So, what does cause pernicious anemia?

June 24, 2014 By

Q: Are there any connections that you know of to pernicious anemia? My grandmother died of this condition and I’ve read about it, much from your site. I started taking sublingual vitamin V12 tablets 2500 mcg about three months ago. I began with one and am now taking two per day, both at the same time. I also take magnesium daily. My restless legs have plagued me for over 20 years rarely disturb my rest now. I do NOT know if the vitamins are the reason, I only cite the circumstances and ask for your advice.

I did try iron supplements but that left me with tarry stools and frequent diarrhea, so that’s out. I did put a soap cake in my bed and most of the time remember to keep it near my legs. Not sure that’s making the difference, if it is just a placebo effect, or if it is the vitamins.

A: To begin with, one common explanation for vitamin deficiency anemia to occur could result from an individual failing to consistently consume sufficient amounts of those vitamins required to produce healthy red blood cells. Red blood cells are those that carry oxygen from the lungs throughout the body. The second cause of vitamin deficiency anemia may occur when the body simply cannot absorb those nutrients from the foods a person eats. There are several B vitamins that come into play here. For example, two vitamins when deficient, cause red blood cells to enlarge – folate and vitamin B12. Folate (folic acid) – also referred to as B9 – is essential for metabolism and maintenance of homocysteine. It helps prevent birth defects. Food sources of folate include dark green leafy vegetables, fruits, whole grain products and more. Vitamin C (ascorbic acid) is an antioxidant required for the growth and repair of tissues. It helps with wound healing and is vital for the formation of collagen used to maintain and repair scar tissue, blood vessels, ligaments and tendons. While a C deficiency is rare, it can occur, with severe cases leading to joint pain, swelling, bruising, loss of teeth, and more. Food sources include citrus fruits, sweet and white potatoes, tomatoes, strawberries and more. Balance is key, since excesses may cause kidney stones, an upset stomach and an increase in iron absorption.

On to a B12 deficiency. This vitamin is found in red and white meats, shellfish, eggs, cheese, yogurt, breakfast cereals, and milk. A diet consistently lacking in this vitamin can occur, or may also be the result of the inability of the small intestine to absorb it from those foods consumed. Pernicious anemia is vitamin B12 deficiency due to lack of absorption of the vitamin; however, there can be other causes of a B12 deficiency such as surgery, infections, medications, or diet. Gastric bypass surgery is being performed more and more frequently and could be a cause of pernicious anemia, as can having Crohn’s disease, celiac disease, a tapeworm, or from a lack of intrinsic factor. Intrinsic factor is a protein secreted by the stomach. It teams up with B12 in the stomach and takes it through the small intestine for absorption by the bloodstream. Without intrinsic factor, B12 cannot be absorbed so it passes through the body as a waste product. A lack of intrinsic factor may be the result of an autoimmune disorder or may also be the result of gastric bypass.

Symptoms of any vitamin deficiency anemia may include fatigue, muscle weakness, heart palpitations, shortness of breath, weight loss, paresthesias (numbness and tingling) of the extremities and more. Risk factors that enter the picture for pernicious anemia other than those mentioned include having an abnormal bacterial growth in the stomach, taking specific medications such as antacids, protein pump inhibitors including Nexium, Prilosec, Prevacid and Protonix, and those medications used to treat type 2 diabetes.

Treatment is available through diet modification, adding B12 supplements in either pill form or through a nasal spray, or even via injection if the deficiency is severe enough. The injections, if given, may be received every other day but will eventually decrease to once a month. B12 injections would also be used in cases where the intrinsic factor is deficient.

Unless your doctor checked your iron level and found you to be deficient, your restless legs symptoms may be better helped by eliminating the iron supplement, massaging them while soaking in a warm tub, using an over-the-counter pain reliever such as ibuprofen, and reducing or eliminating caffeine, alcohol and tobacco products if appropriate. Ask your physician if such prescription products such as Requip, Mirapex, Neupro, Sinemet or others might be appropriate for you. Good luck.

