Disclaimer: Just for fun reading, not to be taken seriously!
Case of Chicken and Chipped Tooth
A mom ate a suspicious chicken burrito from a shady restaurant. This is what happened to her digestive system. DC is a 42 year old woman, presenting to the emergency room with abdominal pain and a massive headache. She tells the admitting nurse that over the last several weeks, she could barely eat bread, rice and fish oil capsules, but they were the only things she could keep in her stomach. 4 months earlier, DC got a chicken burrito from a new place that had opened up. She was running late for a meeting, so she was eating in her car. The burrito was delicious, and she took a big bite at a stop sign. But as she chewed, something suddenly cracked against a tooth in the back of her mouth. It didn’t hurt, but it startled her. She spat out the food and she thought that she could feel that part of a tooth had chipped off. She wasn’t sure how extensive this damage was, but she was panicked. She started digging through the food, frantically trying to find what did this. And then she came across it a chicken bone piece, embedded in the shredded thigh meat from the burrito. But she couldn’t find the part of her tooth that had chipped off. It didn’t seem like a lot of damage. It didn’t hurt. If she went back to the restaurant to accuse them that their food had chipped her tooth, what were they going to do? Thoughts started racing through her mind. She knew that she had to get back to work. The restaurant could just say that she made it up, that she was the one who put the bone there. She didnt want to be confrontational, and because it didn’t hurt and it didn’t seem like a big deal. She drove back to the office to attend her meeting. DC would notice her tooth, but only when she wanted to, but eventually, she forgot about it. It didn’t hurt. But one day, weeks later, she was sitting at her desk and she thought she could feel her heart beating in her gums. Looking in the mirror, she thought like her face was getting swollen.
Sometimes when she’d have a cold drink, that one particular tooth would be ultra sensitive and really start to hurt, with the pain radiating through her jaw. At the dentist, they found that DC’s chipped tooth was… infected. Good thing this was caught in time, because bacteria inappropriately growing inside can spill into the blood and start to cause massive problems. The operation turned out fine. She’d have to deal with some post-operative pain, so they wrote her a prescription for it. And because bacteria was involved, they gave her another prescription for antibiotics. And she was on her way, but one of these was going to turn DC’s life upside down. Bacteria has the potential to grow uncontrollably, causing infection, so, this was the kind of medicine that she needed at this particular point in time, but something was wrong. 2 Days after taking the antibiotic by mouth every 6 hours, DC didn’t feel right. Normally she’d take mid afternoon naps, but when she woke up from this one, she experienced a mental fog that she had never felt before. But even worse, a sense of doom shrouded over her. She had had some experience with feeling down throughout her life, but she started having some truly terrible thoughts and feelings that she just couldn’t shake. At first, she thought it was the pain medicine but she stopped the antibiotics early too. She started feeling better as time passed, but clearly, something had changed in her body, and she wasn’t sure how to feel like she did before the tooth operation. Antibiotics need to be finished in their entirety. If the directions on the bottle says 5 days, you should take it for those 5 days, because if not, the bacteria can grow back; and the bacteria that grows back, can be resistant to that antibiotic, because those were the survivors who might have had traits that helped them adapt against and survive the antibiotic. DC knew this. But the dark and terrible thoughts were simply too much for her to handle, and her tooth and her gums were healing just fine, she thought. This brings us back to the idea of bacteria growing uncontrollably causing infection. That’s. . one part of the equation. You see, humans coexist with bacteria. In the lining of our gut, are trillions of microbes, helping us digest food and live our normal lives. They’re normal. They’re supposed to be there.
They create their own community called the gut microbiome. If antibiotics are given when someone has an infection, which is defined as an inappropriate growth of bacteria, then it lends way to the connotation that “all bacteria are all bad,” and that we must get rid of all of them to be in the cleanest condition as possible, “because that’s disease free,” but that line of thinking, isn’t fully correct. The gut microbiome is essential for normal function. But what does that mean? Well, these trillions of bacteria help do a variety of things, like synthesize vitamins. They metabolize bile, which helps us digest fat, and metabolize hormones. Because the microbiome is like a living ecosystem, it can competitively exclude other pathogens trying to come in and take residence in the gut, protecting their host. And more recently, we’re starting to understand how extensive a role it plays in helping immunity. For example, traditional chemotherapy used for some malignancies have gone by the wayside since the mid-2010s in favor of immunotherapy, medicines that enable the immune system to recognize and attack the tumor. We’ve found that the presence of certain bacteria in the gut microbiome, makes those therapies more effective against the tumors. This strongly suggests that there is a link between the gut microbiome and the immune system, showing just how important this entity is, but, if DC is getting antibiotics that are intended to eliminate bacteria from her tooth infection, then it means that some of the bacteria from her gut are going to be incidentally eliminated in the process. That’s a trade off we need to account for, because the bacteria from that tooth infection could spread throughout her body putting her in the hospital, and could threaten her life, while the bacteria in her stomach should grow back, but how long would that take? And when that bacteria do grow back, how will we know the right species are going to be there? Shortly after all this, on a Monday afternoon, DC had a watery stool. She thought maybe it was the yogurt that she ate in the morning for breakfast. But throughout that afternoon, she kept going to the bathroom, each time the movement out was more intense than the one before, and every time she was “done” she could feel that there was going to be more on the way. But everything was inconsistent. The next day on Tuesday, she was fine. But on Wednesday, she woke up with what she thought was a fever and she felt like her entire digestive system was getting ejected into the toilet. Standing up, she felt like her organs were getting dragged out of her body and into the ground. She couldn’t even keep down water. She’d take a sip, and liquid stool would just gush out her other end. And as she kept getting more and more dehydrated, her head started pounding. It hurt so bad, she couldn’t even swallow headache medicine without having a watery stool. Unable to take this, she drives herself to the emergency room. In the hospital, the medical team gave DC fluids, and medicines, for her headache.
