Polymyalgia Rheumatica by Andrew Smith, MD


            “Wow, I guess I’m just getting old.  Everything hurts and I’m tired even doing little things.” Mrs. Jennings, in her early sixties, was normally one of my more energetic patients.  On further questioning it turned out it really wasn’t “everything” that hurt, but particularly the muscles of her thighs and shoulders, not so much her joints.  Her tiredness was notable particularly when she would exert herself, like walking up her back hill.  She would get back into her house from coming up the hill and feel totally out of breath, achy and exhausted.  All this was a rather striking change from just a couple weeks ago when none of this gave her much trouble at all.


Was she right that age had finally caught up with her?  Or maybe she had some hidden cancer, or late-onset rheumatologic disease, or any number of other problems.  Most of the tests came back pretty normal, but an old, simple blood test, the sedimentation rate, was very high.  It’s a non-specific test, but together with her other symptoms and the normalcy of most of the rest of her tests, it pointed to a diagnosis we see only occasionally: polymyalgia rheumatica (PMR).  The clincher would be how she responded to a course of oral steroids.  They tend to work like magic with PMR and that helps confirm the diagnosis.  Sure enough, a week or so after starting the steroids, we had the younger, energetic version of Mrs. Jennings back.  She was again motoring up her back hill like it was nothing.

As with Mrs. Jennings’ episode, PMR involves the rapid onset of soreness in the large muscles of the thigh and shoulders with a sense of weakness and fatigue.  Sufferers are almost always over age 50 and more than twice as many women as men get it.  The cause is not known and is thought to possibly be autoimmune.  As noted, steroids work wonders for PMR and can then be slowly tapered over many months.  The entire course of PMR averages about three years.  It’s one of those diagnoses you don’t want to miss since it’s so debilitating to have, but so very treatable.

Importantly, about 15% of people with PMR also have a condition called giant cell arteritis (GCA), which has also been called temporal arteritis.  GCA involves inflammation of arteries, most commonly the temporal arteries on either side of the forehead.  GCA causes a substantial temporal headache, and if untreated (with higher dose steroids), can even cause sudden blindness.  Mrs. Jennings actually had some temporal pain that came and went.  In the end we had her get a temporal artery biopsy but happily it was normal.

It is always very satisfying, to doctor and patient alike, to see the debilitating fatigue, weakness and achiness of PMT quickly melt away with treatment.  And unlike almost 50% of individuals with PMR, Mrs. Jennings did not experience a relapse.  Several years later, she’s still going strong, motoring up her back hill like its nothing.

Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville. He is contracted with some commercial insurance carriers and sees Direct Primary Care patients who do not have insurance, who belong to a cost sharing ministry, or who are on Medicare. He is accepting new patients. You may contact him at 982-0835

The Black Dog of Depression by Dr. Andrew Smith

The Black Dog of Depression

            “I am the most miserable man living.  If what I feel were equally distributed to the whole human family there would not be one cheerful face on the earth.  Whether I shall ever be better, I cannot tell.  I awfully forebode I shall not.  To remain as I am is impossible.  I must die or be better.”  That quote is by none other than Abraham Lincoln.  Likewise, Winston Churchill referred to his depression as his “black dog.”  Most depressed patients aren’t quite so striking in their descriptions.  They may complain of a loss of interest in things that used to seem important to them, or a general fatigue, or frequent tearfulness, or just a persistent irritability.