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Underlying cause for rash must be determined

June 23, 2014 By

Q: My wife, age 72, was diagnosed with breast cancer in April 1994. She had a lumpectomy followed by chemo and radiation treatments. She has been cancer free since then. In the past year she has developed a fungus/rash under the breast that had the cancer. Her oncologist prescribed Clortrimazole 1%. It has not helped her and she continues to experience significant pain and discomfort, especially at night.

Can you recommend anything that might give relief and allow her t get a good night’s sleep?

A: It’s very interesting that your letter was chosen to be addressed today, since it’s being written on June 11th – National Cancer Survivor’s Day (even though it will not appear in print until the 23rd) and your wife was among those survivors honored. Congratulations to her.

Many individuals complain of “rashes” under their breasts, particularly if the weather is warm and support garments rub against tender skin. Bacteria and fungi, can appear anywhere on the body but prefer more conducive moist/warm areas such as belt lines and under breasts. One of the more common causes of an itchy rash in such areas is known as Candida, a type of yeast or fungi. Candida appears as white when in the mouth, on a microscope slide as clear and white, and when on the skin it may be red and raw. This type of yeast is common in individuals with diabetes, in antibiotic or chronic steroid use, in obese individuals, and in those with a compromised immune system such as HIV.

Candida may respond well to topical anti-fungal creams such as ketoconazole or anti-fungal powders that will help keep the area(s) dry. Your wife might find less irritation on the tender sites if she were to remove her bra once at home for the day which will allow her skin to dry naturally. She should also pat the affected areas dry following bathing, rather than rubbing them with a harsh towel which may further aggravate the lesions.

Bacteria such as staphylococcus and streptococcus may also be to blame. Again, diabetes and a compromised immune system will increase a person’s risk of getting an infection. The rash from bacteria is commonly red and is often warm to the touch. In this instance, oral antibiotics such as amoxicillin, clarithrymycin, dicloxacillin and others might bring her condition under control.

A skin allergy (allergic dermatitis) may also lead to a rash. Individuals with season allergies, eczema, and asthma are at an increased risk of developing a skin allergy. Common irritants include laundry detergents, topical moisturizing lotions and perfumes are often the culprit. The intensity of this type of allergy will vary from person to person. Topical steroids such as hydrocortisone are the treatment of choice. Keep in mind that the long-term use of topical steroids should be avoided, since they have the potential of leading to chronic skin changes that may promote the overgrowth of Candida and other fungi.

Psoriasis is a type of skin disorder commonly found on elbows and knees, so while mentioning it, I don’t believe your wife’s rash is from this cause. However, a subtype of psoriasis is known as inverse psoriasis that is known to develop in skin folds under the arms or breasts and in the groin area. According to the Journal of the American Board of Family Medicine, inverse psoriasis is commonly mistaken for a Candida infection. Topical steroids may be effective but keep in mind that psoriasis will not improve with anti-fungal creams.

Your wife may need a different antifungal medication or some of the modalities I have mentioned thus far. Further, she might even consider asking her oncologist for a referral to a dermatologist who might have additional ideas for controlling her rash.

On the home front, she might place a layer of soft cotton material such as that from a T shirt to help absorb moisture. Or, cornstarch can be applied to the area that is dry to the touch. Calamine lotion, the pink liquid used to treat poison ivy might provide relief of the itch, while helping the affected skin heal. It should be applied twice daily. Lastly, she might consider applying a cold compress of skim milk and cold water to sooth the itch and reduce the swelling and pain level.

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Four year old is a late speaker

June 21, 2014 By

Q: My grandson living in a different country is four years old and does not speak. He pays attention, is very energetic and loves to walk and explore. At home he is an only child and is well-loved and cared for. When he does use his voice, it is to laugh, scream, etc but not to communicate. His parents are both articulate and well-educated. There are servants in the home who speak different languages. They cannot bring him to the States as they are responsible for taking care of their family there.