Knowing about how her bowel movements have been over the last several days, and that she has a fever, it’s possible that she has infectious diarrhea. They do a quick test, and finds that she doesn’t appear to have a stomach bug, but she still has a fever, so they give her some empiric antibiotics just in case, and some medicine for her headache. And after a few days, she’s discharged from the hospital, feeling ok. But, that would only be for a short time. About a week after that hospital stay, DC started having watery stools again, but this time, something was different. The smell was something that she had never experienced before. It was one of the most awful sensations in her life up to that point and she didn’t want to believe that it was being produced by her. At first she thought something was weird about that yogurt she ate for breakfast again. She looked at the date and found out it was expired. But this time, the stools were really out of control. She was in the bathroom every hour, for days, eating only rice and bread, if she could even keep those down. Back in the emergency room, again. The medical team take a sample of her stool to test, and when the results return, it tells them everything they need to know, about what’s happening. Do you remember the gut microbiome? Well, when DC got antibiotics for her tooth infection, the one that she got, is known to be a culprit for infectious diarrhea. But when she was in the emergency room the first time, they took a sample of her stool to test, and, it said that she didn’t have infectious diarrhea. That might have been true, at that point in time. But at that hospital stay, they gave her a second, different, antibiotic, empirically, since she had a fever and those multiple bowel movements. Do you remember those dark thoughts that DC had after she started taking the first course of antibiotics? Well, it’s hard to say for sure, exactly what happened, but, there’s research that shows links between the gut microbiome and some psychiatric problems. You see, the gut and the brain are connected by the vagus nerve, and this bidirectional connection means that one will have an impact on the other, which will come back and impact the one. If DC started having symptoms possibly related to mental health after the first antibiotic, and antibiotics are known to change gut microbiome composition by eliminating all different kinds of bacteria , then it’s possible that some change was taking place back then, and it not only impacted her brain, but also her gut, judging from those uncontrolled loose stools. And, given that she suddenly stopped that antibiotic, and then went to the hospital afterwards to get a different antibiotic- then we could guess that even more normal gut bacteria was eliminated, when they didn’t need to be. But then the question is, with all of those gone, what bacteria replaces those eliminated? Test results return for DC, and it tells the medical team that the bacteria Clostridioides difficile, also known as C diff, is present in her gut. This is the cause of her diarrhea.
This is infectious. It can spread all throughout the hospital infecting other patients, who may also be on antibiotics but don’t have this particular bacteria growing in their gut, yet. As this result is read, DC was put in a private hospital room. She’s not allowed to share it with anyone. The toileting facilities are dedicated to her. All medical staff have to gown up, and glove up before entering her room, and they must wash their hands after dealing with her, because they inevitably will have to physically deal with other patients, people and objects in the hospital. The thing about C diff is that it makes and releases toxins that not only cause nonstop watery stools, but also damage to the gut inner lining. They destroy the cells of the colon. And then the immune system gets triggered to act in the area, causing colitis. -itis meaning inflammation. As the days pass, DC sits in her hospital room, suffering, with sporadic bowel movements, every day. Her problem was first caused by her chipped tooth not getting taken care of early. It became infected, and the antibiotic she got for that infection started to change everything. Shortly after DC received a second, different antibiotic, the recomposition of bacterial species in her gut microbiome happened, very likely leading to C diff coming in and taking over. Ironically, the treatment for her at this time, is yet another antibiotic, one that has activity against Clostridioides difficile, and in this case, taken by mouth, because the intravenous formulation of that antibiotic wouldn’t have the same activity in her gut, because taking it by mouth puts it directly there. If she’s dehydrated from all these watery stools, and has trouble keeping even water down, then they can replace her fluids, intravenously. In the hospital, days later, DC starts to feel better. This third antibiotic appears to be working for her. She’s rehydrated, and her fever is gone. Several more days pass. She appears well. No more loose stools, no more fever, no more swollen abdomen, as she’s discharged and sent home. And everything appears to be OK, but only for a short time. One day, a few weeks later, DC was eating some fruit with breakfast. In the afternoon, she felt a sour stomach, maybe a little heartburn. She wanted to be careful given everything that had happened recently.
