Chest pain that is not a heart attack

Angina pectoris or chest pain is an ominous symptom which is caused by heart muscles not receiving enough oxygen for its work of "perpetual" pumping. This great mass of muscle actually gets its oxygen from blood brought by arteries that crisscross it. Yes, though the heart contains and pumps blood, it has its special delivery system of  oxygen-laden blood from small arteries springing right at the base of the aorta, that big artery that receives blood as it is pumped out of the heart to supply the rest of the body.

But what about chest pain that is not at all related to an oxygen-starved heart?

There are other causes of chest pain and among the most common is arthritis of the breast bone to rib joint or the costochondral joint. Costochondritis can be mistaken for a heart attack in many occasions and can cause unnecessary laboratory examinations intended to check the heart to be ordered.  ECGs are routine and can be superfluous in this condition. How then can costochondritis be discerned?

from: Google images, mayoclinic.com

There are ways to differentiate costochondritis from a heart attack. First is to suspect it when the pain is movement-related (twisting the torso, for instance) and happens to occur in a young individual, especially females. A specific kind of costochondritis,  Tietze's syndrome, affects females in their 20's and involves the 2nd left rib to breastbone joint, so that the pain it produces is right smack where pain of heart attacks is felt - mid chest. Second, the pain is lancinating and quite severe, but is usually not associated with cold sweats and the "sense of impending doom", which occurs with the chest pain of heart attacks. More so, save for the pain and the rapid heart rate it can produce, costochondritis is not related with serious breathing difficulty and blood pressure problems, as seen quite commonly during heart attacks.  Costochondritis cause pain in the affected chest on pressure over the area, while this does not occur in heart attacks, where the pain is deep and persistent.

It is however, prudent to relate matters like these to family histories of heart attacks or ailments, as well as, lifestyle risk factors like smoking, sleep deprivation, dietary excesses and diabetes. Despite age, a person with chest pain will warrant a thorough check when the above conditions are present.

from Goodle images

The other common cause of chest pain that happens not to be a heart attack is the viral infection Herpes zoster, when it erupts along the spinal nerve of the nipple line. Chest pain is usually more superficial than deep, also severe, and then in about 2 weeks, chicken pox-like eruptions appear over the affected part of the chest. That would clinch the diagnosis, but in the early phase, the pain can be so distressing and cause the patient to be worked up for a heart problem. It is advised that superficial gnawing pain with unusually sensitive skin in localized areas of the chest warrants observation and monitoring for the appearance of skin lesions. Early treatment is necessary to shorten the course of the rash and the disease in general.

Do you have chest pain? In addition to heart attacks, think joints and skin conditions!

Aurora's Fingers

If you are one who awakens at dawn to feel around for your first 3 fingers, you could well have carpal tunnel syndrome or CTS, a malady I have had for the past 3 years and which I fondly call aurora's fingers (did Aurora, goddess of dawn, have it?). 

photo from Google images

Carpal tunnel syndrome is a disturbing hand disease that causes sensation of pins and needles, and numbness of the first 3 fingers (start with the thumb) and half of the ring finger, especially at dawn (aurora). During the first months, the symtoms can be fleeting, a few dawn awakenings due to numbness, and relieved by shaking the hands. Later, these symptoms become more intense, prolonged and associated with weakness of the thumb and index finger grip, or the pincer grip. Each dawn becomes a misery as sleep and the pins and needles vie for the few more minutes of slumber till morning sun.

There are many possible causes including inheritance, age, work-related causes,  as those seen in jack-hammer operators and long distance drivers and other events that cause pressure inside the carpal tunnel, (where the nerve that gives sensation and strength to the 3 1/2 fingers is lodged), to rise and create the nerve pinch. Perhaps for me, it's stick driving, and the vibration of  the wheel during the frequent long drives I do daily.

Rest from repetitive or wrist-intensive hand activities is paramount for relief during the early days of the disease and  a CTS splint can be helpful, but only for a time. Nerve-pain relieving drugs, and injections into the carpal tunnel are also known to relieve the pain. Don't wait though, for the pincer grip to be compromised to the point of being "clumsy", frequently dropping utencils and hand-held stuff.  Decreasing the carpal tunnel pressure by surgery can be a permanent cure.

For those with the inherited trait, prevention may not work, but those who don't have the symptoms yet might have to avoid some activities (operating jack-hammers, vibrating equipment, etc.) 

Common and disturbing as it is, it is far from life threatening and many an elderly chap or lady have lived with the aurora fingers, albeit, with misgivings. 

Is arthritis fatal?

As a big group of diseases, lumped as one in common knowledge as "rheumatism" -  no, arthritis do not kill. Surely, it can mame and relegate the arthritic to a life of pain, but in the lay mind's mind, nobody dies of arthritis.

