Questions for Dr. Hibberd
Headlines (Scroll down for complete
stories):
1. Overactive Thyroid
2. Undescended
Testicle
3. Chronic Hives
4. What is Mastocytosis?
5.
Persistent Diarrhea
1. I am 37 years old, and I was diagnosed with an
enlarged thyroid two years ago. Even though my thyroid is
over-active, I am still gaining weight. I’ve always been skinny, but
I started getting fat after the age of 32. I started taking a
thyroid drug, but I was allergic so I stopped. Am I in any serious
risk?
— Connie S.
Having an overactive thyroid places your body functions in
overdrive, which causes fatigue and anxiety. It also over-stimulates
your heart, placing you at an increased risk for heart complications
related to the rate at which the heart beats (called arrythmias).
This does not contribute to weight gain, though endocrine (hormonal)
disorders are commonly found in some patients. These are referred to
as multiple endocrine adenopathies, a fancy term for multiple
co-existing hormonal conditions.
I recommend you see your medical doctor for evaluation.
Afterwards, request a consultation with an endocrinology specialist.
These conditions need to be treated, because of the complications of
untreated endocrine disease. Leaving your thyroid disorder (which
may not be the only disorder you have) untreated may leave you "mad
as a hatter," and you are placing yourself at risk for thyroid storm
which may cause shock and cardiovascular collapse. Thyroid storm is
a life-threatening medical emergency requiring immediate emergency
treatment, and deaths do occur.
Editor's Note:
2. My Grandson is eleven, and a recent checkup found that
one of his testicles hasn't dropped. He was told he needs surgery.
Is this necessary?
— Jeff M.
Yes. The discovery of undescended testes in an 11 year old is
reason for immediate surgical correction by an urologist. For
palpable undescended testes, surgical orchiopexy is performed, where
the testes is brought into the scrotum and sutured in place. A
commonly associated condition, inguinal hernia, is also repaired at
the same time. For nonpalpable undescended testicles, laparoscopy is
required to fix its place in the scrotum. If it has atrophied, it is
removed.
Usually the lack of descent is noted in examinations done shortly
after birth. Correction should be done by 6 months of age and
certainly before 18 months, because early intervention improves
fertility and reduces the risk of testicular carcinoma development.
Patients with undescended testicles are at increased risk for the
development of testicular carcinoma (cancer!) in both testicles. The
testicular cancer risk also applies to the other descended testicle.
Studies of patients with a history of undescended testicle have
found that 10 percent of cancers will develop on the normal side.
Editor's Note:
3. I have had chronic hives for 17 years. I have seen 11
doctors, and no one can figure out what is causing them or how to
stop them. I have been on steroids for 17 years and am 150 pounds
overweight as a result. Allergy tests show nothing that could be
causing the hives, and doctors assume my problem is caused by my
body producing too many histamines. Do you have any recommendations?
— Connie J.
I find it difficult to justify steroids for treating hives (known
as urticaria with severe cases advancing to deep tissue swelling
known as angioedema), except for a severe episode associated with
angioedema, and then only for several days. Corticosteroids are NOT
generally indicated for long-term treatment.
Primary treatment is with antihistamines (especially the newer
generation antihistamines such as Zyrtec). Most cases of hives are
periodic, and episodes are usually treated with anti-histamines, and
occasionally H1 and H2 blockers for long term treatment. Some
doctors may run a treatment trial with leukotriene blockers such as
Singulair, however this is not FDA approved for this purpose.
Rarely, hives may be seen with internal malignancy or lymphoma.
I advise you to seek a second opinion at a nearby medical center.
First of all, establish whether you have hives or angioedema.
Request a dermatology and immunology/oncology consultation if a
definitive cause is still not evident. Given your large weight gain
and chronic corticosteroid use, an endocrinology consultation may
also be in order.
Editor's Note:
4. I have a female friend, age 44, who takes many pills
and has mastocytosis in her bones. She has to carry an Epy pen with
her also. How many years do I expect her to stay around with us? I
believe cocaine abuse mixed with Vicadin, Oxycotin, codeine, Valium,
etc. may have led to this horrible disease. What can you tell me
about this disease?
— Dennis B.
Narcotic and medication addictions are problematic when dealing
with underlying diseases. They may indeed mask underlying medical
disorders, but are not known to cause mastocytosis.
Mastocytosis is a disease of the immune system whose cause is
unknown. It appears to involve genetic mutations and presents as a
skin disorder (usually in children) and/or as a systemic disorder
which involves multiple organs and bone marrow lesions in adults.
Mastocytosis is fortunately quite a rare disorder, and is
associated with proliferation of mast cells (cells involved in the
body's immune system response) in the skin and/or other organs.
