14 July 2003
Dear Readers: Sincerely,
Dr. Warren hopes to help all who ask his advice and to enlighten all who read Ask Dr. Warren. For your own well being please keep in mind that
advice you read here may not apply exactly to your own situation, and that if you are sick, no information on the web can take the place of a hands on examination by your physican who knows you and cares about you.
Dr. Warren
Thank you very much.
-DS
Dear DS: Allergic reactions can be seen to any medication, Tylenol included; however, spitting up or vomiting does not sound like an allergic reaction. It sounds like more of a response to gagging on the medicine. Try mixing it in a little juice and giving it in a small cup or bottle and see if you get the same reaction.
Sincerely,
Dr. Warren
What do you think Dr. Is that related with any physical or mental activity, like sex for example?
I hope to hear from you as soon as possible on my e-mail. Please if you can not help me give me address for some one can. And thank you very very much.
Yours faithfully
-Mohammed
Dear Mohammed: Acne is not related to any physical or mental activity and is not related to sex. During adolescence, the oil glands become activated by hormones. This can result in the pores becoming clogged by oil, some of which form blackheads and some of which become pimples. Since certain bacteria are involved in the development of acne, the treatment involves avoiding oil on the skin, cleansing the skin, treating with topical or oral antibiotics, and treating with medications that open the blackhead and closed whiteheads.
Sincerely,
Dr. Warren
Our 2½ year old daughter just started screaming a few days ago whenever we tried to put her in the bath saying that her legs were itchy. She has never had this problem before. Do you think she could have developed an allergy to water? She appears to be in pain and she cries very loud when we try to put her in the water. We have tried lukewarm and cold water.Nothing seems to help. We live in Washington DC in case that will help. Her legs do appear to get pink when we place her in the water. We use Johnson and Johnson soap but never get that far. What do you think?
-DC
Dear DC: I never heard of itching from bathing except as a result of dry skin, so I did a search to see if I could find any articles on the topic. To my surprise, the condition is known as "aquagenic pruritus." Unfortunately most of the citations were not available on-line, so I got very little information.
You might be interested in the following citation since it did have an abstract:
Aquadynia: noradrenergic pain induced by bathing and responsive to clonidine. by Shelley WB - Journal of the American Academy of Dermatology - 1998 Feb; 38(2 Pt 2):
Abstract:Noradrenergic pain means that it was mediated by a neurotransmitter. For me, the abstract still leaves open the question of why it happens in the first place. Some of the other citations I found which didn't have abstracts discussed other treatment options. Whether or not this is really what's going in with your daughter, I couldn't say. I would consult a pediatric dermatologist.
We describe two women in whom bathing was regularly followed by intense, widespread burning pain that lasted 15 to 45 minutes, which we term aquadynia. This water-induced pain was not caused by any skin or systemic diseases. We view it as a type of noradrenergic pain induced by contact with water, because it can be blocked with clonidine or propranolol. It appears to be an extension of the phenomenon of aquagenic pruritus, which we have also found to respond to clonidine or propranolol.
Sincerely,
Dr. Warren
-LS
Dear LS: Henoch-Schonlein Purpura is caused by inflammation of blood vessels. The cause of the inflammation may be allergy, infection, or idiopathic (unknown). The inflamed blood vessels leak resulting in bruising. Typically, the bruises of HSP are on the lower extremities and buttocks. Inflammation of blood vessels in the kidneys may result in blood in the urine. Involvement of intestinal blood vessels can cause abdominal pain.
There is no specific treatment for HSP. Symptomatic treatment with NSAIDs like ibuprofen is helpful for arthritis, rash, edema, fever, and malaise. HSP is usually a self limited disease with complete recovery. Serious complications can occur with HSP so close monitoring by your physician with referral to appropriate specialists is essential. Rarely, death may occur during the acute phase from gastrointestinal complications (e.g., hemorrhage, intussusception, bowel infarction), kidney failure, or central nervous system involvement. About 25% of children with initial kidney involvement have persistence of abnormal urine for years; however, most of these patients ultimately do well.
For more information regarding HSP check the NORD rare disease data base at http://www.rarediseases.org/.
Sincerely,
Dr. Warren
-B
Dear Class: Blood clots usually start with platelets. Platelets are very small oval cells which circulate in the blood. When they travel through a normal, healthy blood vessel, they don't do anything. When a blood vessel is cut, the platelets form a plug to stop the bleeding. When platelets are exposed to air or the products of tissue injury, they produce a variety of products involved in making a firm clot and start a complex biochemical cascade which enhances the clotting mechanism, driving it from one step to the next until the clot is formed. There are also a variety of chemicals the body produces to control clotting so that the clot forms only where it is needed. Abnormalities of platelets or any steps in the complex biochemical cascade controlling clotting can cause bleeding disorders. The best known example is hemophilia which occurs when the body can't make enough of Factor VIII, one of the steps in the clotting cascade.
Plaque in blood vessels can result in clotting because the plaque provides a sticky surface that platelets can adhere to. In addition, the narrowing of the blood vessels by plaque interferes with normal blood flow. Heart attacks can occur when clots form in heart vessels narrowed by plaque or obstructed by clots. If there are no collaterals (additional blood vessels supplying blood to the same area) the section of heart muscle deprived of blood dies. Most heart attacks occur because of the narrowing of heart vessels by plaque rather than clots. Exercise helps to increase collaterals as well as lower the cholesterol which forms plaques.