However, there are arthritides that can cost a life. Mostly, these are the untreated, undiagnosed  ones, albeit, rare, still, a fact that one should be vigilant about. The key to avoiding the fatal effects of some rheumatic diseases is early diagnosis and treatment.

Here is a short list of serious types of rheumatic diseases that may directly cause death if left untreated for long:
1. Uncontrolled/untreated lupus
     nephritis or kidney inflammation
     lupus lung hemorrhage
     lupus blood disorders
     lupus brain inflammation
2. Lung and brain hemorrhage of Bechet's syndrome
3. Vasculitis or inflammation of blood vessels especially those in the heart, lungs and brain
4. Blood clots in the lungs in hypercoagulable conditions like APS (antiphospholipid antibody syndrome), and catastrophic APS when many other organs of the body are involved
5. Progressive systemic sclerosis (generalized form of Scleroderma) and  CREST syndrome with their associated pulmonary hypertension

List of complications of arthritis and/or treatment that have proven fatal in the long run:
1. kidney disease of gout
2. Stomach and intestinal bleeding due to unsupervised intake of pain medicines
3. Kidney disease from unsupervised intake of pain medicines
4. Presence of other diseases in the arthritic individual, like diabetes, infections anywhere in the body, heart failure, liver disease, high blood pressure
5. Intake of alternative medicines that can have kidney and liver side effects

It is therefore prudent advise to see a rheumatologist early in a disease with symptoms of joint swelling and pain. 

Some like it hot!

Have you noticed how achy joints get stiff on a cold morning?

This is a major dilemma for many arthritis patients who plan to travel to a colder country. You see, in most parts of the Philippines, a cold December or January means a 25 degrees centigrade and summer is easily a 37. And for many of my patients, at 25 C, the joints complain!

This observation is common and hypotheses abound as to why the so-called "gelling phenomenon" of arthritic joints happen. It is said that the lesser motion during sleep may cause inflammatory elements to remain in the joint areas and cause more tightness and consequently, pain, as the patient starts to move on awakening. Pain on the other hand, is chronic in most of the arthritides, and chronic pain can make an individual sensitive even to a slight touch, temperature/weather change or anything at all, that ordinarily should not cause pain. This is called allodynia, a close equivalent to lowered pain threshold. So, we happily "blame it all on the weather".

The association of cold and achy joints is very strong for some patients and yet, in my experience, as soon as these patients from the tropics get to the colder countries, many if not all, report back that their arthritis has not intensified, or even, that the pain had gone altogether. 

The explanation? Your guess is as good as mine. I do tell my patients who worry about such trips to temperate countries to go and enjoy their visit, because, the weather may not matter after all. Still, the standard advise to get that extra warm mitten or socks, just in case, is still to be given, just in case.

Tendonitis, a sequel

In posting "On fire and frozen...", saying no thank you is many times, not an option. And you are right, after 3 trips in 2 months, lugging baggages around, my left bicipital tendons gave. It is different reading it in books, and having it for real. But this just shows that rheumatism respects no one, and certainly, makes sure that all would experience one form or another of this painful malady in his/her  lifetime.

The good thing about having bicipital tendonitis is that I now actually feel what the patient tells me he feels. That is a good thing, and gives a human side to an otherwise automatic reaction by a doctor to a patient's cry. Suddenly, the pain is lancinating, gnawing, with the patient in real distress - according to MY shoulder!

Being a rheumatologist gives you a plethora of interventions to choose from. What did I choose? A self-made bicipital splint made of an adhesive plaster and tying it around the arm nearest the shoulder,  where it hurts. In addition, an NSAID liniment.

Principle? Fix or splint from too much distending motion, the insertion of the bicipital tendon.
Is it working now? I would like to think so. I'm in the airport yet again lugging my carry on baggage, using a lighter shoulder bag, and carrying both with my right hand and shoulder, and hoping that the right shoulder does not give.

Principle? Rest as much as can be afforded the poor tendons.

Updates forthcoming. In the meantime, smile and get on with life which does not tarry with pain.

On fire and frozen - tendonitis, anyone?

The shoulder is the most movable joint of the body. Anatomically, this joint is where a shallow socket which is the glenoid fossa of the scapula (wings), meets the ball, which is the head of the humerus or arm bone. Despite this unique arrangement, shoulder joints are kept aligned and intact because of a very competent and strong supporting capsule, criss crossed by tendons to make a surrounding, circumferential cuff called the rotator cuff.