She tried an over the counter medicine that someone had recommended to her, one that would help limit stomach acid. They told her that it might take a couple days to start working, but that in the end, she would be all good. But a couple days went by, and DC started feeling kind of weird again. One afternoon, she could feel her guts quake and shake. In the bathroom, again, she had a watery stool, and she started to panic here, because that smell was so familiar to her. Throughout that day, she had multiple, uncontrollable, loose watery stools, again. In the hospital, again. DC was found to be experiencing a recurrent episode of C diff. Do you remember that concept of antibiotics producing resistant strains of bacteria? Well, it doesnt appear to happen often, but data says maybe 20% of patients with C diff will get a recurrence. And even worse, sometimes, it could be associated with that stomach acid medicine that she took. The thing about antibiotic treatment of Clostridioides difficile infection, is that misuse of antibiotics were the cause in the first place. And the ones that are used to target C diff, can sometimes cause C diff. This isn’t meant to scare you about antibiotics, but rather to demonstrate to you that antibiotics aren’t to be taken lightly. Because. . DC can be treated again. And weeks later, the C diff can come back. And some patients will go through this, with no good solutions, suffering every time with bouts of uncontrollable watery stools nonstop that come and go for years. In fact, much of our current system of medication and prescriptions in the United States was created in part because of antibiotics. In 1928, penicillin was discovered, and its production was scaled up greatly for the world events of the 1940s. At least in the United States, before 1950, people could buy almost any medicine that they wanted at a pharmacy and treat themselves without ever seeing any medical personnel. Knowing about DC’s case with C diff, and knowing that antibiotics could, at a minimum, do what they did to her, if not also create ultra-resistant strains of “super bacteria” that would evade every single treatment modality that we know of today, episodes of self-medication with antibiotics could potentially be catastrophic in more ways than what we’re describing here. And so in 1951, the Durham Humphrey Amendment was enacted by the United States Congress to require there be a class of prescription-only medicines, that must be prescribed by a professional who has prescriptive authority, and then the medication on that prescription can be verified, vetted, and dispensed by a professional who has dispensing authority, serving as a check to ensure that the right patient is receiving the right medicine at the right time. It gives authority, produces accountability, and defines liability in the case that something goes wrong. Antibiotics are prescription-only.
The acid suppression medicine from this latest episode of hers is both over the counter and prescription. In DC’s case, In practice, you can still find, pretty easily, when antibiotics are given inappropriately. Like when someone has a cold or the flu, problems that aren’t caused by bacteria. They are still given antibiotics, when they shouldn’t. I even asked this question as a quiz in my community tab, (which I think you should check out) and majority who did answer, got it right, but the amount who didn’t, well, it can cause some issues. Suppose only 10% got it wrong. In a country of 330 million people like the United States, that’s 33 million people. But for DC, her C Diff would keep coming back over several months. She would lose her mind because she’d be fine and then randomly have loose stools, and she knew it was C Diff coming back because of the smell. Her problem was initially caused by inappropriate antibiotic use. Retrying them again and again and again, could work, but there might be a non-pharmacologic treatment that might help. DC was recommended for a fecal transplant, where stool, from a bank, makes its way into her gut, with the intention of making her gut microbiome “normal. ” DC was prepped, and the medical team administered the treatment through her lower GI tract. She was then given some Fecal Microbiota Capsules, which are FDA approved to help prevent recurrence. As she was monitored in the hospital, she was noted to not have symptoms of C diff infection anymore. DC started to notice that her mood was better, and that she was feeling better too. When she was discharged, DC wasn’t sure if she was out of the woods just yet, the infection could come back. But as days turned into weeks, turned into months, DC was able to live her normal life again as she made a full recovery. Please don’t be scared of antibiotics because of this video. Infections can and will be life threatening, and things can spiral out of control in just a few hours. I will never forget, a series of patients I saw who were young, healthy and smiling with me in the hospital, and then 6 hours later, they’re gone, because their infection went out of control. The benefit of preventing the end of a human life outweighs any risk that an antibiotic would pose in settings like that. Now with that said, you’ll want to check with all the healthcare professionals who are seeing you, whether that medicine you’re going to take is the right one for you, at that right time. And if you chip your tooth on food, get it checked out as quickly as you can to try to position yourself to not need what DC needed.
Video Game and Water
A Man Played Video Games Nonstop for 73 hours. This is how his organs shut down. DC is a 25 year old man, presenting to the emergency room, dead on arrival. Paramedics were desperately performing chest compressions to try and push blood back into his brain. To try and push blood into his organs. To try to keep him alive. But it seemed like their attempts, were all in vain. DC was a college graduate, but he never wanted to go to school. He worked a minimum wage job, but he was recently fired. He wanted to be an internet video game streamer, but no one was watching. And he lived at home with his mom where she still cooked for him, but she kicked him out when he was no longer going out to look for a new job. Depressed and lost, DC binged on video games at the local internet cafe for days at a time. Sometimes he’d sleep at the computer, and wake up to play some more. He gave up personal hygiene. He gave up friendships. His life was games. He was obsessed, and he just couldn’t stop playing. One weekend, DC played for 73 hours, nonstop. Glued to his seat, he barely ate any food.
He hardly drank any water. He didn’t even get up to use the bathroom, having already released a few times in-between, and finally couldn’t hold it in anymore. He got up for the first time in days as he stood up from his chair. He suddenly felt lightheaded. He blacked out. And then instantly collapsed. At the front desk of the internet cafe, the owner was oblivious to the fact that someone had fainted on his property. 30 minutes pass and DC was found on the floor, unconscious and struggling to breathe. 911 is called. In the ambulance, DC suddenly flatlines. His heart stops beating and he stops breathing. Paramedics desperately begin CPR as he’s brought to the emergency room where we are now. Doctors continue chest compressions. Ultrasound immediately reveals that the right side of his heart is swollen. It’s larger than the left ventricle, which is the part of the heart that’s responsible for pumping blood to the entire body. The left ventricle has more muscle so it’s largest part of the heart in every normal functioning human. But DC can’t function normally now. His heart is twisted. It’s disfigured.
