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The Curious Case of Miriam

Few months ago, Sen Miriam Santiago announced she has stage 4 lung cancer. Some went sad because they, myself included, saw in her someone who could be their leader for a better governance.

Then afterwards a few months, in a press conference she announced that she has been cured, “I licked cancer.” She was cured! And now she is ready to accept the challenge to lead the country to a better future. Many, especially those from the medical field got baffled how easily would she be cured, in barely three months. Between her announcement of having a cancer and getting cured, you see her occasionally attending functions and delivering speeches. You never saw her wear a wig, get bald. She said her doctor had been giving her a new kind of treatment modality. Alright, fine. Perhaps that is someone I am not familiar too as oncology is not my field of specialty.

Then she declared her candidacy. People are used to her giving several pick-up lines of one liner jokes before her main speech to the amazement and entertainment of her audience. Even in her sorties that I have attended, she always commanded and drew attention to her with those jokes she never failed to deliver. But during this time, there were no pick-up lines, one liners. The speech was only a short 5-min run. And then she sat down and allowed photo ops with her followers. A very very unusual thing to happen.

People became skeptic. Did she really beat cancer in mere three months? Why the sudden change of her speaking style? Did she not really get cured and now cancer is taking its toll?

A doctor challenged her to present her case, whether it be a medical certificate or medical abstract to prove her claim of cure in barely three months. She is running for a sensitive position and as a voter we ought to know her health status, she claimed. But Miriam was so adamant that she invoked her right to privacy. Okay, so we respect that, but that leaves us hanging as to how she really is… cured? in remission? or worse, did she just make up stories to gain sympathy? I hope not.

We know that lung cancer, stage 4 at that has a very low survival rate. In fact, a 5-year survival rate of if the lung cancer at the time of diagnosis is already stage 4 is nil, barely 1%. Many of them would not even last six months from the time of diagnosis. We usually use the terms survival rate, in remission, but we rarely use the term “CURED.” I know of one patient (a relative of one of my patients) who had full remission, but being workaholic, he wanted to resume his stint in the government service. His doctor however advised him not to because the stress might just trigger relapse, causing expression of genes for replication of cancer genes.

If indeed her claim is true, personally I wanted to congratulate her for beating a stage 4 lung cancer. Such is not an easy feat.

The doctor wanted to know the state of health of MDS as campaigning and sorties would be energy-draining and stressful. But without really her medical abstract or certificate of full remission one in the know would cast doubt as to the authenticity of her claim. Her case is a curious one, I would say it is worth discussing in a medical conference. Her case is a statement that a stage 4 lung cancer is curable, inspire others not to lose hope.

Then recently, she changed her story… she is currently on chemotherapy, but her cancer is “stable.” Wait, whaaaat? So what happened now to “she licked cancer?” Was she really cured at all?

And what were the implications of her presumptive “cured” statement? She actually demoralized patients or relatives of patients who died for receiving a different treatment regimen. The indigent people would despair “pwede pala tayo mabuhay sa stage 4 lung cancer kung may pera lang tayo kagaya ni Miriam.” Chain or heavy smokers can say “why quit from smoking when stage 4 lung cancer is curable?”

She was just so hasty to let her audience know that she still can run for presidency. Wrong move though I must say…

 

 

 

 
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Posted by on December 4, 2015 in Uncategorized

 

My First Case of Congenital Cytomegalovirus Infection

I have this opportunity to demystify an infant’s case of long standing jaundice…

The mother’s prenatal course was apparently unremarkable, save for gestational diabetes that was controlled. The mother cannot remember any other symptoms such as flu-like illness, skin rashes, nor was she hypertensive during the prenatal period. Baby was delivered via repeat cesarean section, small for gestational age. He stayed quite long in the hospital because of infection. He was purely breastfeeding. His newborn metabolic screening result was normal. I was not the attending then.