There are 4 of these tendons, and one other tendon just outside the capsule that can cause trouble - tendon of the biceps muscles, with its 2 heads, the short and the long head. These tendons are lodged in a groove along the front of the arm bone, but as how biceps go, we can twist and over exert during lifting, and so we can "over-pull" the tendon. The resulting pain can be exquisite, and each motion of reaching out to the lower back to scratch an itch becomes impossible.

Bicipital tendonitis is quite a common occurrence, and with rest, the biceps tendon quiets down. But some "pulled" tendons don't. The pain smolders and like embers, can be fanned into a full blown conflagration, and rightly so -  continued work or gym-related lifting, pulling and other daily activities, just cannot be avoided. Increasing pain keeps you to move the shoulder less and less.  A week or 2 of decreased shoulder motion gets the rest of the rotator cuff tendons stiff. They later "freeze" to cause the "frozen shoulder".

Biceps tendon  on fire and shoulder cuff frozen - bad combination. It spells sleepless nights, gnawing shoulder pain, painful limitation of activities that in the past you could do without thinking. And for a working and active individual, this is catastrophe, indeed!

What else do we need to know about tendons?

Tendons are  found where there are muscles. They insert muscles to bone, thereby moving the skeleton as muscles move. But there is a catch - they are not well supplied with blood, and this makes healing slow.

Rest is best, with guided physical treatment, using deep and superficial heat or sometimes cold. Please avoid massage during the painful phase, it will only prolong the healing process. Exercises are introduced slowly and designed to allow slow but sure recovery of motion. Some cases count years, with residual limitation on stretching out of arms, but full recovery is possible.

Pain medicines? Not fully helpful. Treatment is applied over the area that hurts, and this can include anti-inflammatory liniments and steroid injection. The latter can effectively remove pain fast, but the recovery of motion takes the slow and long way.

And so, tendonitis anyone? I'd say, no thanks.

Photos from Google images of rotator cuff tendonitis.

Arthritis and mood disorders

Practicing rheumatology is hearing the word pain  - patient in and patient out, on every clinic day, making the practice a class all its own. The rheumatologist sees that pain is handled in as many ways as there are individuals with arthritis. On some occasions, patients react to pain violently enough to create a "transference" of sorts that causes many a rheumatologist to find the last patient's pain already in his own joint.

While pain is the most important protective mechanism of all of animal kingdom, pain lasting longer than 6 weeks or so becomes a "disease". Arbitrarily, 6 is not a magic number, but denotes chronicity and a duration where many processes in the nervous system have been activated to transform the pain complaint into the "pain disease".

I invite you to recall the last time you had a headache. Normally, headaches make a person moody, withdrawn and quiet. Some would try to sleep it off, but not before taking the favorite pain pill for relief. Even then, knowing that this pain would go away does not keep bad mood at bay. Invariably, all sorts of pain, the quick ones like stubbing the toe, or the headaches you can sleep off, can spoil a well meaning day.

Pain of arthritis is a different story. It can be of varying intensity, with gout pain possibly occupying top spot, followed by the pain of ankylosing spondylitis and reactive arthritis. Add to that duration- arthritis pain can be "forever". But wait till a rheumatoid arthritis patient comes in in tears, wanting never to wake up, and you know that this is a different kind of pain. It is as if dying is relief and the only hope. But a patient with arthritis who wants to die is pathetic. Many arthritides mame but do not kill.

We recently held a symposium on mood disorders in the arthritides. This was prompted by our paper which uncovered that about 40% of our lupus patients have anxiety/ depression. This is a high rate and is disturbing, since mood disorders can affect the way patients view the illness, but more important, accept treatment. Likewise, treatment for different forms of mood disorders is available and can spell the difference between a difficult-to-treat patient and the rest of them. Putting principles learned from this symposium, let me cite a case.

Mr D. was admitted yet again for a bout of gout affecting this time, as many as 6 joints. He is bad case of chronic tophaceous gout, with crops of urate deposits, 5X6 cm masses over the hands, elbows, knees and ankles. Dehydrated and irritable, he would only take the medications he was familiar with but had poorly complied. Suggestions to bring in a physical therapist and to call another doctor for his other problems were met with a flat no. Arthritis improved over the next 7 days, but by the 10th day, he still refused to budge from bed due to pain. Finally, I decided to  give an antidepressant. He was smiling the following day (!) and was moving his lower extremities, finally sitting up and dangling legs on the 12th day. He consented to calling the second doctor to check his other problems. It could not have been just the arthritis treatment - the overall recovery was amazingly fast. While anecdotal, it validated what I long wanted to do- treat the patient and not just the arthritis.

One sees the importance of recognizing mood disorders that accompany medical problems that cause prolonged pain. Additional treatment for such disorders may actually make sending a happier patient home easier.