This immediately tells the medical team that he’s suffering from Acute Massive Pulmonary Embolism. Embolus from Ancient Greek meaning a wedge, or in this case referring to a blood clot. Pulmonary meaning Lung. And Massive referring not to size of the actual clot but to the SUDDEN hemodynamic collapse that it caused in DC. A blood clot wedged into the lungs causing his heart to disfigure. Causing his heart to stop beating because it is disfigured. Causing his organs to shut down because they’re no longer receiving oxygen due to the fact his heart has stopped beating. Acute meaning that he didn’t have any underlying medical issues leading to this problem, except for sitting at a computer playing video games nonstop for 73 hours. Doing anything nonstop for 70 hours is dangerous, but sitting down nonstop for 70 hours is deadly, because of venous stasis. This is a time when a lack of movement of the legs causes blood to pool. The blood pressure in the body’s veins is already low because there isn’t anything directly pumping it back to the heart. Venous blood oozes its way back. Without moving the legs for 70 hours and given that sitting down compresses the veins, a compartment of the body where blood flow is already slower than normal, then this pooling of blood causes some of it to clump together into a clot, called a deep vein thrombosis, which is what happened to DC as he sat there, for days, but there’s more. As the clot formed, it stayed in his legs for as long as he was sitting down. He got up, it broke off, it went directly into the right side of his heart like how blood normally does, but then lodged itself directly into the pulmonary artery where the right side of the heart connects to the lungs. This back up of blood into the right ventricle, caused it to stretch. To distend. To disfigure. But this is only the beginning of the dysfunction.
The right ventricle of the heart typically has a thinner wall than the left. It has a lower volume to surface area ratio. This makes sense because blood from here goes directly to the lungs. You don’t need high pressure going to the lungs when they are right there. But when the right ventricle swells due to flow backing up, wall stress increases. It pushes against the interventricular septum, causing it to bow out into the left ventricle. This increased pressure and volume in the right displaces the left, reducing cardiac output. In DC’s case of hemodynamic collapse secondary to massive pulmonary embolism, an occlusion into the pulmonary artery meant a filling defect on the left as blood cannot be pumped out to the rest of the body. There is no longer an adequate oxygen supply in his body as his organs all start to die. His heart, while still trying to beat, can no longer function. It arrests, as he comes into the emergency room, without a pulse. But it wasn’t like this when they found him. Paramedics tell the medical team that DC was found gasping for air. That he did have a heartbeat when they found him, but it was fast, from his body detecting hypoxemia, a low oxygen presence in blood. His blood pressure was low from the then hemodynamic compromise. And that it was on the way to the emergency room that his heart suddenly stopped beating. That all of this happened just minutes ago, meaning that it might not yet be too late. There might still be a chance to bring DC back to life. Is there a way, we can somehow remove the clot from DC’s lungs?
Maybe. But it has to be done, immediately. Surgery and cutting him open to pull it out, isn’t an option because it would take too long. Guiding a catheter through his veins to direct medicine that can dissolve the clot directly, is also not an option because of time. The quickest solution, is to infuse that medicine directly into his entire body. This systemic fibrinolytic therapy, is his last hope. On the emergency room bed, DC is immediately infused with a large bolus dose of lytic as chest compressions are continued. Additional lytic was set for infusion over time as this aggressive dosing means the medical team will continue CPR until he either comes back to life, or it is absolutely certain that DC is lost. As the chest compressions are desperately applied, minutes pass. A detectable heart beat is found and this return of spontaneous circulation is a good sign. DC is not lost. But several hours pass, and he doesn’t regain consciousness. Admission into the intensive care unit finds that he is missing cognitive factors. Shining a light into his eyes, a normal functioning human will exhibit a pupillary reflex, where the pupils will constrict in reaction to the increased presence of light. Absence of this indicates brain damage, and in DC, it’s absent. In a normal functioning human, motor response to pain is natural reflex. Absence of this reflex indicates brain damage, and in DC, it’s absent. As the days go by, DC’s mother arrives to the hospital to see her son. She tries to speak to him but no response.
He may not have listened to her in life, but the only thing she would like to see now is a response, an indication, something, from her son that tells her he can hear her, but nothing is returned. The several minutes where DC’s body was not receiving oxygen because of a clot blocking the point where his heart and lungs connected, caused this permanent anoxic ischemic damage. Most people can easily pick out that healthy individuals can’t stay up and play games for 3 days straight, without sleep, without going to the bathroom. Most people can’t stay up 3 days straight for anything. That to be able to play that much means that that person, has a problem. Internet gaming disorder has been described as a condition needing further research for several years now. Back in 2013, The Diagnostic and Statistical Manual of Mental Disorders, revision 5 put that description on paper. And in 2018, the World Health Organization placed gaming disorder as a diagnosable condition in the 11th revision of the International Classification of Diseases. DC is at one extreme end of the spectrum of what can be described as internet gaming disorder. The actual people who will have this are a small subset of the population, because, most people won’t have this level of obsessive behavior. Context here matters, make no mistake. People who only hear headlines may be underinformed as to what internet gaming disorder really is. What behavior those words are describing. It’s probably not describing a kid who wants to play games with his friends after school, who day dreams about the game during class, but is a functional person who is OK if they don’t play games for a few days. Who can comply with their responsibilities. It also probably doesn’t describe a 25 year old who plays 20 hours total on the weekend, but can still show up to work during the week, hold a relationship and family obligations without problem. Internet gaming disorder doesn’t describe these people. But, if someone lets their kids or pets starve to death because they were too focused on playing a game, then something might be wrong. If someone continues to obsessively play after getting forcibly kicked out their parents’ house, plays for several days at a time nonstop, not getting up, not eating, not using the bathroom, and not sleeping, well then something could be wrong.