At home, baby was quite fuzzy and irritable. Baby has been being attended to by the original neonatologist. He was jaundiced. In cases of purely breastfed babies, sometimes jaundice can be expected to last for about 3 months but the intensity is not that much compared to that during the first week of life. His stool color was still yellow. He developed umbilical hernia. The skin texture was fine; tongue was normal in size; hair was not coarse; there was no hypotonia; nor was there any constipation (something that is a remarkable findings among babies with hypothyroidism). Baby was worked up for possible hypothyroidism. Thyroid function test was normal. They were advised to go to a pediatric endocrinologist for evaluation.

Mother brought baby to my clinic for second opinion. I saw the laboratory result, it was normal. But what is puzzling is the jaundice that was quite intense. I could not evaluate baby well, especially the abdomen, because he is irritable. I advised mother that baby needs further test and treatment thus they agreed to be confined in the hospital.

I repeated the thyroid function test, it was normal. That reassured me baby has no congenital hypothyroidism which is one dreaded condition a baby can have because of life dependency on thyroid hormones for better quality of life and to attenuate whatever cognitive impairment it has already caused. I still called up an endocrinologist friend to confirm my understanding of baby’s thyroid function test result and she agreed baby is not a case of metabolic disorder.

I treated the baby as a case of sepsis pending work up results. Ultrasound of the abdomen showed the liver is enlarged, the biliary tree is intact. I am not afraid that this baby has biliary atresia which is another “lethal” condition that usually leads to baby’s death in a slow fashion.

Liver enzyme, alkaline phosphate and bilirubin were all elevated (it was a direct hyperbilirubinemia). I started the baby on ursodeoxycholic acid to help eliminate the bilirubin that could also cause inflammation of the liver cells.

After a week in the hospital, baby’s jaundice has significantly decreased and yet the direct hyperbilirubinemia (50%) was still persistent, and alkaline phosphatase level was still significantly elevated. I have discharged baby with instruction to undergo karyotyping and TORCH screening as I haven’t ascertained yet what was causing the baby’s jaundice.

A week later, mother brought back the results of baby’s tests. Karyotyping was NORMAL (thank God). On the other hand, TORCH panel revealed (+) IgM and IgG for cytomegalovirus. I referred the baby immediately to an ophthalmologist for chorioretinitis screening, and to a pediatric infectious disease specialist for further management. CT Scan of the head showed that there were periventricular calcifications near the parietal areas of the brain.

Baby is still jaundiced although the intensity is no longer that dark. He is on supportive treatment.

He will undergo repeat head CT scan as well as chorioretinitis screening one month after the first.

 
 

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My Struggle Continues…

I was the happiest person last August of this year (2014) when I finally had a normal cholesterol level. This was accomplished through several means. First: I went hard on my diet. I literally had been eating veggies more often than not, and only taking meat 2 days in a week, in the form of chicken or fish. Second: the dose of my ruosovastatin was increased from 20 mg to 40 mg daily. My exercises were still zumba once to twice daily for 5-7 days.

My doctor as well was very elated with the result. So on that day, she decided to a) decrease my ruosovastatin back to 20 mg daily, b) decrease my ezetimibe to one tab every M-W-F, c) asked me to come back with repeat lab test after six months. On a personal basis, I tried now to enjoy eating some chicken more frequently, but not on a daily basis. I happily complied with decreasing the ruosovastatin (as it is very expensive) but I was on doubt of decreasing my ezetimibe to thrice weekly, so I secretly kept it daily. In my mind, I think six months is a long wait for my repeat lab tests, so I decided to have a repeat test after two months.

The repeat tests shocked me. My LDL went above the acceptable value for a post-bypass surgery patients like me. My total cholesterol went up from 120s to 180s, although it is still within the normal value. I got sad. I felt guilty for having a go with my meat intake just because I was getting bored with merely veggies daily.

I informed my physician that I will be increasing back my ruosovastatin to 40 mg daily and go back to mostly veggies diet (no matter how lifeless it seems).