Can you think of anything we could do from here to help him communicate?

A: When children fail to speak at the “normal” time, parents and caregivers can become anxious and worried, assuming something is automatically wrong. However, in the majority of cases, there is no cause for alarm. Most children will begin at their own pace, particularly boys who tend to develop language skills slightly later than girls. While every child is different, there are “guidelines” set by the American Academy of Pediatrics that indicate by the end of the second year, a toddler should be able to speak in two-to-three-word sentences, follow simple instructions, and repeat words spoken by others; by the end of the third year, the child should be able to identify pictures and objects and understand most of what is said, follow instructions that may have two to three steps, and be understood by others outside the family; by the end of the fourth year, the child should master the basic rules of grammar and be speaking clearly. It should be noted, however, that many of the words may be pronounced incorrectly which is not a cause for concern; by age five, the child should be able to re-tell a story and use more than five words in a sentence.

If a child doesn’t use many words but appears to understand, there are fewer reasons to be concerned. If the child appears to comprehend what is being said and can follow commands, there is still less reason for concern. Of interest is that the number of cases of late-talking children is on the rise on our country per Marilyn Agin, MD, a developmental pediatrician in New York City and co-author of The Late Talker: What To Do If Your Child Isn’t Talking Yet. The incidence of chronic ear infections can impair hearing and may contribute to speech delays. Then there’s the thought that exposure to substances such as mercury could cause neurological damage which, in turn, might affect speech and language.

I wonder if your grandson hears his parents and those around him and can pick up on statements such as “dinner is ready” or “it’s bedtime”. What happens if someone winds a music box in his presence, or better still, can his parents “read his expression” if he winds the music box himself? If he doesn’t acknowledge individuals in his presence or a jingle on television, it may be because he has a hearing problem, a condition that should be checked by an audiologist. Hearing is essential for speech and language development. Hearing loss may be present at birth or may develop later on, perhaps because of ear infections. I feel a specialist should be consulted who can note his progress in other areas in an attempt to determine if this is a consideration. Lastly for this article only, some children exposed to more than one language early on may not speak as early as single language toddlers. In most instances, children will typically catch up in due time and do well. So if he responds to questions or comments from those around him, that’s a good sign and he’s probably just a late talker. If not, his parents should seek the help of a specialist. Early intervention works wonders, so the sooner action is taken, the better off everyone will be.

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Are those nosebleeds HHT?

June 20, 2014 By

Q: Every time you comment on someone’s concern about chronic nosebleeds, I worry so much about HHT, as this is the most common symptom. You write often on “orphan” diseases. Well, this one is large but certainly an orphan. There are hospital treatment centers of excellence to deal with this disease worldwide.

Both my husband and son suffer from almost daily nosebleeds. There are treatments available, though the condition can’t be cured.

A: HHT (hereditary hemorrhagic telangiectasis) a/k/a Osler-Weber-Rendu syndrome is an inherited autosomal dominant genetic disorder of blood vessels (arteries and veins) that affects approximately one in every 5,000 individuals – male and female alike from all ethnic groups. Our arteries carry blood under high pressure out to all areas of the body, while veins carry blood that should be under low pressure. Then there are usually very small blood vessels known as capillaries that connect arteries to veins. A person with HHT has a tendency to form blood vessels that lack normal capillaries, meaning that the blood under high pressure flows directly into a vein without first having to squeeze through very small capillaries. It’s where these arteries connect directly to veins that can rupture and bleed, simply because they are fragile. When the vascular formations present on the tongue, lips or skin, they may resemble pin-point red or brown dots. The abnormal blood vessel referred to in this instance is known as telangiectasis if it involves small blood vessels. These areas present on the lining of the nose and can be responsible for recurrent nosebleeds, the most common symptom of HHT. Other areas of the body affected include the liver, digestive tract, lungs, brain, and skin. When the abnormality involves a larger blood vessel, it is referred to as an arteriovenous malformation or AVM for short. Some individuals with HHT may also have AVMs in one or more organs. Those that occur in the lungs and brain may lead to serious complications. Therefore, the HHT Foundation strongly recommends that all patients and families with HHT be assessed for screening and treatment.