Even worse if blood pools in the legs while that person is playing, forming a deep vein thrombosis, that became a massive pulmonary embolism, with end organ malperfusion and hemodynamic collapse resulting in residual organ dysfunction and hypoxic brain damage. Something that results in tangible, detrimental and life-threatening consequences due to one’s lack of self control over playing video games, IS a problem, and it’s a good thing that it’s been classified as such. For DC, limited neurocognitive function was recovered as he suffered from rounds of pneumonia and sepsis during his stay in the intensive care unit. Diminished urine output and elevated transaminase levels indicated kidney and liver damage. The loss of pupillary reflex and absent extensor motor response days after admission were 100 percent specific factors to indicate poor outcome following anoxic injury, secondary to massive pulmonary embolism. At autopsy, extensive neuronal damage was found in the parieto-occipital-temporal cortex of his brain. Cerebellar injury was observed along with losses at the thalamic nuclei. Little could be done by the time he was found unresponsive at the internet cafe as too much time had passed in a setting where minutes and seconds matter. The only hope was to salvage whatever the medical team could, once DC fell into cardiac arrest. For gamers today, be sure to keep yourself hydrated and don’t sit for more than an hour at a time. Get up, walk around even if just for a couple of minutes. And most importantly, be kind to yourself. Internet gaming is actually stressful, even if it’s fun.
Junk Food Nightmare
A Boy Ate Only Potato Chips & French Fries for 10 Years. This Is What Happened To His Eyes. DA is a 17 year old boy, presenting to the emergency room with a progressive deterioration in hearing, sight, and vitality. He tells the admitting nurse that his field of vision had been slowly going dark over the last several months and a ringing in his ears had been washing out his hearing for some time. You see, DA was an average teenager. He didn’t take any medicines or have any past history of disease. At his age, he didn’t have any records of recurring behavior. A few years earlier, a 14 year old DA came in for his regular checkup. He reported good health, but some chronic tiredness and told the doctor that he preferred eating only french fries, potato chips, and white bread because he enjoyed their texture. A blood test at this visit noted that DA had macrocytic anemia. An meaning without and emia meaning presence of blood. His blood cells were larger than normal, and, he didn’t have a lot of them floating around in his body. Less blood cells means less oxygen getting to the brain, which could explain his chronic tiredness. This was accompanied by a marked vitamin B12 deficiency, unifying all his problems. Low vitamin b12 causes anemia. Potato chips, French fries, and white bread are completely devoid of vitamin b12. The body doesn’t make b12 on it’s own, but that’s ok because basic foods like eggs, beef, yogurt, and fortified cereals have it, so it’s almost impossible to miss. But his levels are low, so DA was given vitamin injections to boost his levels. The doctor gave him dietary advice to add more variety in his foods, and 14 year old DA was sent home with no problems.
Several months after that first visit, DA was examined by a different doctor. He complained that there were spots hanging out in front of his eyes. An MRI of his brain found no abnormalities and a slit lamp exam returned normal. Nothing seemed to be the problem, and there were no signs of immediate life threatening injury, so come back if you have more problems, they told him. Over the next several months, DA noticed something wrong when his field of vision started going dark. Maybe looking at screens for too long, he thought. One day, he turned his headphones to the maximum volume and could barely hear anything. Probably watched too many of those loud meme videos, he thought. Skin-deep, DA appeared to be healthy. But, a neuro-ophthalmology examination finds bilateral central visual field defects, confirming blind spots in his field of view. Nerve fiber loss was detected in both eyes. But his motor and cognitive functions were normal. All of this pointing to some potential neurodegeneration localized to his optic nerves. There was definitely something happening to him. As the days go by, DA is acutely aware of the deteriorating sight in both his eyes. Normal vision is typically 20/20, meaning that you can see something that’s 20 feet away. But DA’s vision is 20/200, meaning for an object that’s 200 feet away, he needs to be 20 feet from it to see it. That is the E on the chart, and by definition, 20/200 is legally blind in the United States. A repeat slit lamp examination finds no abnormalities in optic nerve appearance.
No visible damage can be seen. Typically, an injury to the brain may cause visual field defects, but a second MRI confirmed no lesions present. These need to be ruled out immediately because they could signal an immediate life threatening emergency. A test was administered for Leber hereditary optic neuropathy. Neuro referring to the nerves. opathy- meaning a disorder and optic referring to the eye. A disorder of the nerves of the eyes. This genetic disease is characterized by painless, vision loss in both eyes, that disproportionately affects young males. It’s not common. It’s almost a perfect fit. But the test returned negative. Analysis of DA’s blood reveals the same macrocytic anemia found at his original checkup from 3 years ago, but this time, something’s wrong. Malnutrition is well documented to cause optic neuropathy, but subsequent testing of his liver, thyroid, and vitamin b12 levels return normal. DA’s history of B12 injections from 3 years ago had lapsed meaning he hadn’t received them for quite some time now. If it’s possible that a lack of this vitamin could be causing DA’s vision loss, but his b12 levels are normal, and he still has that anemia from his initial visit, then what could be going on? Well, there’s some biochemistry to be known here. Vitamin B12 is a coenzyme, meaning it’s a chemical needed by an enzyme to function. An enzyme, is a protein that makes a chemical reaction happen. If there’s a problem with an enzyme in the body, no chemicals, or maybe the wrong chemicals are made in the cells, which would cause disease.
