Your cholesterol has been perfect ever since you started that new medicine, but now your muscles hurt. The statins are an extremely popular class of medication used to lower cholesterol and prevent conditions like heart attacks and stroke. The most popular ones are atorvastatin/Lipitor and rosuvastatin/Crestor. Although statin-related muscle pain is a hot topic, it occurs much less often than the statin naysayers claim. People who do experience pain tend to notice it most when rising from a chair, climbing stairs, or raising their arms above their head. The pain may actually be from other medical conditions (like thyroid disease or low vitamin D levels) or interactions between statins and other medications, such as colchicine (for gout), niacin and fibrates (also for cholesterol), cyclosporine (for suppressing the immune system), and steroids. Also note that grapefruit juice can increase blood levels of statins and cause muscle pain, but only if you regularly imbibe more than eight ounces per day. If you think your muscle pain is from your statin, speak to your doctor. Switching to another statin may be enough to fix the problem. Although statins do lower coenzyme Q10 (CoQ10) levels, there has been no compelling evidence that CoQ10 supplements prevent statin-associated muscle pain.
You’re taking antibiotics for a urine infection or diarrhea, and you have sudden pain and swelling in one joint. An antibiotic known as ciprofloxacin/Cipro, commonly prescribed for urinary tract infections and diarrhea, can cause irritation and even rupture of muscle tendons. The risk is highest during exercise. Try to slow down your exercise regime until the pills are finished. If you experience sudden-onset pain in or near a joint while taking this medication, call your doctor right away.
You recently walked around in the woods or in tall grasses, and now you have new-onset joint pain. Lyme disease results from infection with Borrelia burgdorferi, a kind of bacteria transmitted by deer ticks. In most people, the first sign of Lyme disease is a rash that looks like a bull’s eye (or the Target logo): a large red spot surrounded by a red circle, with normal skin in between. Other symptoms include fever, chills, and body aches. Over the following weeks to months, many people experience pain that moves from one joint to another. Your doctor can diagnose Lyme disease with blood tests. Antibiotics are very effective but need to be taken for several weeks.
You have pain in a few joints and some new skin lesions a few days or weeks after a night (or day) of unprotected passion. Gonorrhea can spread beyond your naughty bits to involve your joints and skin. The skin lesions usually look like small pimples scattered on your arms and legs, and the pain can affect multiple joints at once. You may not have the usual signs of a sexually transmitted infection, like discharge from your nether regions. Your doctor will test your urine, blood, and joint fluid for gonorrhea and start you on antibiotics. (You’ll have to let your partner or partners know they need treatment too.)
Your muscles constantly feel sore and tender, even after rest. You may have a condition known as fibromyalgia, which causes widespread muscle pain that gets worse with stress, exertion, poor sleep, and exposure to cold. Additional symptoms include fatigue, numbness and tingling, headache, insomnia, poor concentration, and depression. A regular exercise program and the frequent use of relaxation techniques (like meditation) may significantly improve your symptoms. If they don’t, your doctor may prescribe medications. Some antidepressant medications (duloxetine/Cymbalta, amitriptyline/Elavil) and antiseizure medications (gabapentin/Neurontin, pregabalin/Lyrica) are particularly effective.
You have sudden-onset pain, redness, and swelling in your big toe. You may be experiencing a gout attack. In this condition, tiny crystals of uric acid form in a joint and trigger the immune system. Gout usually affects the big toe but can also occur in the knee, ankle, wrist and elbow. Get a same-day appointment if possible. If it’s your first episode, your doctor may remove some fluid from your joint to confirm the diagnosis.
Gout attacks are treated with pain relievers and, in some cases, steroids. Your doctor may prescribe medications (colchicine/Colcrys, allopurinol, febuxostat/Uloric) to help prevent further attacks. If you take diuretics to lower your blood pressure, they can increase the risk of attacks, so your doctor may swap them out with other medicines.
People with gout should reduce their intake of foods that increase the risk of future attacks, like meat, seafood, fruit juice, high-fat dairy (whole milk, ice cream), nondiet sodas, and candy. They also need to stay hydrated and try to lose weight, if possible. Of note, eating fresh cherries on a regular basis may help prevent attacks. (You should hold off on the ice cream sundaes, though.)
Get to the E.R.
One of your joints recently became swollen, warm, red, and very painful. You may be experiencing a gout attack (see previous section) but could also have a bacterial infection inside your joint. In the latter case, the joint can sustain severe damage if it isn’t promptly cleaned out and treated with antibiotics. To determine the correct diagnosis, a doctor may need to use a needle to withdraw fluid from the joint.
You have pain in your thighs or shoulders, and your urine has turned dark red or brown. You may have widespread muscle breakdown, a condition known as rhabdomyolysis, which causes pain and swelling in your muscles. The broken-down bits of muscle fiber can turn your urine dark red and plug up your kidneys, causing kidney failure. The many causes of rhabdomyolysis include crush injuries, prolonged immobilization (people who can’t walk and get stuck in a certain position), excessive exercise, seizures, heat stroke, certain medications (statins, colchicine), alcohol, and drugs (like cocaine, heroin, and amphetamines).