Each child born to an HHT parent has a 50% chance of inheriting the HHT gene mutation with one copy inherited from the father and the other from the mother. Individuals diagnosed with HHT have one normal copy of the gene and one mutated copy, so when a person with HHT has a child, he or she may either pass on the normal copy of the gene or the copy with the mutation. The child that inherits the gene with the mutation will have HHT, while the child who inherits the normal copy will not.

Diagnosis is accomplished through clinical examination or genetic testing, the latter consisting of analyzing DNA, the genetic material carried in cells. Genetic testing is commonly done on a small sample of blood but can also be accomplished on saliva. There are various types of genetic testing for HHT available. The first is known as “sequencing” of the genes that involves examining the precise sequence of building blocks in the DNA sample to determine if there is an abnormality. The next is “deletion and duplication” to determine if there is a piece of the gene missing or duplicated. Single mutation analysis reviews to determine if one particular mutation previously identified in another family member is either present or completely absent.

While there is no means to prevent telangiectasis or AVMs, most can be treated once they occur. The current recommendation for treatment will depend on the location of the body in which it occurs and its size. Because recurrent epistaxis (nose bleeds) occurs in up to 95% of all individuals with HHT, that particular event may lead to anemia which may be handled with iron supplements and other forms of treatment.

So, while this complex disease exists, I wouldn’t automatically make a rapid connection – although it certainly is a possibility – with HHT and nosebleeds. Yet thanks to your knowledge of the disorder, readers may now be better informed and can take steps to determine if this genetic disorder may be to blame. Additional extensive and easy-to-understand information can be found through the HHT Foundation by logging on to maryleigh.krock@hht.org or by calling 410 357-9932. There is also a newsletter published three times each year by the foundation that provides up-to-date information on this little known disorder. So, thank you for educating me to look beyond the obvious.

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Reader suffers from persistent ear pain

June 19, 2014 By

Q: I have been having an earache that develops overnight while I am sleeping. It usually goes away during the day. My family physician did not find any infection and ear wax was removed. I do not have TMJ. I have been having this problem for about a month. Do you have any suggestions?

A: There are a number of reasons for otalgia (ear pain) to exist. In order to determine where the pain originates, it will help to understand that primary otalgia is pain that originates from within the ear, while referred otalgia is pain from outside the ear. When the pain occurs in a child, the first thing we generally consider an infection, yet this is generally not the case when adults are concerned.

Pain and diminished hearing may occur when air and fluids build up behind the eardrum, a condition referred to as serous otitis media; a situation that can occur if congestion blocks the Eustachian tube (the tube that naturally drains the middle ear), tumors of the head/neck/chest are present, the patient has nasal allergies, or bacterial middle ear infections. Left untreated, a blocked Eustachian tube may take weeks or months to clear. Meniere’s disease is an inner ear disorder that causes ringing in the ears, a feeling of fullness, pressure, and disturbances in both hearing and balance. Middle ear infections (acute otitis media) are one of the most common causes of ear pain, particularly during the winter season. It might be preceded by the common cold which, by itself, is sufficient to cause ear pain.

Other less common possibilities include mastoiditis (inflammation of the mastoid bone, myringitis (eardrum inflammation), chondritis (inflammation of the cartilage of the external ear), and cellulitis (inflammation of the cartilage in the external ear. Something that should not be overlooked is a dental issue. Often, ear pain involves a person’s molars.

Treatment should be dictated by the underlying cause of the symptoms presented. When the cause of the pain lies within the ear itself, it is easier to identify and treat; however, in those instances where the cause isn’t evident, a more in depth evaluation may be warranted. Over the counter oral pain relievers, ear drops, decongestants and even antihistamines may diminish or dissipate the symptoms that can take weeks or months to otherwise clear on their own. When OTCs fail to produce results, an ear-nose-and-throat specialist (an otolaryngologist) might choose to prescribe a nasal spray which should reduce the swelling present in the nose and Eustachian tube and allow the ear to drain.