I havent done yet my thyroid hormones as of posting but I plan to do it in the next few days to see if I might again need thyroid hormone supplementation.

On the other hand, I noticed that I got thinner again compare to two months ago. So I am guessing that my thyroid hormones are still within normal limits. Otherwise, I should have gained weight again. So if I am still losing weight, and yet my cholesterol is increasing, then I am guessing that I really had a very very bad gene for this disorder that I really need a strong dose of my anti-cholesterol. Because if I am gaining weight at the same time my cholesterol is rising, then it would mean that my cholesterol elevation is related to hypothyroidism, which causes a decrease in metabolism.

 
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Posted by on October 18, 2014 in Uncategorized

 

Those Painful Teenage Years

In my work, I accidentally encounter problematic teens when they get admitted under my service as the consultant on duty. I would like to share these two stories that I have come across with. Let us not judge them too quickly until we have finally come to the bottom of their stories.

Teen Y was a 15 year old female who was brought to the hospital for attempted suicide; she drank a silver cleaner. We were glad she did not have any caustic injuries down her alimentary tract or else I would have been so stressed. I kept her for observation but while in the ward, I was not able to talk to her in depth. She always covered herself in blanket. She was always with a friend; the mother or parents never took watch.

I asked the mother to pay me a visit at the clinic as she is always busy with their retail store and I could not meet her by chance when I do my rounds. She revealed that her daughter was born out of wedlock during her younger years. She is now married to another man who accepted the elder daughter like his own. However due to conflicts with her, the daughter gets to live with the grandmother sometimes. Just before the suicide attempt, she was trying to call her daughter. Apparently her daughter was not taking her call, which made her mad. When her daughter arrived, she reprimanded her. While the daughter was trying to explain why she wasn’t able to get the call, the mother refused to listen. She raised her voice instead and had told the daughter that she is disrespectful and has no sense of indebtedness.

I discharged the patient after more than 24 hours observation and told her to follow-up at the clinic after a week. I was glad she came over with the mother. So I asked the mother that I needed to talk to the daughter alone, while she waits outside. I asked her what made her mother get mad at her to the point she had thought of committing suicide.

She said she was at home but on the next door building, manning the store. Then her phone’s battery got drained. She left the phone at the first floor and went upstairs. That was when the mother was calling. She had no way of knowing her mother calling. So when she saw her mother later, she was surprised why she was being reprimanded. She tried to explain that her phone died, but her mother kept on ranting. She got so desperate because deep inside her she knew she did nothing and yet here she is being wrongfully accused. She went back to the next door store, saw the silver cleaner and drank it.

I called the mother and talked to them both. I had to explain things, let the mother know that sometimes she also needs to listen to her daughter and if she thinks the daughter becomes disrespectful as she talks to her, then she can point it out in a non-authoritative manner. Meanwhile, I also told the daughter to listen to her mother as I was sure the mother only want good things to happen to her, and that she might not repeat whatever mistakes her mother had done during her younger years.

— 0 —

A 17-year old female came to the labor room with cervix fully dilated. History reveals she is 28 weeks pregnant. She came to the hospital with an 18 year old cousin. There was no time to transfer the mother to the delivery room as when the baby was at the treatment room, the head was already crowning. Baby was born vaginally and had to be brought immediately to the neonatal ICU. Baby was stabilized and initial x-ray didn’t show respiratory distress syndrome. But knowing that the mother was not given antenatal steroids, I was anticipating that eventually the baby will deteriorate respiratory wise in the next hours. I was not present at the labor room during the delivery but my resident was so I had been giving my instructions via phone call. He did a great job.

Baby had vomited repeatedly even if we only give minimal enteral feeding once. I had requested for x-ray to be repeated. On evaluation of the film, true enough, respiratory distress progressed. We needed surfactant to be administered so I asked what was the financial status of the patient (we don’t have surfactant in the hospital but it can be bought from a nearby pharmacy). I was told that the teen mom is unsupported, apparently she was disowned, and the boyfriend does not support her either.

