D.  Yet we know these achievements fail to truly make us healthy.  They bolster not cure.  Even still, at our core, we know we can’t exercise forever.  Eventually we must stop and eventually our disorders and dysfunctions and diseases  will get the better of us.  We inherently hope that MEDICATION BEATS EXERCISE.  Maybe they’ll find a cure one day.

What I have learned and what I try to teach myself everyday is this: DIET BEATS EVERYTHING.  Your food choices will dictate your health more than any other factor.  You will never be able to out exercise a bad diet but you can always out eat good medication.  It is easy for me to eat such that I still have a heart attack after finishing the Appalachian Trail (my version of marathon running).  DIET BEATS EXERCISE.   It is easy for me to eat such as to develop diabetes and go blind never to see my wife again.  DIET BEATS MEDICATION.

Focus today on what you eat.  Focus right now on making your next meal better, healthier, and more life-giving.  Stop eating the poison however pretty or tasty or fulfilling it might be. (Desires of the eyes, desires of the flesh, pride of life, anyone?  1 John 2:16)

If you don’t know how to change, call me.  My office number is 539-0270.  Call it right now.  Call my office and set up some time with me or our Medical Nutrition Management Counselors.  These board certified, medical professionals are experts at helping you make your dietary plan one that beats anything else you will ever do to be healthy and functional.

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Cholesterol Myths

“So, my cholesterol’s running high?  It’s probably all those eggs I’m eating.  Give me a couple of months and I can fix that with my diet.  I don’t want a heart attack… but I also don’t want to be on one of those statin drugs.  Who wants something that saves your heart but then wrecks your liver?

Those are the kinds of statements I hear day in and day out in my practice.  They express several of the myths that are rampant about cholesterol.  In fact cholesterol has recently been in the news because the government’s Dietary Guidelines Advisory Committee is reportedly going to remove their longstanding recommendation to restrict cholesterol in the diet.

The wheels of science often grind very slowly and sometimes get stuck in a misguided rut for long stretches.  One of those ruts has been the idea that cholesterol in the diet, such as is contained in the yolk of an egg, needs to be carefully limited in order to protect one’s heart health.  It seemed to make sense since cholesterol is found in some of the plaque that blocks arteries and leads to heart attack and stroke.  But over the years the evidence for the evils of dietary cholesterol has simply not shown up.  In fact, as heretical as this may at first sound, a lot of folks with the very common pre-diabetic metabolic syndrome would do better having an egg and a little cheese for breakfast rather than a bowl of oatmeal.

Even after decades of study, we are far from figuring out all that there is to know about cholesterol and cardiovascular health.  But if we can’t give all the answers, let’s at least explode a few myths.  Besides the one noted above about the assumed dangers of dietary cholesterol, here are three more:

  • Myth #1: High cholesterol is mostly due to a bad diet and can be readily fixed by adjusting your diet.  Reality: For most people cholesterol is about 80% genetics and 20% lifestyle.  So it can certainly be improved with a healthy lifestyle, but there is a large part of it over which we have little control.  It’s still good to work at the 20%, but it’s not a simple fix.
  • Myth #2: Anyone with high cholesterol is at risk and would probably benefit from a statin drug.  Reality: These cholesterol-lowering medicines do work very well to lower cholesterol.  However, the main place that they have shown a reduction in events (such as heart attacks) is in folks with known heart disease, or (less so) in those with very high risk factors for heart disease.  Some folks with high cholesterol are actually at very low risk for heart disease and stroke.  That’s why in trying to better answer whether one of our high cholesterol patients should consider a statin, we employ tests such as the coronary calcium scores and/or a specialized arterial ultrasound called a carotid intimal medial thickness test.  These are non-invasive and affordable tests which help us sort our high cholesterol patients into those who are clearly plaque-formers and those who don’t seem to be.  We then recommend consideration of a statin, as well as other aggressive preventive measures only for the plaque-formers.
  • Myth #3: Cholesterol-lowering statin drugs are quite dangerous and can wreck your liver. Reality: Although, as noted above, they are certainly not needed by everyone with high cholesterol, they have been quite thoroughly tested and their side-effects are well-known and manageable.  For example, there is no statistical increase in liver failure among those on statin drugs vs. those not taking a statin.  However they do bump blood sugar up mildly and probably around 15% of folks get muscle aches that cause us to switch brands or take them off statins entirely.  So statins are neither the big answer nor the big villain; they’re just another tool.

We could go on, but you get the idea. As with most things, reality is a little more complicated than the myths.  It is often said that half of what we put forth as medical truth is false… and the trouble is we don’t know which half is which.  It should keep us humble, but it shouldn’t make us despair.  After all, for about 1900 years after Christ, the average life-span was stuck at about 38 years (partly because of the high number of infant and childhood deaths) whereas we’re at more than double that now.  Over time, if we follow the evidence and resist impatiently grabbing the newest too-good-to-be-true fix-all promises, we do arrive at some helpful realities.  In cholesterol management as with the rest of life, hang in there and keep holding out for the true and the good.

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