Depression may be the 3rd most common psychiatric disorder behind anxiety and phobias, with approximately 15 million Americans experiencing a depression each year. So, since we can all have some bad days or a period of sadness, what, from a medical perspective, defines an actual depression?  According to the most common psychiatric definition, as contained in something called DSM 5, a major depression involves: A depressed mood or a loss of interest or pleasure in daily activities consistently for at least a 2 week period.   Overall functioning must also be impaired by the change in mood.  In addition, at least 5 of the following symptoms must be present:

  • Depressed mood
  • Decreased interest or pleasure
  • Weight change of 5% or more (up or down)
  • Sleep disturbance
  • Psychomotor agitation or retardation – consistently slowed movements or agitated movements
  • Fatigue
  • Feelings of worthlessness or excessive or inappropriate guilt
  • Diminished ability to think or concentrate, or indecisiveness
  • Recurrent thoughts of death and/or suicide

As you read through that list, some of you may be seeing a description of yourself or someone you love.  Before we take a moment to look at what can be done about it, let’s first ask how does someone get here – what causes someone to get depressed?  That can be a complicated question as depression is often the result of any combination of several factors.  Everything from genetics to circumstances and how we think about those circumstances can play a role.  Sometimes chronic stress and anxiety or even physical illness or loss can trigger a depression.

The wide range of causes of depression plays into the several kinds of treatment that are employed.  Primary care doctors are sometimes called the psychiatrists of the masses since the majority of depression treated medically is carried out in primary care offices.  When seeing your primary care physician for possible depression, a number of physical contributors such as hypothyroidism , low testosterone, or medication side effects can be ruled in or out.

If these physical causes are not a significant factor and a major depression is diagnosed, several treatments can be considered.  Starting with simple approaches, regular exercise such as a brisk walk has been shown in studies to sometimes help as much as a prescription antidepressant.  Likewise, informal counsel with any mature friends or family can be helpful.  Pastoral counsel from a trusted pastor is often a further aid in working through a depression.

Beyond these helps, specific medical interventions can be considered.  Formal counsel can often provide further tools to battle depression.  Finally, prescription meds can have their place as well.  These are far from 100% effective and it can sometimes take time to find the one that is most effective for a given individual, but at times they can be enormously helpful.

Depression, as Lincoln said, can be absolutely miserable, both for the individual, and for those around them.  Ideally, it should be responded to as aggressively and directly as a heart attack, since in its own way it can be just as devastating.  So if you suspect the black dog of depression is sinking its teeth into you, get it checked out.

Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville. He is contracted with some commercial insurance carriers and sees Direct Primary Care patients who do not have insurance, who belong to a cost sharing ministry, or who are on Medicare. He is accepting new patients. You may contact him at 982-0835

Maintain Your Brain by Dr. Andrew Smith

Seventy year old Mrs. Lansing drew a complete blank as I asked her if she could recall any of the five words I’d given her to remember some 4-5 minutes ago as part of her mental status exam.  Inwardly I always wince at those moments.  It feels like I’m unintentionally bullying a harassed person into looking the fearful specter of their approaching dementia directly in the eye.  Her husband quickly came to her rescue with a small white lie, “That’s alright darlin’, I don’t remember any of them either,” and we all smiled with relief.

Dementia is the common term for a set of symptoms including memory loss, mood changes, and difficulty with communication and reasoning.  Modern medicine is trying to replace the term with “major and minor neurocognitive disorder”.  Yah, for now let’s stick with the term everyone knows, dementia.  There are several types of dementia, with the most common two being Alzheimer’s disease (AD) and vascular dementia (due to atherosclerosis [plaque] on the blood vessels supplying the brain) coming in a close second.

AD currently affects about 5 million Americans.  There are a handful of approved prescription medications to treat AD.  They delay (but do not stop) the progression of the disease by about 6 to 12 months.  This is useful, but far from a cure.  Likewise various supplements and vitamin treatments have come and gone over the years.  When subjected to careful scrutiny the results have generally been disappointing.  The likelihood of AD dramatically increases with age, roughly doubling in likelihood every 5 years after age 65.  If one lives to 85 years old the likelihood of having AD is almost 50%.

So can anything be done to prevent it?  Of course certain risk factors cannot be altered, such as age, family history and genetics.  But at the same time, there is a growing body of research showing that certain lifestyle choices have a substantial impact on whether AD or vascular dementia will indeed show up in your life.  Certain treatable maladies contribute to a significant increase in dementia.  For example, dementia is:

  • 41% higher in smokers
  • 39 % higher in people with high blood pressure
  • 22% higher among whites who are obese
  • 77% higher in diabetics

So obviously there is room for better lifestyle and aggressive treatment of these

conditions to help delay or prevent the onset of dementia.  A recent article predicted that substantial improvement in lifestyle factors could reduce the risk for AD (and perhaps even more so vascular dementia) by 50%.