Part 8
Skin and Hair
Excessive Sweating
Afraid to raise your hands above your head? Worried that when you show up on a first date, you look like you’ve just been swimming, or that you smell like a high school locker room?
The evaporation of sweat helps you cool down, and millions of sweat-producing glands are located all over the body, particularly on the forehead, palms, and soles. If you’re working out nonstop, you can produce several liters of sweat each day. (Think about that the next time you hit the gym without a water bottle.)
The sweat on your forehead and palms may lead to some embarrassing pictures and handshakes, but it doesn’t smell bad. A subset of your sweat glands, located in your armpits and groin, are responsible for your musk. They produce a special type of sweat that is thicker and milkier than the water-like sweat produced elsewhere. When your skin bacteria feast on this creamy goodness, they generate your signature aroma—which, in much simpler times, would help attract a mate. (Now we have sports cars and Tinder profiles for that.) The hair in these areas acts like a sponge to soak up and retain your characteristic stench.
Sweating becomes excessive when it is not clearly related to body temperature and causes anxiety and embarrassment that interfere with your quality of life. About one in twenty people experience excessive sweating, also known as hyperhidrosis. The good news is that you’re probably not sweating like a pig. In fact, pigs do not sweat, so it is more accurate to say you are sweating more than a pig.
So should you just start bringing extra shirts to work? Or is it time to see your doctor? (After a shower, please; there are other people in our waiting rooms.)
Take a Chill Pill
You come from a long line of sweaters. If you have excessive sweat around your palms, soles, and armpits, you may have an inherited sweating condition called primary hyperhidrosis. (Scan the table for pit stains at your family’s next Thanksgiving dinner.) Of note, the problem usually begins before age twenty-five and does not occur during sleep. The condition isn’t dangerous, aside from an increased risk of skin infection. Nonetheless, you should let your doctor know, just in case he or she wants to check for other causes of sweating. The main treatment is aluminum-based antiperspirants, which should be applied at night to maximize effectiveness. (The aluminum will form a seal in the sweat glands when you’re resting and dry, and it will not wash off in the shower the next morning.) Also try alternating
your shoes every other day, giving each pair time to fully dry, and using relaxation techniques to help calm your nerves. If these measures fail, your doctor may offer prescription-strength deodorants—strong enough for a horse, but made for a human?—and, as a more desperate measure, injection of Botox into the bothersome areas. The Botox will “paralyze” the sweat glands and help them stay dry.
You’re having hot flashes. One common symptom of menopause is hot flashes, or waves of heat and flushing that briefly overtake the face and chest. Unfortunately, hot flashes can continue for years and seriously interfere with your life. The underlying problem is the decrease in estrogen, which messes with your body’s temperature control center. The simplest solution is to dress in layers and rapidly shed clothes when a flash occurs. If symptoms become frequent or severe, speak to your doctor about hormone replacement therapy, which restores normal estrogen levels and helps quell flashes. If you’d rather avoid hormones, many medications used as antidepressants can also eliminate flashes.
You’re in the final throes of a cold or flu. When you get an infection, your body raises its temperature goal to a higher level. You bundle up, shiver, and shake until you reach the target—a fever. It’s thought that the higher temperatures of a fever actually help fight infections. Once the infection is over, your body resets its temperature goal back to normal, and you sweat profusely in order to cool down until the fever breaks. (Of note, if you take medicines like acetaminophen/Tylenol to lower your fever, the sweats may arrive and the fever may break before the infection ends.) If the sweats last for more than a day or two, however, you may have a lingering infection or something much worse (see the next section).
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Quick Consult
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A Nagging Fever
Feeling hot and bothered? Fever is usually associated with other symptoms, covered elsewhere in this book, but can sometimes occur on its own. Should you just pop some meds, stay home from work, and wait for it to pass? Or is your body trying to warn you about something more serious?
First, a quick review of the basics. Your brain normally keeps your body’s temperature within a narrow range. You generate heat by burning calories, either due to normal metabolism or exercise, and retain that heat under your clothes. When your temperature gets too high, your brain prompts you to take off some clothes (as immortalized in Nelly’s hit song “Hot in Herre”), so the heat can radiate off your skin. You also sweat, since the evaporation of fluid cools your skin, and lose some heat in your breath. When your temperature gets too low, your brain tells you to put the clothes back on (sorry, Nelly), and you also shiver to burn calories and generate heat to warm back up.
A fever is usually defined as a temperature of greater than 100.4°F (or 38°C, for our overseas fans). Having a fever means your body has increased its target temperature, usually to fight an infection. (The higher temperature makes your body a more hostile environment for invaders.) In some cases, however, a fever gets triggered by conditions other than infections—such as cancer, autoimmune diseases, blood clots, brain injury, and severe physical stress.