Clots in the carotid arteries in the neck can cause strokes. The carotid arteries supply blood to the brain.
When blood vessels to the leg muscles become narrowed interfering with blood flow, it causes muscle pain, especially with walking. Smoking causes damage to these arteries as well as heart vessels and contributes to the problems we've discussed.
Blood usually continues flowing through arteries because of the pressure produced by the heart beat. The flow is only slowed when the arteries are significantly narrowed by plaque. On the other hand, the pressure in veins is very low. Inactivity such as being bedridden, prolonged crouching, or wearing constrictive clothing around the legs could contribute to poor blood flow in leg veins and allow clots to form. Aside from causing painful swelling of the leg, theses clots can break off and travel to the lungs. This is known as a pulmonary embolus. It can damage part of the lung and make it hard for the lungs to deliver oxygen to the blood.
By the way, while you're learning about this, let me reassure you that these things don't happen to healthy eighth graders.
Sincerely,
Dr. Warren
Recurrent, intermittent and/or persistent symptoms:
-Katherine
Dear Katherine: Neurofibromatosis causes growth of neurofibromas and other tumors in various parts of the nervous system. These tumors are benign and cause symptoms primarily based on their location. Gastrointestinal tumors, usually neurofibromas, have been said to occur in 25% of patients with neurofibromatosis. The gastrointestinal neurofibromas are generally asymptomatic, but there may be abdominal pain, gastrointestinal bleeding, obstruction, or intussusception. Overgrowth of nerve fibers from the neurofibromas can compromise the blood supply to the intestines with results ranging anywhere from intestinal dysfunction and constipation to infarction (death of tissue due to lack of blood supply) of bowel. With the results of the MRI, your gastroenterologist and pediatric neurologist should get together and help you sort out the degree to which NF is contributing to your son's pain.
Beyond the issues of NF and your son's abdominal pain, I find myself with many unanswered questions in your son's history. He had reflux which improved with medication. He stopped after 4 months and then started screaming again. Why isn't he on treatment for reflux if he was better on medication? Frothy, foul smelling stools with undigested food in them - has he had a stool analysis? Has he been evaluated for malabsorption? Low IgA - does your doctor want to consult an immunologist? IgA deficiency may be associated with intestinal infections, gluten-sensitive enteropathy , food allergy, Crohn's disease, and disaccharidase deficiencies (resulting in inability to digest certain sugars). Why does your son drink 100 ounces of diluted juice per day? That's an enormous amount of fluid for a small child. Even diluted, he may be getting enough fructose and sorbitol to cause diarrhea and/or gas pains.
Sincerely,
Dr. Warren
Please help me regarding this. I know you will not throw this to the waste paper basket. My reply mail is: xxxx@xxxx.com
Thanking you.
Yours sincerely,
-T - From SRI_LANKA.
Dear T: If your daughter has had a thorough evaluation and been found to have nothing wrong, then her eating problem may be behavioral. Forcing children to eat never does anything to improve a child's appetite or develop good eating habits. Before doing anything else, your daughter needs to be fully evaluated for failure to thrive in order to make sure there is nothing interfering with her growth. While it is true that children who don't get enough calories grow poorly, it is also true that if a child is not growing, he won't have much need to eat and therefore will not have much appetite. Therefore, the baby needs her thyroid checked, she needs a thorough cardiac exam, a urinalysis and urine culture, and a neurological evaluation and speech evaluation to check the adequacy of her oral mechanisms for eating.
If your daughter has a complete medical clearance, try to offer her a higher calorie feeding like Pediasure, and offer her a small selection of foods each mealtime without forcing her to eat anything. Make mealtime pleasant and offer it consistently so that she will get used to the way food will be offered. If you don't pressure her, eventually she will probably start eating more.
Sincerely,
Dr. Warren
His condition surfaced two weeks ago. At first we thought it was an allergic reaction to TIDE W/ BLEACH (normally use regular TIDE). We immediately switched and re-cleaned all laundry (for the whole family) including all the bed linens, towels etc. w/ Deft for babies. We have also vacuumed his mattress. Removed all down comforters etc from his room. Cleaned the house w/ mild soap and water. He has not eaten anything new for the first time. We haven't changed soaps etc. We only use Johnson's Baby Shampoo on him in the bath.
I took him to see his doctor a few days ago. The doctor found no signs of infection and determined that his condition was dry skin or an allergic reaction to a detergent/soap. He doesn't have dry skin anywhere else on his body. We have tried applying a small amount of hydrocortisone to the affected area and Benadryl cream. Both help him to stop rubbing his eyes but it is only temporary. His vision seems fine.
Thoughts or suggestions as to what this could be a reaction to would be welcome. He did have a tonsil/upper respiratory infection a month ago and took erythromycin for 14 days. He hasn't taken any other medications in months.
-SC
Dear SC: If your son has an eczematous rash under his eyes, he may continue to require treatment with the cream that clears it up. Hydrocortisone cream can clear a patch of eczema, but it doesn't cure it. If the condition persists, you should see a dermatologist so that you are sure what you are treating and what the best treatment is. If the eyelids are inflamed, he may need to see an ophthalmologist. An ophthalmologic evaluation may be necessary to be sure that an eye condition is not responsible for the itching, with the rash being secondary to moisture and rubbing.
Sincerely,
Dr. Warren
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