Low quality research, infectious mononucleosis, and clinical experience.

 

People and doctors think twice

For a test that’s ten times the price

When for a positive test

The treatment is rest

And the quick, easy lab seems so nice. 

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In 2010, I danced back from the brink of burnout and traveled for a year doing temporary medical assignments from Barrow, Alaska to New Zealand’s South Island.  I’m now working at a Community Health Center part-time, which has come to mean 54 hours a week.

Eight viruses belong to the human herpesvirus family.  Herpes 1 brings cold sores or fever blisters; herpes 2 gives the recurrent STD blisters.  Herpes 3 is the Varicella-Zoster virus and gives rise to chickenpox and shingles.  The Epstein-Barr virus belongs to the same family, and causes infectious mononucleosis, or mono.

My personal experience with mono came in January of 1969, with a sore throat, nausea, loss of appetite and headache.  I dragged myself to the Department of University Health, got a blood test and went to sleep for the next week and dragged myself back.  The doctor declared I did not have mono.

I didn’t get better, and 8 weeks later dragged myself to a different doctor in the same building who announced the diagnosis of mono.  No, I replied, the other doctor told me the test came up negative.  Well, he said, look at the lab slip.

Sure enough, someone had written the word POSITIVE on the yellow 3×5 lab slip.

They used the Beef Heterophile Agglutination test back then; the updated version carries the trade name MonoSpot.

Twenty percent of the population cannot make the chemical that causes the reaction; we now have sophisticated confirmatory tests that can distinguish between mono acute, chronic, recent past, distant past, and not mono.  But it costs ten times more than the Monospot.

Chronic mono happens but not very often; those patients who get it have other problems with their immune systems.

I had to explain those things to a patient Wednesday who kept having problems with recurrent severe sore throats (and who gave me permission to include a good deal more information than I have) for years.

The standard treatment for mono boils down to six weeks of bed rest.  More common non-standard treatment includes steroids.

No one would use the word brilliant to refer to the research done last century on the use of Tagamet (cimetidine) in mono.  The patients in each arm numbered in the few dozen.  The publication did not mention the dose.

Within 5 years of reading the article I had personally treated more mono patients with cimetidine than had been in the original study.  After 10 years, I could tell my patients my clinical experience: 25% of mono patients bounce back dramatically under Tagamet in less than 24 hours, 50% bounce back but less dramatically in less than a week, and 25% do not respond.

The patient considered the costs of the lab tests and the cost of the generic cimetidine, and decided for treatment.

I’ll know the outcome next week.

Hepatitis, joint pain, and missing the solution to the mystery

To what disease do the symptoms belong,

When dark urine lacks odor so strong?

     I made a few points

     When I asked about joints

But the truth is I’d rather be wrong.

Synopsis: I’m a family practitioner from Sioux City, Iowa.  While my one-year non-compete clause ticks away, I’m having adventures working in new places and visiting friends and relatives.  Right now I’m staffing a clinic in Keosauqua in southeast Iowa.

My month in Keosauqua draws to a close tomorrow.

A patient (who gave me permission to write this information) came in today with a puzzling constellation of symptoms for two weeks: fatigue, malaise, chills and sweats, joint pain, morning stiffness, abdominal pain, vomiting and diarrhea.   The fingers on the right hand were swollen, visibly larger than those of the left hand, and index and middle fingers had swelling of the knuckle joint close to the hand.  I found other abnormal items on the physical exam, my fingers gliding over tiny, painful lymph nodes at the inside of the upper arm, just above the elbow.

On the basis of an impulse whose source I do not know, I asked the patientiof the color of stools had lightened and that of the urine had darkened.  They had.

At the end of the visit I said, “You want me to be wrong about everything I’m thinking of because the best diagnosis we can hope for is infectious mononucleosis.  That’s the best one.  You don’t want rheumatoid arthritis, Lyme disease, or hepatitis, or any of the worst things that I can think of.  And I suppose it’s possible that it’s work related.  We’ll have to see.”

Not widely known, but the rheumatologists make the diagnosis of hepatitis B more often than the gastroenterologists. Early in the course of the disease, any hepatitis can look like rheumatoid arthritis.  Patients can, and do, have severe joint pains without any abnormality of the liver function tests. 

Hepatitis B should be prevented by immunizations administered in infancy.  However, some parents choose against immunization (which I find foolish) and a very few people will not make antibodies in response to the vaccine.

Hepatitis C can cause similar joint pains, but usually doesn’t.  Mostly it causes an overall sensation of fatigue, less often the classic signs of hepatitis, with jaundice and swollen liver.

In medical school, hepatitis came in the classifications of infectious and serum.  By the time I finished residency, infectious hepatitis bore the name A and serum hepatitis was called B.  The third one, called non-A non-B hepatitis, eventually found the name C.  Ten years ago, hepatitis C mostly smoldered along and every once in a while resulted in liver cancer.   Five years ago we had a cure rate of 10% and now we have a cure rate better than 50%, and improving.

In the end, the patient’s diagnosis will come from lab work, but by the time the results come back I will have moved on.  I will not witness the denouement, the answer to the mystery.

At the end of the afternoon, I introduced the patient to one of the other docs here and made arrangements for follow-up.

The patient lives in a world, a social context with relatives, friends, and a job or two.  I will miss out on seeing how the disease affects the person and the world around them.

I will wonder.