What lifestyle factors can substantially impact the likelihood and/or timing of you or me getting dementia?

  • Being a regular exerciser could reduce AD by 21%. A recent study showed 5% greater brain mass retention in active folks vs. inactive.  Five percent may not sound like a lot, but when it comes to the brain, it is substantial.  A reasonable goal in terms of time and activity would be a 30 minute brisk (3-4 miles per hour) walk or the equivalent 5 days per week.
  • Quit smoking
  • Avoid excess alcohol. Anything beyond one drink a day in females or two daily in males is associated with increased risk of dementia.
  • Stay socially connected and mentally active.
  • A heart-healthy diet rich in nuts, seeds, whole fruits and vegetables, olive oil, fish and other low fat meats, and low in sugars and simple carbohydrates is beneficial in reducing vascular dementia.
  • Finally, if you have diabetes, cholesterol issues, obesity, or high blood pressure, treating these well can impact the incidence of dementia.

In the end, there is no way to guarantee that you will avoid the scourge of dementia.  At the same time, we want to avoid the fatalism that assumes that nothing we do will impact its likelihood or timing.  Dementia is a grim enemy.  While more weapons against it are sought, it’s worth using every one that is available to delay or prevent it.

Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville. He is contracted with some commercial insurance carriers and sees Direct Primary Care patients who do not have insurance, who belong to a cost sharing ministry, or who are on Medicare. He is accepting new patients. You may contact him at 982-0835

Painful Spasms of the Face by Dr. Andrew Smith

As I sat in the midst of a group of folks pleasantly chatting at a friend’s surprise birthday party, I couldn’t help noticing the grimaces of a woman across from me.  Every minute or two she would wince as though being jabbed with a needle.  When I asked about this privately she filled me in.  “Since this morning it feels like every couple of minutes or so I get a really sharp, excruciating stab of pain near my left ear.  It lasts just a couple of seconds but they’re so frequent its wearing me out.”

This lady was describing a somewhat uncommon, but extremely painful condition called trigeminal neuralgia (TN), or less commonly, tic douloureux (which just means “painful spasm”).

TN is a jolting jab of pain along one of the five branches of the trigeminal nerve.  The trigeminal nerve is the main nerve of sensation for the face and part of the scalp.  Most of the time the cause of the nerve malfunction is unknown and there is no simple blood test or imaging study to diagnose this.  But the symptom is quite characteristic and usually makes the diagnosis clear.

TN has been described for well over 300 years and surgical treatments for it began over a century ago.  In fact a first century Greek physician, Aretaeus of Cappadocia is thought to have been referring to TN when he described a headache in which “spasms and distortions of the countenance took place.”

The frequency of TN is only about 1.5 cases per 10,000 people per year.  It occurs primarily in the middle-aged to elderly population, rarely occurring before age 40.  The relative rarity of TN is a good thing as it can become so severe in some cases that, if not treated, it has pushed patients to the brink of suicide.  The agonizing jabs of pain can occur anywhere from once every couple of days to hundreds of times per day.  Most commonly they shoot from the corner of the mouth to the angle of the jaw.  But they can also shoot from the area around the upper canine teeth toward the eyebrow.

So, what can be done about this agonizing malady if it strikes?  Fortunately, there are some fairly effective treatments.  For starters, certain medicines like Tegretol, gabapentin and Lyrica have shown benefit.  Other meds can be used as add-ons if needed.  These can give desperately needed relief.  The course of TN is quite variable.  So sometimes, if one of these meds can help in the short run, the pains dissipate over a few months and the person can go off the meds and do well.  But in a majority of cases the pain returns at some point and it is not uncommon for the meds to begin to lose their effectiveness.