In humans, vitamin B12 coenzymes for 2 specific enzymes. In the mitochondria, powerhouse of the cell, B12 works on Methylmalonyl Coenzyme A mutase to feed into the cycle that produces ATP, which is what the cell uses for energy. — In the cell nucleus, Vitamin B12 works on the enzyme methionine synthase, which drives the process of synthesizing DNA, allowing cells to generate the necessary genetic material to function. — Both these processes either generate or consume a unique chemical. If normally, homocysteine is consumed in the nucleus to help make DNA, then high levels of it would mean it’s not being consumed by the process involving vitamin B12, meaning B12 is likely absent. If methylmalonic acid is produced in high amounts instead of the correct chemical to produce energy for the cell, then it means vitamin B12 is absent. — As the medical team orders homocysteine and serum methylmalonic acid levels in DA, the results come in at 3 times higher then the upper limit of normal for both, meaning even if DA’s B12 levels in blood are “normal,” he is functionally deficient. But, how? In America, Europe, and Australia, a common cause of B12 deficiency is malabsorption. Mal meaning bad and absorption denoting the process whereby one mass is incorporated into another, meaning that it’s not that people aren’t consuming it, but that their body doesn’t allow them to have it. B12 is almost everywhere and clinical starvation is not usual in the overwhelming majority of people in these countries. This problem of absorption, is important because the vitamin doesn’t just float around in your body, it has to be carefully escorted in the GI tract. You see, the stomach isn’t just a bag that holds chewed food. It produces a protein known as intrinsic factor, which binds to B12 and this intrinsic factor-vitamin b12 complex gets absorbed in the far end of the small intestines. The problem is, the body can sometimes send the immune system to wrongly attack the stomach, preventing intrinsic factor production, so that B12 never gets absorbed. This autoimmune disease can become worse in a person and attack other parts of the body, like the pancreas and cause type 1 diabetes. But DA has no evidence of autoimmune disease, or genetic disease, or underlying brain injury, meaning that the small detail of his diet actually consisting of only French fries, and potato chips is the cause of this malnutrition. This is not to say he was lying and wasn’t believable about his dietary intake, but without writing down and recording meticulously everyday what you eat, it’s easy to miscalculate details about one’s own food. This concentrated lack of variety in his diet and absence of a vital nutrient, is the cause of his problems, bringing us back to the idea of a coenzyme.
DA presented at age 14 with macrocytic anemia. To be oversized, means something was wrong in the cellular DNA. And DNA, is in the cell nucleus, where Vitamin B12 cofactors for the enzyme methionine synthase to help drive the cycle to produce genetic material. Without B12, those materials aren’t properly made. This impairs the maturation of the nucleus, limiting the rate of DNA repair, and limiting the blood cell’s ability to hold oxygen. But the cell’s overall maturation isn’t impaired, and this dysynchrony means less cells are created, and each one is larger than normal bringing us directly to the definition macrocytic anemia. Without a presence of blood, where each cell is larger. But this isn’t the end of DA’s problems. In the cellular mitochondria, absence of B12 prevents the production of ATP, which is energy. But as the mitochondria tries to make more energy, it starts to use the wrong chemicals. This might be ok in tissues that don’t really need constant fresh sources of energy. The muscles can recycle some of the correct molecules and still function. Other parts of the body that don’t move don’t need so much mechanical energy, so they can do for some time without it too. But how about the nerves? The nerves are covered in a fatty myelin sheath to help conduct signals. Fat is energy dense. It absolutely needs the right molecules to be properly formed. If the wrong chemicals are being used, because the right chemicals just aren’t present, then the myelin sheath doesn’t develop properly. Small vacuoles begin to creep their way in forming gaps.
Over time, swelling and separation of the sheaths develop into lesions that begin to scatter. The myelin becomes spongy and no longer the formed sheath it should be, coalescing into a combined degeneration, impairing nerve conduction. If the nerves can’t properly conduct a signal, minimal communication happens. Without a signal, the brain can’t interpret sensory information. And if parts of his optic nerve become damaged because vitamin b12 wasn’t present for methylmalonyl-CoA mutase to convert propionyl CoA to succinyl CoA so that the Krebs cycle in the cell can properly produce the ATP and fatty acids needed for synthesis of its myelin sheath, then this could explain why DA has become legally blind from his strict diet of French fries, and potato chips, because these are foods that are devoid of vitamin b12. This didn’t have to happen. Optic neuropathy has a long list of causes. Nutrition is not typically the first thing anyone medically trained in America, Europe, and Australia think of because, malnutrition especially in the context of Vitamin B12 is simply not common. DA’s bodyweight was well within average for his height. He didn’t look malnourished from the outside. If doctors just thought of nutritional optic neuropathy right from the start, and just simply stopped and didn’t look into the other causes of his blindness, in this case, they would have been correct. But what if it wasn’t nutritional in origin? What if they missed a more common and life threatening cause of his blindness and let that disease progress? You can’t just stop at a nutritional cause in this case without ruling out the possible etiologies. There’s a lot of CYA in medicine, this is a very clear example of it. Do you remember the name of the stomach protein intrinsic factor? Well, humans didn’t know what was the extrinsic factor that binds to it to alleviate the pernicious anemia that these patients were getting. In the late 1800s, humans starting feed patients with this deficiency raw animal liver, with some success. This was the dietary extrinsic factor at play as liver has a lot of B12.