An isolated fever is not itself dangerous unless your temperature is extremely high. (If your temperature is above 104°F, go to the E.R.) The underlying problem usually becomes more obvious if you wait another day or two. In the meanwhile, you can take acetaminophen/Tylenol to combat the fever. If, on the other hand, your fever lasts for three or more days without any signs of a cold (congestion, runny nose, sinus pain), flu (diffuse muscle aches, headache, fatigue, cough), or other infection, you should see your doctor. You could have an internal infection (such as within the heart), or one of the other conditions listed earlier in this section. Depending on how long you’ve had a fever, and what your blood tests show, your doctor may order a scan to help find a diagnosis.
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Make an Appointment
You’re also losing weight. An increase in your overall metabolism can produce weight loss and excessive sweating. Indeed, frequent sweating and weight loss (in the absence of constant exercise) can be a sign of conditions like an overactive thyroid gland, certain types of cancers (such as lymphoma), a brewing infection (like HIV/AIDS or tuberculosis), and generalized anxiety disorder. Your doctor will perform blood tests to help identify the likely cause.
You’re soaking through your sheets. Night sweats, by definition, are severe enough to make you change your sheets or pajamas. They can be a sign of a life-threatening disease or, well, nothing at all. First things first: make sure your room does not get too hot overnight and that you’re not sleeping under an oppressively thick blanket. Next, if you have diabetes, check your blood sugar in the middle of the night, as it may dip while you’re sleeping and cause sweats. If you wake up with a bitter taste in your mouth, you may have acid reflux (see here), which sometimes causes night sweats. Try elevating the head of your bed and taking medications to deacidify the stomach. If all else fails, speak to your doctor, as you may need to be evaluated for conditions that increase your metabolism, like thyroid disease, infection, and cancer.
You take insulin. If you have diabetes and take insulin to lower your blood sugar, hopefully you’re checking your numbers on a regular basis. If not, your frequent sweating may be a sign of low blood sugar (a.k.a. hypoglycemia). Get a glucometer and check your sugar the next time you start to sweat. If your sugar is below sixty, drink some juice immediately to bring your level back to the normal range. Call your doctor right away to adjust your insulin dose.
You have brief episodes of sweating along with headache and/or palpitations. You could have a rare tumor known as a pheochromocytoma, which releases periodic surges of adrenaline. The tumor usually arises from the adrenal gland (perched right on top of the kidneys). Many patients with pheochromocytoma also have elevated blood pressure. Your doctor can perform some blood and urine tests to make the diagnosis.
You have brief episodes of sweating along with paralyzing fear. You may suffer from panic attacks, which are rapid-onset episodes that cause fear along with symptoms like sweating, shortness of breath, chest pain, and palpitations. Full-blown panic disorders, characterized by recurrent attacks, usually start in your twenties or thirties and are twice as common in women as men. Because panic disorders are so disabling and the available treatments so effective, it’s essential to seek help as soon as possible.
Don’t sweat it, it’s just your medications. Medications are a common cause of sweating, flushing, and night sweats. The biggest culprits are antidepressants, which cause excessive sweating in about 15 percent of users. Other potential causes of sweating include pain medications like acetaminophen/Tylenol and nonsteroidal anti-inflammatory medications, or NSAIDs, especially if they’re being used to treat a fever; heart medications like niacin, calcium channel blockers, and nitroglycerin; migraine medications (triptans); hormonal agents used for prostate and breast cancer; and sildenafil/Viagra. Please speak to your doctor before stopping any of your medications.
There are ninety-nine bottles of beer on your wall. Alcohol can cause flushing and sweating in certain individuals, particularly those with certain genetic variations (most common in Asians) that make them slow metabolizers. Of note, heavy drinkers (more than four to six glasses per day) who suddenly abstain can experience profuse sweating during withdrawal, along with nausea, vomiting, insomnia, palpitations, tremor, and agitation. If untreated, withdrawal can progress to life-threatening complications, like seizures. The symptoms of withdrawal usually start one or two days after the last drink. If you think you could be in alcohol withdrawal and can’t get a same-day appointment with your doctor, head to the nearest urgent care center or E.R.
Get to the E.R.
You have a very high (greater than 104°F) temperature. Your body is likely reacting to a major stressor, like an infection or problem in your brain, and pouring out sweat in an attempt to lower your temperature. You need to be seen right away—not only to address the underlying issue, but also because a really
high temperature (higher than 106°F) can seriously harm your organs. An alternate but equally dangerous explanation for your very high temperature is heat stroke, which occurs when you have prolonged exposure to a hot environment and can’t keep your internal temperature under control.
Itchy Skin and Rash
EDITED BY LINDSEY BORDONE, M.D.
Are you comfortable in your own skin? Hopefully you are in the figurative sense. (You’re amazing!) But are you also literally comfortable in your own skin? Does it provide a comfortable outer surface to your body, and is it mostly free of marks, stains, and holes?
Your skin is by far your body’s largest organ. (Accordingly, this is one of our longest chapters.) If you removed all your skin, which we strongly discourage, it would weigh twenty to thirty pounds. Your skin contains three layers: the epidermis (the outermost, waterproof layer), the dermis (home of sweat glands and hair follicles), and the hypodermis (connective tissue and fat).
Am I Dying Page 19