In more stubborn cases, certain surgical procedures can be effective, such as a procedure where pressure is taken off of the afflicting nerve branch.  Obviously TN is no picnic to go through.  But at least there are a few fairly effective options that weren’t around when Aretaeus observed his patient with “spasms and distortions of the countenance.”

Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville. He is contracted with some commercial insurance carriers and sees Direct Primary Care patients who do not have insurance, who belong to a cost sharing ministry, or who are on Medicare. He is accepting new patients. You may contact him at 982-0835

What to drink?

What to Drink? 

​Besides water, it sometimes seems like there is nothing truly safe to drink. Let’s start with the most obvious problems – sweetened drinks. Unfortunately this includes most of our favorites,such as sweet tea, Mountain Dew, Dr. Pepper, Coke, Pepsi, Gatorade, Powerade, Red Bull and many more. As a major source of empty calories and carbs, these are seen as the number one dietary cause of obesity. What’s more, they are major contributors to diabetes. As this liquid sugar is consumed it hammers the pancreas into putting out a big bunch of insulin to deal with it. Over time the body gets less and less responsive to this insulin, which then leads to diabetes. Eventually the pancreas usually wears out in its ability to secrete adequate insulin.

​Ok, so how about diet drinks? Many of these, unfortunately, have their own problems. This is currently a growing area of research. Some recent studies showed that consuming a diet soda daily was associated with a higher stroke and dementia risk. It looks like some of this may have been due to other factors rather than a direct result of the diet soda consumption. Still, it certainly gives one pause. Similarly, another study showed that routine diet soda drinkers had higher levels of certain hormones that stimulate transport of glucose (sugar) into fat cells. Likewise, switching to diet soda consumption doesn’t routinely encourage weight loss. This may have be due to the just-mentioned hormone effect, or perhaps drinking diet sodas keeps the taste and desire for sweet things in our brain so that we seek them out.  

​Even juices don’t get a pass. Like sweetened drinks juices are rather packed with calories and carbs. On the plus side, at least they provide some nutrition and vitamins in the mix. But in general it is better to eat the whole fruit rather than just the juice.

​Milk? Many folks have lactose intolerance and get gastrointestinal symptoms if they drink milk. Others worry about the calories in milk. Still, if you tolerate milk, drinking it in moderation (perhaps an 8 ounce glass or so per day) at least gives some protein, calcium, vitamin D and other nutrition in exchange for the calories.

​Well, what about unsweetened coffee or tea? Here the findings are mostly positive. Of course if you have problems with anxiety, heart palpitations, or acid reflux, caffeinated beverages may not be for you. On the other, if you don’t struggle with these issues, unsweetened tea and coffee may be a reasonable options. Several coffee studies have indicated positive benefits such as lower incidence of type 2 diabetes, diminished Parkinson’s disease, decrease in certain cancers, and sharper mental focus.  

​Naturally, alcohol also has its challenges. Some simply don’t like it or have been impacted by alcoholism in a loved one. If a person has no objection to drinking alcohol and can limit themselves to no more than two drinks daily (if they are males) or one drink daily (if they are females) then alcohol in careful moderation may be ok. Of course it will still often have empty calories and carbs.

​So finally that brings us to water. Here is still the best source for quenching our thirst and hydrating. There is no scientifically based right amount of daily water intake for everyone. But keeping well hydrated and thirst-quenched is certainly a good start. Yet even water has a couple of cautions. Drinking it unfiltered from local streams can lead to catching parasites such as Giardia. Even the plastic bottles that bottled water comes in have come under suspicion in recent years. Some studies have suggested that a chemical called PBA leaches from the bottles into the water, or other liquids, that they contain. It has been suggested that this may have negative effects such as lowering testosterone in men. The findings are still early, but they are enough to promote concern.