I went to interview the teen mom after I did my rounds. She was from the south who was sent to the metropolis to stay with a male cousin, first-cousin, the reason why, I failed to ask. While being in Manila, the cousin would make her drink until she passes out. The next day, the girl would notice that her vulva feels sore. This had happened several times according to her, until she got pregnant. She never reported it, but she let her cousin know that she got pregnant. She then came over to the highlands. Her granny, who has end-stage renal disease came to learn about her condition. (But she could not support also this hospitalization as she is just dependent on her son for her dialysis expenses.) Teen mom only had one prenatal visit before the delivery. While I was interviewing her, my voice broke and said, “so, this is rape.”

I got to do something. I told the OB in-charge to notify the Women and Child Protection Unit, even if the crime was not committed locally. Meanwhile I wanted the baby to be transferred to another hospital where they can give surfactant for free. But we cannot make major decisions as the mom is a minor, and the cousin cannot sign for the consents. As I was about to leave the hospital I was glad I met a relative of legal age who took the role as the guardian of both the teen mom and the baby. Baby was transferred within few hours.

 
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Posted by on August 28, 2014 in Adolescents

 

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The Prize of My Sacrifices

My life has been an open book, especially after that dreaded meet and greet with Death and his scythe. I have allowed it to be, so people would be aware of their lifestyles; and make them learn from my example on how they are going to live their lives towards health.

Few months after that emergency bypass operation, I was never able to control the main culprit that made me this “known” to my colleagues. I was already in quadruple drug therapy for my lipids (ruosovastatin, ezetimibe, fenofibrate, EPA+DHA). I got back to working out two months after my surgery. I had been watching my food intake, avoiding red meat and only preferring vegetable and white meat. Aside from that, I also have problem with my heart beat rhythm hence I was maintained on amiodarone. Eleven months after the surgery, finally I saw light. Total cholesterol and triglycerides went to normal levels, although LDL (bad cholesterol) was still high for a patient who underwent a bypass operation. I was then advised to have another follow-up visit after the holidays to check the effect of christmas celebrations.

Not only did my laboratory result became abnormal and back to pre-operation level, I gained weight. The light I saw few months ago was just a glimmer. On investigation, my thyroid hormones suggested hypothyroidism leading to hypometabolism, which now explains my weight gain and abnormal lipid levels. These were the result of my anti-arrhythmic amiodarone. We had to drastically revise my medications. I had to take thyroid hormone supplementation, change amiodarone to beta-blocker bisoprolol, increase the dose of ruosovastatin and increased my workout. At first I was still having palpitations and skip beats with bisoprolol and thus dose was increased. I was supposed to undergo holter monitoring in case my arrhythmia would persist.

At 18 months after the surgery, getting depressed with all the elevations of my lipids, weight gain, I decided to make a drastic change in my diet. I dropped meat and went quasi-vegetarian (having chicken or fish once a week). It was a very difficult lifestyle change as I easily get hungry, forcing me to have a lot of snacks, sometimes taking pastries (which I should also be avoiding; not that I have high blood sugar, but then simple sugars have been identified as one culprit in causing chronic inflammation of the blood vessels trapping cholesterols and forming a plaque, even if your cholesterol level is not necessarily high). Being a residency training officer of the department of Pediatrics at SLU-HSH, I decided to quit the post while maintaining the post as head of breastfeeding committee and neonatal services unit of the same hospital.

Then having been a Zumba enthusiast, I went on training and earned my license to be an instructor. Having kept this diet, exercise and religious medication, I had my follow-up on my 20th month after the surgery. Sacrifice and effort finally paid off. My total cholesterol was now down to 156.96mg/dL (from a previous of 423 the first time I found out I had elevated levels to 212 prior to my cardiac arrest). Low density lipoprotein (LDL) was now down to 92 mg/dL, and my triglyceride was still maintained below 200mg/dL at 105.32. My liver enzyme was very slightly elevated and thyroid hormone was within acceptable normal limits, bordering hypothyroid. I lost two kilograms, I can now wear my old pants and I feel a little more confident than the previous months. Because of these, my cardiologist decided to discontinue my thyroid hormone supplementation, decrease my dose of ezetimibe and lower my ruosovastatin from 40 mg to 20 mg.