A Nobel Prize was won in 1934 for those experiments. Decades later, humans used X-ray crystallography to see what extrinsic factor or what we know as vitamin b12 is today, looks like. And Professor Dorothy Hodgkin was the winner of the Nobel Prize, for doing exactly that, paving the way for it to be synthesized in the lab. To be added to foods. To make supplements out of it and injection formulations of it if their stomach won’t allow them to absorb it. To have it so most people can’t miss it, because we know without it, the deficiency will cause anemia and neurodegeneration ranging from mood impairment to blindness and dementia. . But some will always slip through the cracks. The people most susceptible to b12 deficiency today are those who follow an abnormally strict vegetarian or vegan diet. Who wrongly refuse supplementation. Who don’t eat cereals, which in the US are almost all fortified with vitamin B12. For DA, vitamin B12 injections were restarted. He was counseled for his eating habits. Problems coming from vitamin B12 deficiency can be reversible if caught early. And while his rate of vision loss stabilized, DA’s optic neuropathy and associated hearing loss was not reversed.
Too much Energy Drinks
A Man Drank 12 Energy Drinks In 10 Minutes. This Is What Happened To His Organs. JS is a 36 year old man, presenting to the emergency room with breakthrough abdominal pain. He tries to tell the admitting nurse what was happening, but he had to grip the armrests of his chair to stop himself from emptying his stomach on to her shoes, again. You see, JS was a man living the dream. When he was growing up in the 80s, he was always around video games. His parents liked playing them. But, JS didn’t have friends who played video games, because he really didnt have any friends at all. When he was 14 in 1998, Pokemon had just come out. Some of the Pokemon in Red and Blue could only be had if players traded with each other on their gameboys, but because JS didn’t have any friends, he could never make the trades needed to get those Pokemon. As the years passed, what JS didn’t have as a kid, he tried as hard as he could to have as an adult. If he couldn’t have Gengar when he was young, that’s a Pokemon that required a trade to get, then JS had a lot of Gengar as an adult. If there were games and movies he didnt have as a kid, he had them as an adult. But these were material things. If he didnt have friends and recognition as a kid, then he tried as hard as he could to get them as an adult. One day, at his workplace, JS thought it would be funny to chug some energy drinks. The admin loved to stock them in the fridge, and the company always touted the drinks as a wonderful benefit for a great place to work. At the table now, JS wanted to put on a show. He was going to chug 12 energy drinks in 10 minutes, and it was going to be legendary. At first it felt cold on the way down. He could feel the burn at the back of his throat. But as the cans continued, the burn started to become discomfort as it felt like sores were growing and tearing up his mouth.
Immediately after chugging all 12 energy drinks, JS didn’t feel well. The bottom of his chest was burning. He wasn’t sure if it was his stomach or his heart hurting. He was short of breath and to take his mind off of everything, he started playing some games. As the hours passed, JS could feel his heart fluttering. But this shouldn’t be happening, he thought. For him, caffeine really never had much of an effect. Even if the max daily recommendation is 400 milligrams a day, JS easily pushed seven, eight, nine hundred milligrams during LAN parties and weekend gaming marathons. I must just have good genetics to breakdown caffeine quickly, he thought. What started as a discomfort at the bottom of his chest started radiating out to his back, in-between his shoulder blades. JS knew he was wired, he could feel it all throughout the night while he was playing games and watching his friends stream. He thought taking a small shot of some other drink could help relieve some of this pain. But problems started happening when JS emptied his stomach into the kitchen sink. He had been feeling nauseous for several hours. After letting it all go in the sink, he started feeling even worse. He could feel his heart beat in his eyes. The back pain would burn just under his neck, and the pain in his stomach would come in waves, each one more intense than the last. Any time he tried drinking some water, that water would come right back up. JS tried holding out for a few days, because he believed that none of this could have been the energy drinks. Those should have already passed through his body, so it must be something else. But finally, JS couldn’t eat anymore. He couldn’t drink anything anymore.
And the pain was so sharp and burning as he calls for 911, and he’s brought to the emergency room where we are now. Doctors noticed that JS was nauseous. He had already thrown up on the nurse’s shoes. His breathing was stressed and he said that his abdominal pain would radiate to his back, like someone had taken a crowbar and started prying it apart. A blood test finds that JS has hyperglycemia. Hyper meaning high. Glyce referring to glucose, another name for sugar. And -emia meaning presence in blood. High sugar presence in blood. Each can that JS drank had more than 50 grams of sugar. 12 cans means that he chugged over 1 pound of sugar in 10 minutes, so hyperglycemia should make sense. But the problem is that he chugged those energy drinks more than a day ago. He hadn’t eaten anything afterwards because his abdomen just hurt so much. And the body typically tries to get rid of excess blood sugar as quickly as possible, so sugar shouldn’t be high in his blood. The pancreas releases insulin to help lower blood sugar. JS has abdominal pain, and the pancreas is in the abdomen. There could be a problem with his pancreas, maybe it’s not releasing insulin. Maybe something is blocking it from releasing insulin, or maybe it is releasing it, and his body isn’t responding to that insulin. This could mean that JS has diabetes. But that isn’t in his medical record, and another test of his long term blood sugar levels suggest he had prediabetes. But with the pain and the vomiting, doctors have a different idea of what could be happening. In the emergency room, doctors use an ultrasound machine to get an idea of what’s happening to JS’s pancreas.