If your primary care physician is unable to zero in on a diagnosis for your complaint, it’s time to request a referral to an ear specialist. If your teeth are in need of repair, it may be a good time to have them checked out, as well. Make those appointments now so you can get back to enjoying life to the fullest without the annoyance of ear pain.

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Diabetic ketoacidosis is a true emergency

June 18, 2014 By

Q: My husband was planning a recent trip to the Eastern portion of the United States recently from Denver. We thought he was plenty well enough to make the trip but he was suddenly in the acute phase of diabetic ketoacidosis. His doctor frightened me when he indicated my husband was very seriously ill. What happened? Suffice it to say he didn’t make the trip but I’m baffled by the whole thing. Can you shed some light on this?

A: Diabetic ketoacidosis is a potentially life-threatening complication that occurs when the body of a diabetic suddenly produces high levels of ketones, blood acids. The body becomes unable to produce sufficient insulin (the substance that generally is key in helping glucose (sugar) enter a person’s cells). Without sufficient insulin, the body breaks down fat and muscle as fuel which causes toxic acids to build up in the bloodstream and eventually leads to diabetic ketoacidosis if left untreated. Signs and symptoms may develop rapidly and may include high ketone levels in the urine and hyperglycemia (high blood sugar levels).

Diabetic ketoacidosis may be triggered by stress, a heart attack, surgery, physical or emotional trauma, high fever, illness such as pneumonia, urinary tract infections, because of erratic insulin therapy such as forgetting to take insulin in a timely manner, inadequate insulin therapy or because of alcohol or drug abuse. The risk of advancing to diabetic ketoacidosis is increased for those individuals with type 1 diabetes, in individuals younger than 19 years of age, and if insulin doses are missed frequently. People with type 2 diabetes can develop the condition; however, it is far less common.

Your husband’s primary care physician or endocrinologist likely tested his blood sugar levels, arterial blood gases, ketone levels, and he may have also done a urinalysis and chest X-ray.

Treatment is with electrolytes, fluids and insulin – all through an IV. The electrolytes will help keep the nerve cells, heart and muscles function normally, the fluids will rehydrate the body and replace those fluids lost through the process of urination, and the insulin will reverse the entire process of the ketoacidosis.

My guess is twofold. First, it is possible your husband did not know he was a diabetic and this was his first encounter with the disease. Or second, he did know of his condition and may have been preoccupied with his plans to travel and neglected to take his insulin in a timely manner as he should have. He may not have eaten properly or failed to monitor his blood sugar and ketone levels. Lastly, most diabetics are trained to adjust their insulin levels as needed depending on their readings. He was lucky to have taken rapid steps to remedy the situation. In all likelihood there will be another trip to look forward to and the lesson you both learned this time will obviously put both of you on your toes so it doesn’t happen again.

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What are all these spots on my skin?

June 17, 2014 By

Q: What is the difference between skin tags, warts, moles, and liver spots? Some of the liver spots on my face are darker and scaly. My dermatologist has checked them and tells me it is just more of the same spots that I have on my back, arms and legs. I have had many removed by her but it costs a lot of money. The itchy liver spots on my back are covered by my insurance but no others. Are there any proven home remedies that I can use on skin tags and moles?

A: Skin tags are literally flaps or tags of skin that appear on the body. The most commonly affected areas are the neck, underarms, eyelids, under the breasts and the groin folds. Anyone can develop skin tags at any point during their lifetime but the most prone individuals are the elderly and women. Weight gain can be a factor.