Whether these changes were due to my more frequent exercise or diet restriction, or lesser stress from work, it doesn’t matter; it also means that I will have to maintain these statuses so as to keep my lipids in check. I thought I could already have the clearance to eat lechon, sigh… Well, better this than have another heart attack soon. The sacrifices paid off.

Next goal: a sculpted body? I dare myself.

 
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Posted by on August 17, 2014 in Personal

 

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And The Battle Continues…

Last November 2013, I thought I had one of the happiest moment of my life when after all the rigid routines I followed – food control; exercise and medication, my total cholesterol finally went down below 200 mg/dL for the very first time, however my bad cholesterol (LDL) was still high at around 140s. According to my doctors and friends who I talked to, for a person who underwent cardiac bypass, the ideal LDL level should be around 90mg/dL or less.  Nevertheless, that was a significant achievement I had so far as far as my blood picture was concerned. At that time, my medications consisted of (1) ruosovastatin at 20mg/day, (2) fenofibrate 160mg daily, (3) ezetimibe 10 mg every MWF, (4) EPA + DHA at 1 softgel daily, (5) clopidogrel 75mg daily, and (6) amiodarone 1/2 tab every M/Th. My cardiologist, Dr. Sophia Black, told me to come back on January as I might be indulging during the Christmas break, which was of course expected, especially among Filipinos who love to party. And when you say party in the Philippines, there’s a barrage of food of all sorts, making me at risk to have a rocket-high resurgence of my cholesterol levels.

During the holidays, I tried not to disappoint my doctor by trying to avoid parties as much as possible. And if ever I cannot resist the invitation, I would only opt for white meat at the most. I had lesser exercises too however, which I regretted immensely. To my memory, there were only 2 parties I went to, that of the Dept of Pediatrics at SLU, and Christmas celebration at home. January came, I started to feel tired when I climbed 4 flight of stairs that I routinely used to do with ease where I live. My doctor also noted that I started to gain weight, I was in denial though I noticed my clothes getting tight already. The laboratory results showed that my cholesterol increased all over again, and what was remarkable was I became hypothyroid, which is a possible adverse effect of my amiodarone. Hypothyroidism brings about decreased metabolism (explaining my weight gain), and a surge in cholesterol level (which should never happen anymore). We decided to discontinue amiodarone and shift my anti-arrhythmic into bisoprolol 2.5mcg/tab, 1/2 tab daily. Levo-thyroxine 25mcg/tab, 1/2 tab daily was added. Ezetimibe was increased back to daily and the rest was maintained. I will have to come back after 2 weeks. I resumed my usual exercise schedule as before. (Please note that I only took the levothyroxine UNDER prescription).

During my follow-up, 2weeks after starting with bisoprolol, my doctor noted that I had skip beats, which I barely noticed. She increased my bisoprolol now to 1/2 tab twice daily. If after 2 weeks and my skip beats will still persist, I will have to undergo holter monitoring. She then advised me to come back again after 2 weeks. On my follow-up, it was good news that no skip beats were no longer appreciated, thus the holter monitoring was no longer pursued. I had my repeat blood test, my thyroid hormones were already getting back to normal values but still I was fat (at 68 kgs from a previous of 63 last november). So I still had to continue my levo-thyroxine. I still felt this tightness/fullness in my chest after I jog for about 5 seconds. And I had this allergic rhinitis and postnasal drip cough bugging me at the same time. I was on levocetirizine and montelukast. I took antibiotics to no avail. Montelukast really knocks me off when I take them thus I can no longer stay up for a longer time to do my paper works.