​So, what to drink seems to boil down to plenty of water from safe sources with options for unsweetened tea and coffee, and smaller amounts of juice and milk, and even smaller amounts of alcohol. There do seem to be a few non-sweetened seltzer type drinks that are likely not harmful as well. So when somebody asks, “What’ll you have to drink?” it’s a bit more complicated than it used to be… or on second thought, maybe the known healthy choices are getting fewer and simpler. One way or the other, find a way to keep healthy and hydrated in these hot summer months in Tennessee.

Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville. He is contracted with some commercial insurance carriers and sees Direct Primary Care patients who do not have insurance, who belong to a cost sharing ministry, or who are on Medicare. He is accepting new patients. You may contact him at 982-0835


Allergies in East Tennessee

Oh, the sneezing and sniffling and runny noses and itchy eyes that are all around us this time of year.  And it’s not just your imagination – Knoxville ranks as the fifth worst city in the country for allergy sufferers.  That comes as no surprise to the legions of residents who this spring are dealing with all that sneezing and sniffling.  Add on the headaches, fatigue, cough, and popping in the ears, and you have a real damper on your enjoyment of spring and summer.  Further complications to allergy can include asthma flare-ups, sinus infections, ear infections, and sleep disturbance to name just a few.

Estimates vary, but up to about 20% of the population suffer from allergy, and about 20% of allergy sufferers also have asthma.  That doesn’t even include a category called non-allergic rhinitis (rhinitis is the medical term for an inflamed runny nose).  These folks have all the symptoms of allergy, but upon testing, come up negative.  There are seven different types of non-allergic rhinitis and each is treated a bit differently from true allergy. We won’t delve further into all that, but it is one reason why treatment of allergy symptoms isn’t a one size fits all proposition.

Diagnosis of allergy often involves simply recognizing the symptoms and doing a trial of an over-the-counter antihistamine such as Claritin, Allegra, Zyrtec or one of their generic equivalents.  If that does the job, it’s sometimes not a bad way to go.  If not, it’s probably time to check in with your physician.  Treatment options will include:

  • Environmental control measures and allergen avoidance: These include keeping exposure to allergens such as pollen, dust mites, and mold to a minimum
  • Medication management: Patients are often successfully treated with oral antihistamines, decongestants (if high blood pressure is not a problem), Singulair, or nasal steroids, antihistamines, or anticholinergics to name only some of the available options.
  • Immunotherapy (allergy shots): This treatment may be considered more strongly with moderate or severe disease or poor response to other treatment options.

Specific allergens can be identified by skin testing or blood testing, with skin testing generally being deemed the most precise.  So, who should have allergy testing?  Allergy testing can have several benefits.  First of all, it can identify those who have non-allergic rhinitis.  These folks will generally not respond to traditional antihistamines and need other approaches.  Secondly, allergy testing may identify certain allergens to which the person can reduce their exposure.  For example dust mites, mold, animal dander or cockroach are indoor allergens which can be reduced by a variety of methods.

Finally, for those who are not getting good relief despite meds, immunotherapy may be a good option.  Its success rate is generally over 80%, although it usually takes a few months to see improvement.  The entire process may take a couple years to establish and maintain the benefits.  But for those who habitually sneeze and sniffle their way through the day in misery, often grabbing meds on a daily basis, it can be well worth while.

So if the sights and smells of this beautiful East Tennessee spring and summer are being blurred by watery eyes and masked by a runny nose, check in with your doctor and see what can be done!

Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville.  Contact him at 982-0835

Heart Failure

            My middle-aged patient was both confused and concerned.  “I don’t know what the deal is; I can barely make it the hundred yards to my mailbox and back without huffing and puffing and stopping to rest.  And I’ve never been a smoker, so what’s the deal?”

As it turned out, after a full work-up, the deal was heart failure.  Simply put, heart failure is when the pumping ability of the heart weakens to where it can’t readily keep up with the demands of the body.  It affects nearly 6 million Americans of all ages and is responsible for more hospitalizations than all forms of cancer combined.   In fact it is the number one cause of hospitalization for patients 65 years and up.  Nearly 50% of heart failure patients will die within 5 years of their diagnosis.