These mast cells contain various inflammation triggers, such as
histamine, leukotrienes,and various cytokines, whose release is
triggered by exercise, narcotics, NSAID medications (such as
aspirin, ibuprofen etc), insect bites, physical irritation such as
trauma, or simply rubbing or scratching the skin. The absence of
organ involvement relates to a good prognosis and is often treated
with H1 (Zyrtec, Benadryl, etc.), H2 (Tagamet, Zantac, etc.), and
leukotriene (Singulair, etc.) blocker medications. Treatment is
aimed at preventing mast cells from releasing inflammation triggers.
No treatment is effective to permanently reduce the number of
tissue mast cells, and this is where various gene therapies and stem
cell transplantation may have a future role.
The skin form of this disorder is associated with intense itching
and redness around specific skin lesions, but is not itchy over
uninvolved skin which is free of rash. The skin lesions are treated
topically and H1 blocker medications are effective. This skin form
rarely progresses to systemic disease in children, although it may
occasionally progress in adults.
Systemic disease is more serious with multiple bone marrow
lesions and several levels of organ involvement (such as skin, lymph
nodes, bowel, liver, spleen, etc.). Symptoms often include nausea,
vomiting, abdominal pain, abdominal distension, bone pain, multiple
joint pain, chronic diarrhea, and various mood changes. The outlook
is not so rosy in the presence of other blood disorders (often
referred to as "cancer" such as lymphoma, and mast cell leukemia
etc.) or impaired organ function resulting from organ infiltration.
Systemic disease requires aggressive treatment with interferon,
corticosteroids (prednisone), and often the use of cytotoxic
(anti-cancer) regimens to induce remission and improve the
significant mortality of this disorder. Your friend's life
expectancy will depend upon her disease involvement and her response
to the treatments she is given.
Editor's Note:
5. I have a friend who has had terrible diarrhea and
stomach cramps for almost a month. Antibiotics have caused even MORE
diarrhea. She stopped taking those meds, but hasn't had any relief.
She has no appetite and when she does eat, she almost immediately
gets diarrhea. What can she take to help stop this vicious cycle?
— Donna H.
Your friend has now entered the "chronic diarrhea" diagnostic
category, and she requires proper investigation. The most important
matter is to ensure hydration, nutrition and electrolyte balance.
This can be rapidly evaluated by a complete examination accompanied
by laboratory studies such as complete blood count and blood
chemistry.
Complications and deaths with diarrhea are the result of
electrolyte and hydration deficits caused by the diarrhea, not the
diarrhea itself. Cultures and stool examination may be useful as
will a stool assay to detect clostridium difficile toxin (often
associated with antibiotic use). Other useful tests may include
cultures, stool examination and endoscopy.
While undergoing testing, there are effective anti-diarrheal
agents your doctor can prescribe, such as Imodium. These
anti-diarrheal agents are not to be self-prescribed for diarrheal
illness of over 4 days duration or when associated with fever,
vomiting or abdominal pain.
The question of course is whether she has secretory diarrhea from
infection, inflammatory diarrhea from invasive disease, an
underlying disorder, or the usual common diarrhea induced by
antibiotics. Some antibiotics are worse than others in causing
diarrhea (most often by killing off good bacteria leaving resistant
species behind), and some actually induce overgrowth of resistant
bacteria, such as clostridium difficile, which can cause severe
symptoms or even hospitalization.
Remember that our bowel function relies on a balance of different
bacteria that is easily disturbed by antibiotic use. Probiotic
yogurt (such as Actimel which contains active cultures of
lactobacillus casei, L casei imunitas, L bulgaricus, and
Streptococcus thermophilus) has been shown to prevent
antibiotic-associated diarrhea as well as prevent Clostridium
difficile associated diarrhea in hospitalized patients. To date,
however, probiotic usage has no proven role in the treatment, only
in preventing antibiotic-induced diarrheal illness.
Editor's Note:
Editor's Notes:
Dr. Peter Hibberd is a doctor of medicine whose
advice is based on over 25 years of outpatient and
hospital-inpatient experience. He is a fellow and active member of
the American Academy of Family Physicians, a career emergency
medicine consultant, and an active member of the American College of
Emergency Physicians. The previous are questions from our readers
and answers from Dr. Hibberd. If you have a question, e-mail the
doctor at askdrhibberd@newsmax.com.
Dr. Hibberd will not reply directly, but look for your questions and
his answers in future e-mails.
IMPORTANT: These
responses are for informational purposes only. Please consult your
primary care physician for a specific diagnosis and treatment
options.