I had monthly follow-up afterwards. On the month of May, we repeated all my lab works. Thyroid hormones were still on the above normal values. Cholesterol was still high. So my doctor decided to maximize my dose of ruosovastatin from 20 to 40 mg daily, with an advise to have a liver function test one month after to check on the effect of the statin to my liver. I also saw my pulmonologist, Dr. Kareem Eustaquio, who also gave me fluticasone nasal spray on top of my anti-colds medications. Still not completely ruling out GERD, I took pantoprazole as it is the only potassium-pump-inhibitor that will not interact with my other lifetime medications (again, UNDER prescription). They say that statins usually makes muscles sore when taking it. When I had it at 10, 20 mg daily, I never felt such even after intense workout. What I noted though is that after taking it at 40 mg daily (even if my workout is just plain cardio), I would feel very tired and doze off easily, even if I haven’t taken yet my montelukast. And of course I have still to take my montelukast for my rhinitis. With that effects of statin and montelukast combined, they knock me off immediately, impeding my planned paper works to accomplish before I call it a night. From this time on as well, I have decided to have my food devoid of meat – both white and red, as much as I can. But there were occasions where I could not completely avoid eating meat (chicken and fish) and that happened less than 5 meals in a month.

One month after, at the first week of June, I did my liver function test. It was a good news after all, my liver was not adversely affected by my high dose of statin. I mentioned to my doctor the chest tightness I feel initially when I do my exercises, and she told me that it could be an effect of my bisoprolol. So since my blood pressure is still maintained (last check up it was 90/70), and I don’t have irregularities of my heart beat, she reduced my bisoprolol to 1/2 tab daily already. All the other medications were maintained… I now weighed 67 kgs. (Just 1 kg shed off, it’s too slow!)

This made me realize how hard it must be for patients with hypothyroidism to lose weight. Mine was an acquired type, and yet it is taking me a difficult time to shed weight. I thought that since we already discontinued the culprit and I was on thyroxine supplementation, I would be able to lose weight fast. It is not that easy. So you can’t blame those overweight people with the same problems, especially if it is congenital, or if the factor causing it remains, to remain obese no matter how hard they try to lose weight. It’s not that simple.

Meanwhile, I am still strictly watching my intake. I still do my exercises, at least 4x a week, where I would spend about 1-2 hours in the gym dancing zumba with spinning, or some resistance training… My next visit will be 2 months after (August), with repeat lab works. So, here’s to wishing myself a normal cholesterol, after depriving myself of all the food I wished to have eaten.

To the enlightenment of everyone, if I avoid going to scientific fora or a party where food is involved,  it’s not because I dislike the company that sponsored it, it is because I don’t want to insult the host by not eating the food offered; I only have a few food I can take. That is also the only time I could go to the gym and workout. And, take note that exercise is my lifetime prescription. I can’t go with the excuse of “minsan lang naman…” No. That missed one chance to exercise may be detrimental to me, which may not be applicable to your scenario. I am not the same as you all are. Remember that I am not diabetic nor hypertensive, I was watching my food, I exercised, I took medications and yet I had my cardiac arrest, compared to you have none of these that I have…

 
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Posted by on June 12, 2014 in Personal

 

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Measles Infection Timeline

Measles Infection Timeline

Incubation Period: After exposure to an infected person, it will take about 10 to 12 days for the disease to develop within the exposed person.

Prodromal Phase: The disease is heralded by appearance of the 3 Cs (cough (brassy in character), conjunctivitis (makes the person photo-sensitive/avoid bright light source), coryza/colds, and fever

Exanthem Phase: on the 3rd to 4th day of fever, rashes start to appear from the head (face, nasal bridge, nape) then spread downwards (cephalo-caudal fashion)

Convalescence: When rashes reach the lower extremities, fever disappears, and then desquamation takes place also from head downwards

The person is communicable between 4 days before and 4 days after appearance of the rash.

 
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Posted by on January 11, 2014 in Uncategorized

 

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