Fortunately the lesions are very common and harmless so nothing need be done unless the tag is especially large or in a place that causes pain due to pressure and rubbing, such as under the strap of a bra or belt. Removal is easily done by a family physician or dermatologist in the office either by scalpel, cryosurgery (freezing) or electrosurgery (burning with electrical current). Home remedies include tying dental floss or thread tightly around the tag to remove the blood flow, covering the lesion with clear nail polish and more.

Moles are skin growths that are typically black or brown and can occur alone or in groups anywhere on the body. Most appear between early childhood and age 30. It is common to have between 10 and 40 moles by adulthood. Moles slowly change over time, becoming darker and/or raised. It is also common for hairs to develop on the lesion. In some instances, they may even disappear over time.

There are several types of moles. Congenital nevi (those that appear at birth) may be more likely to develop into melanoma (cancer). Dysplastic nevi are moles that are larger than a pencil eraser with irregular borders and coloring. These, too, are more likely than common moles to develop into melanomas. Individuals with these type usually have more than 100 such lesions over their bodies. Any mole may become cancerous so it is important to check on them, either through a yearly dermatological visit or by a primary care physician. If any change is noticed (shape or size, bleeding, scabbing, oozing, etc.) then an appointment should be made with a physician or dermatologist for a professional inspection and possible testing if appropriate.

That said, most moles are harmless, and like skin tags, don’t need to be removed or otherwise treated unless cosmetic reasons, such as if a large lesion appears on the face or if the mole(s) causes pain such as from rubbing against clothing or jewelry.

Warts are the result of an infection by the human papillomavirus (HPV). There are more than 60 strains such as common, plantar or genital types. Based on your question, I assume you mean common warts so that is what will be discussed in this column.

Common warts appear on the hands, fingers and near the fingernails. Contrary to popular belief, warts are not a result of uncleanliness or touching frogs, but rather direct contact (either person-to-person or person-to-object) with the virus.

Treatment depends on the location, size, type and severity of the wart. Plantar warts which appear on the bottoms of the feet are much more difficult to treat than are common warts. Genital warts can be cured and it is true that many recur but it is equally true that up to 20% will resolve spontaneously. Depending on their size, either a medication can be placed on them or they can be frozen or surgically removed. Common warts are generally harmless and may disappear without treatment. Several OTC options are available such as home-freezing agents, medicated bandages, and medicated liquid which is applied then bandaged over. Home remedies include duct-tape, garlic and more. For large, persistent or recurring warts, a dermatologist can offer more advanced treatments such as freezing with liquid nitrogen, surgical removal (via scalpel or laser), prescription medications, and cantharidin which causes the skin blister around the wart allowing the physician to remove the dead portion of skin and the wart.

Liver spots (a misnomer) most commonly appear on individuals over the age of 40. They are brown or black flat lesions that appear on sun exposed skin such as the hands, arms, face and shoulders. They are harmless but because many people may not be able to differentiate between liver spots and moles, it is best to play it safe and have them checked by a health care professional. Treatment is not needed; however, freezing, laser removal and bleaching creams/lotions are available by a dermatologist for cosmetic reasons.

Because your liver spots itch and some are scaly, they may not be liver spots at all. Seborrheic keratoses are similar skin growths that are more likely to cause itching and scaling. I recommend you return to your dermatologist to discuss your situation and to the find what your lesions really are.

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Obesity troubles teen

June 16, 2014 By

Q: I am 15 years old and currently weigh 312 pounds. I have tried eating nothing but vegetables and fruit and working out all day. I have a low metabolism and don’t know how to get my weight under control. It is very discouraging when I work out every day and don’t get any positive results. I have been having back problems and I suspect that it is because of my weight. I don’t know who else to contact and you help so many other people so please help me.

A: Well, you may have a weight problem but I’m impressed with you already because you appear genuine, articulate, and want to turn your life around.

As with so many medical conditions including diabetes, hypertension, thyroid abnormalities and cardiac issues having a genetic component, my first thought is whether your parents or grandparents may have also struggled with obesity. There are countless articles available to indicate that genes can play a role in obesity because genes may influence everything from rates of food absorption to the sensitive nature of our metabolism.