What causes heart failure?  There is quite a list of factors that can contribute: everything from blocked coronary arteries, diabetes, high blood pressure, heart valve abnormalities, infections and inflammations, toxins (such as excess alcohol) and certain genetic tendencies.  Often a heart which has been weakened a bit by one or more of these factors is pushed into symptomatic failure by excess salt intake, uncontrolled high blood pressure, a new heart rhythm disturbance such as atrial fibrillation, a heart attack or some serious infection.

Initially heart failure may show no symptoms at all.  However eventually a person may experience a long list of symptoms including shortness of breath with minor exertion or with laying down flat, rapid heart rate, tiredness, puffy ankles, chest pain or heart palpitations.

If you were to experience some of these symptoms and present to your doctor, several things could be done to help diagnose whether you had the beginnings of heart failure.  Of course a thorough description of the course of your symptoms including what makes them better or worse would be undertaken.  Likewise a physical exam (with particular focus on the heart, lungs, and blood vessels), blood tests, an EKG and tests such as a chest x-ray and echocardiogram would likely be ordered to assess the heart’s function.

What if in the end you did indeed have the beginning of heart failure?  You would then be given an idea of how advanced your heart failure was and a treatment plan would be put in place.  Certain lifestyle recommendations such as a low salt diet, quitting smoking or excess alcohol, avoiding certain meds such as NSAIDs (ibuprofen, naproxen), and aiming toward an ideal body weight and modest exercise would be discussed.  Likewise, there are a few meds that have been shown to be beneficial in certain types of heart failure and these would likely be started.  Risk factors such as high blood pressure, high cholesterol and diabetes would need to be carefully controlled.

Of course to pursue a healthy lifestyle to avoid the factors that lead to heart failure would be best of all.  But if in spite of that you or someone you love start showing symptoms of possible early heart failure, have it checked out; the earlier you start treating it with both lifestyle and appropriate meds the better your precious heart is likely to do.

Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville.  He is contracted with some commercial insurance carriers and sees Direct Primary Care patients who do not have insurance, who belong to a cost sharing ministry, or who are on Medicare. He is accepting new patients.  You may contact him at 982-0835

Living and Dying By What We Eat

           “Let food be thy medicine and medicine be thy food.”  This was the advice of one of history’s best known physicians, Hippocrates, who lived around the 4th century B.C.  He must have had an okay idea of things as he apparently lived to around 90 years old when many were dying quite young.  At the same time, our diet isn’t the only determinant of disease and wellness.  Genetics, exercise, toxic habits, chronic stress, accidents, infections and many other factors play into it.

            A recently released study did a statistical analysis of the relationship between certain dietary habits and early death from heart disease, diabetes and stroke.  Ten particular dietary habits were connected with these bad outcomes.  A bit surprisingly, excess intake of salt had the biggest negative impact.  Here you want to be eating non-processed whole foods as much as possible, while avoiding fast foods and, unfortunately, going very carefully with any restaurant food as well.  Most of the salt is already in the food even if you don’t add any at the table.  Read labels, but almost anything in a box, bag, jar or can already has a good bit of salt in it.  Shooting for less than 2 grams (2000 mg.)of sodium per day is a good goal.

            Next in line for increasing early deaths was having too low of an intake of seeds and nuts.  Who knew squirrels were so smart? So, munch on those almonds, but don’t get the super salty variety.  High processed meat intake came in third in negative impact, so try to minimize cold cuts, hot dogs and sausages.  And since low seafood intake (with its healthy omega-3 fats) was another cause of increased early deaths, replace them with tuna or salmon a couple times a week.

            Here we come to no surprise as numbers five and six were too low an intake of vegetables and fruits.  The goal of about four servings of each per day is ambitious but pays off.  And while you’re eating all those fruits and veggies, take a pass on the sugar-sweetened drinks.  The sweet teas, Mountain Dews, full-sugar sports drinks and other sugary drinks drive us toward obesity, diabetes, and earlier death.  Of course water is best.  The non-calorie flavored drinks, though not perfect, can be consumed in moderation.  For the most part, “Don’t drink your calories” is a good motto to go by.  Strikingly, higher intake of sugar-sweetened drinks was the factor with the highest impact on early cardiovascular death in the younger (25-64 year old) population, while salt kicked in more in the 65 and older population.