Maybe a gall stone is blocking it, backing up flow, and causing problems. But they didn’t see anything there. As they sent him in for a higher resolution scan, more results come back from the lab— JS has hyperlipasemia. High Lipase Presence in Blood. Lip from Greek Lipos referring to lipids, or fats, and -ase referring to enzyme. High fat degrading enzyme, presence in blood. Lipase comes from the pancreas. It helps us digest the fats we eat from our diet. If its levels are high in the blood, then it means the pancreas is leaking it out. And if it digests fat, and the pancreas is partially made of fat, then it means that JS’s pancreas is starting to digest itself. The abdominal pain radiating to his back. The nonstop nausea and vomiting. The inability to keep anything down and the hyperlipasemia. All of these together meaning JS has acute pancreatitis. -ITIS meaning an inflammation of the pancreas, because something happened to it, enzymes started leaking out of it, and now it’s starting to digest itself. Acute meaning this is all happening suddenly, and the medical team wants to know why. In the emergency room, doctors don’t know that JS chugged 12 energy drinks in 10 mintues. He didn’t tell them that. What doctors do ask him, is if JS consumes a lot of alcohol. Because he’s young, excess alcohol may not have permanently damaged the liver yet— that takes some time, but it can hurt the pancreas suddenly. It’s the second most common reason for pancreatitis, after gallstones, which the ultrasound showed, he didn’t have. JS did say he did have one shot of liquor when the pain started.
They took his word for it. But they were suspicious thinking that it could have been more than just a shot, but the reality was he took the shot several hours after the pain had already become severe, and doctors just had no idea about the 12 energy drinks. JS was started on IV fluids. He was dehydrated because he couldn’t keep any water down. They give him medicines for the pain because it’s so excruciating, and everything seemed to be going OK. But only for a short time. When body parts appear to be damaged, the immune system reacts. This is to protect you. The problem is, sometimes the immune system overreacts. And it does that overreaction, when it shouldn’t be reacting in the first place. JS’s pancreas digesting itself is body part damage, so the immune system is there trying to protect him from that damage. But when inflammation, pancreat-ITIS, happens, the area can start to swell with fluid. And in JS, where his pancreas was supposed to be, is starting to swell with fluid. Typically in a 36 year old man with no diagnosed past medical history, this kind of pancreatitis resolves itself. The medical team elects to watch and wait, because even though his abdomen is swelling with fluid, doing surgery and cutting him open could be doing more harm than good. Even if the image looks scary, the body has a way of healing itself. And as a few days pass, things seemed to be holding steady, JS probably didnt need to have that surgery, and he’s probably ready to go home, they thought. As the medical team gets ready to discharge him from the hospital, everything seems to be going smoothly. But as the hours pass, JS starts to get chills. He starts running a fever, as his blood pressure starts to drop. His heart is trying to keep up by pumping harder and faster, but it’s not enough. Another CT scan finds that gas is now in the space where the fluid was swelling.
The stomach and the intestines have some air in them, but they’re usually closed off so their contents don’t leak in to the abdomen, so if JS’s stomach isn’t punctured, then where could this gas be coming from? A blood test finds that not only are JS’s liver and kidneys starting to shut down now, but that he now has an infection. If bacteria and fungus floating around in the abdomen, outside of the stomach, can produce gas, then it means that fluid buildup from his inflamed pancreas, is now infected. But it doesnt just stop there. Whatever is infecting him, has now spilled in to his bloodstream. The immune system detects this and tries to react again by dilating the body’s blood vessels. But this drops the blood pressure. Adequate oxygen can’t get to organs like the liver and the kidneys, as they start to shut down. JS comes in and out of conscious as limited oxygen gets to his brain. All of this happening from pancreatitis in JS, that came from chugging excess energy drinks, as he finally utters to the medical team what happened. But why did this happen? Good question. Generally, most people know that energy drinks can be dangerous when consumed in huge excess. If you have one once in a while, and you’re young and healthy, it’s probably not a big deal. But if you start chugging multiple cans back to back, then bad things are probably going to happen. Most people immediately think of the caffeine content. Each can that JS drank had 160 milligrams of caffeine, so 2 cans get you very close to the recommended daily limit. Too much caffeine can make you wired, make your heart race, your breathing will become fast, it’ll make you shaky and jumpy, and in some people, lots of caffeine will feel like a panic attack. This energy drink cardiotoxicity, has been well documented. Check out this video from my cardiologist friend MedLifeCrisis, link in the description below. Energy drinks are more than just caffeine. And we dont know exactly how much of any one of these ingredients are in a single can.
No one intended for someone to chug 5 and a half liters of anything in 10 minutes. What we do know, is there might be an association with excess energy drink consumption, and pancreatitis. It’s not just the caffeine and stimulants in there that’ll get you in the heart. Whether it’s chugging 12 cans in 10 minutes, or drinking three, four, five, six cans a day everyday, the pancreas can get injured. We can’t experiment on people in this setting— because we can’t give everyone huge amounts of energy drink until their pancreas starts digesting itself. And of the people who do drink 6 cans a day, we can’t cut them open and look at their pancreas at any given time, because it’s buried so deep inside the human body. For JS, this became a wake up call to him for his health. He didn’t have diabetes, but the blood test said pre-diabetes. He didn’t have hypertriglyceridemia, which can come from diabetes and cause pancreatitis. But the lesson is pancreatitis can spiral out of control very quickly, even when the patient looks great and ready to go home, just like JS. He was holding steady, until his organs just suddenly shut down because the inflammation got infected, and spilled in to his blood. With supportive care, and antibiotics. A diligent medical team, and a renewed sense of life, realizing he had everything he could ever want, JS was able to make a recovery.
Comments
Post a Comment