One study in Czechoslovakia was conducted for just this purpose. A registry of twins separated from each other at birth and given to different foster parents found, many years later, that both children were equally likely to be obese and have the same resting metabolic rate, which is a measure of how many calories each will burn while doing absolutely nothing. It didn’t matter whether the foster parents were heavy or thin, what each family ate, or how much they exercised. Ghrelin is one of the hormones that controls hunger, yet it isn’t clear if the problem is simply the production of ghrelin which is produced primarily in the stomach and duodenum, but also how the ghrelin affects receptors in the brain. .

A study at Boston Children’s Hospital involved mice and found a rare genetic mutation that prevented the animals from burning off fat calories. The mutation in the Mrap2 gene led the mice to consume fewer calories, while gaining twice as much weight as they should have, causing the mice to hold on to the fat rather than breaking it down for energy. The researchers found that within a group of obese individuals, the same gene was mutated.

Now, on to other possible causes for obesity that include leading a sedentary lifestyle, consuming more calories than are burned off, and some medical conditions. In order to lose weight, an individual must take in fewer calories a day than he or she burns. Let me give an example of losing one pound per week. Many individuals must reduce their caloric intake by 3,500 calories in that time period. This is easy enough to do simply by eliminating that candy bar after work each day or a treat that contains 500 calories. Keep in mind, however, that if a person is already at his or her maximum efficiency for weight, it will differ from someone who is weight-deficient and someone else who is overweight. The body will react differently to different situations.

I recommend you make an appointment with your physician for an examination, lab work and possibly other testing if appropriate. Should you have undiagnosed hypothyroidism, Cushing’s disease, or depression, there may be a correlation with your increased weight. If you are currently taking seizure medication, steroids, some antidepressants or even a drug for high blood pressure, they, too, could cause your weight gain. Ask if a referral to your local hospital’s dietitian is appropriate. Exercise regularly and by all means, maintain a positive attitude. Help is out there for you.

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Causes for itch elude woman’s doctors

June 12, 2014 By

Q: I have been a reader of your column for many years. I am a female, 54, of normal weight, and lead a healthy lifestyle. I never suffered from constipation but am at my wit’s end because of an intolerable anal itch that has developed during the last couple of months. I ruled out a GYN problem and saw a rectal surgeon thinking it may be from a hemorrhoid. Except for the significant inflamed area, both the gynecologist and rectal surgeon didn’t see anything wrong. The rectal surgeon said there was a very small internal enlarged vein that could not cause the problem, so he diagnosed me with anal pruritis and prescribed Prax. Pruritis is just a Latin term for itching, as you know, so he really did not enlighten me.

I have used almost all available OTC ointments and creams and also prescription strength hydrocortisone. The itch is worse in the morning and at night. It subsides during the day when I sit. I hope that you will be able to advise me on some alternative remedy.

A: Some of the most common causes for anal itching may be from pinworms (a parasite seen primarily in young people), fungal infection, a hemorrhoid (external or internal), the dyes on toilet paper, or from irritating foods such as spices, peppers and hot sauces that are expelled through a bowel movement. The presence of continuous moisture to the area from liquid stools, diarrhea or incontinence may be to blame, since moisture increases the possibility of anal infection – particularly in patients diagnosed with diabetes and HIV. Factors that increase a person’s risk for developing an anal itch include having psoriasis, seborrhea, dry skin conditions, diet, fecal soiling, genital warts, diarrhea, profuse sweating, a fissure, moisture from wearing wet clothing such as a swim suit, in rare instances cancer, or from fistulas. A fistula is an abnormal connection between an organ or intestine and another structure. They are generally caused by injury or surgery but can also be the result of of an inflammation or infection.