            A final couple of factors that were negatives were too little intake of polyunsaturated fatty acids (think olive oil, salmon, nuts and similar sources of “good fats”) and whole grains.  Excess intake of unprocessed red meat had only a very minimal negative impact – whew!

            None of us is going to eat perfectly, but some attention toward accentuating the good stuff and passing on the bad stuff can help a lot.  This study showed that almost half of early death from stroke, heart disease and diabetes could be attributed to one or more of these dietary habits.  And with a little attention, you really can find a lot of foods that you actually like and are still good for you.  Don’t believe the line, “If it tastes good, spit it out.”

            In the end we’re told in Psalm 90 to “…number our days that we may obtain a heart of wisdom.”  I do believe our days are ultimately set by our Creator, but He generally works by using means in our life, and a healthy diet can be a potent one.  The idea is to enjoy a healthy diet, not to obsess or stress over it.  Dig in!

Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville.  He is contracted with some commercial insurance carriers and sees Direct Primary Care patients who do not have insurance, who belong to a cost sharing ministry, or who are on Medicare. He is accepting new patients.  You may contact him at 982-0835

Whooping Cough: Still Lurking

The 3 year old girl sat quietly on the exam table as her mom described her symptoms.  “A couple of weeks ago she had what just seemed like a cold.  Then she developed a little cough.  But day by day it’s just gotten worse and worse.  She’ll seem fine in between coughing spells  but when she starts coughing she just goes and goes until she finally has to take a big breath in.  Sometimes she coughs so hard it makes her throw up.  And night-time is terrible; that’s when it really picks up.”

That description is quite typical for whooping cough, also called pertussis, and sure enough the nasal swab we used to test this little one came back the next day positive for pertussis. Whooping cough gets its name from the “whooping” sound that is made when gasping for air after a fit of coughing.  It is sometimes called “the 100 day cough” but it often drags on even longer.  Worldwide there are still an estimated 30-50 million cases of whooping cough yearly with about 300,000 deaths.  Pertussis is particularly prevalent in the many nations where vaccination rates are low.  One study found that, in eight countries where immunization coverage was reduced, incidence rates of pertussis surged to 10 to 100 times the rates in countries where vaccination rates were sustained.

In the U.S., before pertussis immunizations were available, nearly all children developed whooping cough. Between 150,000 and 260,000 cases of pertussis were reported each year, with up to 9,000 pertussis-related deaths.  Since the onset of routine vaccination, pertussis has fallen to about a 10th of that number of cases and last year, for comparison, there were 18 deaths from pertussis.  Case numbers show that children who haven’t received pertussis vaccine are at least 8 times more likely to get pertussis than children who received all 5 recommended doses.

The majority of deaths occur among infants younger than 3 months of age and more than half of infants less than 1 year of age who get pertussis are hospitalized.  That’s why, besides the need to start vaccination of infants promptly at 2 months of age, vaccination of preteens, teens and adults – including pregnant women – is especially important for families with new infants.   Unfortunately, this little 3 year old is from a big family who doesn’t immunize, and the disease is quite infectious.

            Here’s the tricky thing about whooping cough: It starts just like a cold, followed a few days later by an increasing cough.  So at first, it really doesn’t seem like anything very serious.  By the time the cough has really shown itself to be something suggesting whooping cough, antibiotics (such as azithromycin and other relatives of erythromycin) only slightly change the course of the illness.  Antibiotics do at least render the person non-infectious which is no small thing given how highly contagious it is.

            So, what are the take-home messages?  Old, and potentially deadly, illnesses like whooping cough are still around and can rear their ugly heads, especially when vaccination rates fall.  So be sure and protect yourself, your kids, and your community with timely immunization.  When whooping cough is around, there is no need to panic, but there is certainly a need to be vigilant.  Even minor respiratory symptoms need to be checked out early to stop the progress of this miserable, and potentially dangerous, malady.

Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville.  He is contracted with some commercial insurance carriers and sees Direct Primary Care patients who do not have insurance, who belong to a cost sharing ministry, or who are on Medicare. He is accepting new patients.  You may contact him at 982-0835.


Respiratory Syncytial Virus (RSV)

“He’s really just been moving a little slower than usual and not eating or drinking as much… and he’s kept a fever for a few days.  Oh, and I noticed he seems to be breathing a bit quicker than usual, and just seems tired.  Other than that just cold symptoms with a runny nose and a cough.  Finally I decided to bring him in to be checked.”  Mrs. Clay, a young mom of a cute but tired-looking 3 year old boy, was relating the recent chain of events that had landed her son, Tommy, in our office after 5 days of symptoms.

Tommy looked deceptively OK.  He just sat rather placidly on the exam table waiting for me to check him over.  He didn’t look like he was in any particular distress.  When I listened to his lungs there were no crackles or wheezes, just normal breath sounds.  But those breath sounds were at a rate of almost 60 breaths per minute – two to three times the normal rate for him.  And his oxygen level from the pulse oximeter was an even 90% when a healthy 3 year old should be in the high 90’s.  It was all enough to convince me he needed a chest x-ray.  Sure enough, the x-ray showed pneumonia on both sides.  That made my next decision easier – next stop, Children’s Hospital in Knoxville for what ended up being a two day hospital stay for supportive treatment.

The cause of Tommy’s pneumonia was respiratory syncytial virus (RSV).  During these days when we are seeing schools close due to illnesses, we are seeing flu, strep, flu-like viruses, and yes, RSV.  RSV is the leading cause of lower respiratory tract infections (think pneumonia, and a wheezing condition called bronchiolitis) in infants and young children. In the U.S. each year, 4-5 million children younger than 4 years old acquire an RSV infection, and more than 125,000 are hospitalized.

Symptoms of RSV infection may include fever, cough, rapid breathing, shortness of breath, fatigue, wheezing and other abnormal lung sounds.  In young infants, apnea and cyanosis (turning bluish) may occur.  Of course with any of these symptoms at a significant level it would be wise to have a child examined, their lungs listened to, and their oxygen level checked.  When appropriate, there is a fairly easy in-office test that can be done to confirm or rule out RSV.        When it comes to treatment, it is mainly supportive – keeping them hydrated, making sure they are not getting exhausted with their breathing, being sure they are maintaining a good oxygen level.  Those who have more severe cases are the ones who end up in the hospital on IV fluids and oxygen.  There are also some rather rarely-used meds and preventives used primarily on the very young or those with congenital heart and lung conditions.  Otherwise, bronchodilators help only a few and most of the other treatments such as steroids haven’t really proven themselves in studies.  So all-in-all, treatment is mostly to support the patient while their body fights off this rather miserable virus.

Infants hospitalized for RSV are at higher risk for subsequent wheezing and abnormal pulmonary function and this increased risk may persist for up to 10 years or longer. RSV’s role in causing subsequent reactive airway disease (asthma) remains controversial. By age 3 almost all children have had at least one episode of RSV.  It is primarily in those well under a year of age that the illness can, rarely, be life-threatening. Unfortunately recurrent infection can occur and usually produces illness lasting 7-10 days rather than the typical 3-4 day illness caused by most colds.  Even the elderly can get severe RSV infections and November through February tends to be peak RSV season in Tennessee. So if those respiratory symptoms seem a bit worse or are dragging on longer than expected, best to get them checked out and see if those three letters, RSV, have gotten you.

Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville.  He is contracted with some commercial insurance carriers and sees Direct Primary Care patients who do not have insurance, who belong to a cost sharing ministry, or who are on Medicare. He is accepting new patients.  You may contact him at 982-0835.