The cause for an anal itch can often be determined by having a physician taking a history and performing an examination. Signs of such things as infection are relatively easy to identify and will likely cause the physician to perform a culture in order to determine what type of germ is involved. Should the problem be pinworms, they may not be seen during the day, so a physician may have the patient pit a piece of Scotch tape over the anus, allowing the minute pinworms to be caught on the tape. Because you have already determined that sitting diminishes the itch, you might find that moisture or friction might play a role in your ongoing problem. A protective barrier such as glycerin, aluminum hydroxide gel, white petrolatum, zinc oxide, or cod liver oil might provide relief. Astringents such as witch hazel, calamine and zinc oxide will promote dryness to the area which may help relieve itching, burning and pain. On the home front, the area should not be scrubbed with soap and water but might be cleaned gently with a baby wipe.

You have already gone the cortisone route; however, have you considered that the itch may be from pin worms? Were this to be true, anti-parasitic pills obtained via prescription from your physician might be in order. The Prax you are taking is an over-the-counter anesthetic. Whatever the cause, you need to be examined by a top-notch physician at a nearby teaching hospital who can get to the bottom of things (no pun intended) and get you back on track. Good luck.

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Patient should seek help at a university dental school

June 11, 2014 By

Q: In the past you answered a question involving BMS. Your advice was correct but could have gone one step further. As a pathologist with dual dentistry and medicine degrees, I am very familiar with BMS. You could have also suggested the patient seek help at a university dental school where there are oral; pathologists and oral medicine specialists who deal with these issues on a daily basis. The patient in question said they had gone to the Mayo Clinic so it sounds like he or she is in the Minnesota area. There is an oral medicine clinic at the University of Minnesota.

I have to add that I read your column every day and find your responses spot-on, both educating patients about their conditions and including the limitations of what we doctors can and cannot do; a very balanced approach. Thank you.

A: Thank you for the compliment and you are correct in that I could have referred the reader to a university dental school for follow-up. I often indicate patients should be seen by physicians in this and other facilities but guess I just have dropped the ball this time.

BMS (burning mouth syndrome) is a complex syndrome in which the tongue, lips, cheeks, roof of the mouth or areas of the entire mouth feel as if they have been scalded. There may be a loss of taste, a metallic taste in the mouth, with increased thirst. Interestingly, the condition may last for months or years and in rare instances, may rapidly dissipate or occur less frequently.

Primary burning mouth syndrome presently doesn’t have a specific cause. It may be related to issues with taste and the central or peripheral nervous system; however, secondary burning mouth syndrome is known to be caused by an underlying medical condition such as having an allergy, gastroesophageal reflux disease, oral thrush, dry mouth from a variety of medications (specifically those prescribed to treat hypertension),diabetes, hypothyroidism, wearing poorly-fitting dentures heart problems, anxiety, depression, or issues with the salivary glands, or even because of a nutritional vitamin B deficiency. The risk of burning mouth syndrome increases if a person has a URI (upper respiratory infection), has had recent dental procedures, is on specific medications, has had a traumatic life event, or is depressed. The condition affects women more than it does men and between 30 and 50% of patients improve spontaneously.

Unfortunately, burning mouth may be a diagnosis of exclusion, meaning there is no one test to provide a definitive diagnosis so several may have to be ruled out. Because of the dry mouth aspect, salivary testing will confirm whether there is a reduction in salivary flow, an oral culture may help zero in on fungal/bacterial/viral infection, and lab work may provide additional information that will help with making the diagnosis. Should the problem continue, an MRI, CT or other imaging tests may help rule out other condition.

Self-help on the home front may improve burning mouth. Alcohol and alcohol-containing products should be avoided because of potential irritation of the lining of the mouth. Spicy foods should be avoided, as should those foods that contain cinnamon and mint. Foods high in acids including orange juice, soft drinks, coffee and tomatoes should be avoided, as should highly spiced foods. Patients should consume more fluids. Lastly, reducing stress should also be attempted.

So readers with burning mouth syndrome, attempt the home remedies recommended and by all means consider making an appointment with a university dental school near you. You’ll be glad you did. And now I’m glad I did (make the recommendation).

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