I Can't Breathe

 Dyspnea or Shortness of Breath

PKGhatak, MD

“ I can't breathe” has become a worldwide slogan for social justice after the killing of George Floyd in Minnesota.

I can't breathe, difficulty in breathing, sense of suffocation, air hunger, shortness of breath, short of wind, tightness in the chest, uncomfortable in breathing, not getting enough air, are some of the ways patients describe their difficulty - in medicine known as dyspnea.

The word dyspnea is derived from the Greek word dyspnoia – meaning breathing disorder.

The American Thoracic Society calls dyspnea” as a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity.”

Can't breathe is one of the most frightening symptoms of human experiences. A sense of impending doom overshadows all other concerns. The patient fights with all his might to right the situation.

A healthy person may experience shortness of breath during strenuous exercise like climbing several flights of stairs or hiking mountains and visiting high altitude places.

Shortness of breath in all other cases is due to an abnormal condition/condition in the lungs or heart or neuropsychiatric causes.

Points to remember that dyspnea is subjective and varies in intensity.

When patients present with dyspnea the doctor categorizes them into groups according to 1. its severity. 2. episodic or chronic.

Some of the conditions of life threatening acute shortness of breath (SOB) are.

1. Allergic and anaphylactic. 2. Asthma. 3. Acute left ventricular failure (commonly called Pulmonary edema). 4. Cardiac tamponade (pericardial effusion or bleeding) 5. Rupture of the lung (pneumothorax). 5. Broken ribs and bloody pleural effusion 6. Pulmonary emboli. 7. Massive hemorrhage. 8. Choking. 9. Bilateral pneumonia like covid -19. 10. Carbon monoxide poisoning.

Chronic cases of SOB are 1. COPD. 2. Congestive heart failure. 3. Chronic anemia is secondary to systemic diseases. 4. Neuromuscular diseases like ALS, paralysis of the diaphragm, myasthenia gravis. 5. Morbid obesity. 6. Ascites. 7. Large intra-abdominal mass like Wilms tumor. 8. Chronic bilateral pleural effusion. 9. Interstitial pulmonary fibrosis. 9. Deformity of chest wall e.g. Kyphoscoliosis.10. Subphrenic abscess.11. Chronic illness or disability leading to deconditioning.12. Anxiety and psychosis.

Treatment:

The goal is to restore the normal functioning of the lung, heart, blood and brain as soon as possible.

Pulse oximetry is in wide use since the covid pandemic, it is the initial test and any lack of oxygen should be immediately corrected by giving oxygen.

The other conditions are just too many to discuss here. But the best place is the emergency room for severe acute situations and the doctor's office for non-life-threatening conditions.

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Chest Pain.

 

Chest Pain.

 (Pain Pathways of the Heart).

PKGhatak, MD

The American Heart Association and its affiliates have been very successful in educating people on the significance of chest pain and its relation to an acute heart attack.

Heart muscles are not richly supplied with pain nerve fibers (called Afferent or sensory fibers) compared with the pericardium (fibrous covering of the heart). A wider area of the heart muscles has to be injured to elicit pain sensation. Even then, the pain is not felt in the heart but projected on the Central chest wall, neck, Lower jaw, and arms down to the fingers, upper abdomen, or on the back in between the shoulder blades.

This peculiarity of projection of visceral pain onto the skin is limited to organs innervated by the Vagus nerve.

In the early stage of fetal development, the human body was a segmented tube; each segment had its own pair of blood vessels and pair of nerves. In the later phase of development, as limbs and internal organs developed, that representation remained intact.

In the case of the heart, the location of pain felt on the skin is due to the fact that the heart developed from the pair of blood vessels from Cervical 7 to Thoracic 3 segments. The sensory nerve fibers of the heart join the vagus and sympathetic nerves to carry pain sensation to the brain.

In 1991 Dr. Armor described a new concept – Heart-Brain, consisting of 40,000 neurons situated in the heart and function as a mini brain. Nerve fibers from these neurons make direct connections with the amygdala, hypothalamus, thalamus and relay information to the cerebral cortex. The sensation from these neurons modifies effects of both the sympathetic and parasympathetic nervous system, and according to Dr. Armor, generates memory, emotion and modulates pain sensation.

Sensory nerves of the heart.

The Vagus nerve and nerves of the sympathetic nervous system carry Pain sensation to the brain.

The sensory nervous system of the heart is distinct. The nerve cells, nerve fibers, and ganglions are separate from the outflow tracts of both the parasympathetic (vagus) and sympathetic systems.

Vagus nerve.

The sensory fibers of the heart originated in the Nodose Ganglion of the Vagus, situated in the Jugular foramen. These fibers travel with the vagus nerve into the chest. Fibers destine to innervate the heart pass through the cardiac plexus without making any connection. The pain sensation from the heart is carried to the sensory nucleus of the vagus – Nucleus Tactus Soliterious, situated in the dorsomedial medulla. From there the 2nd order neuron carries the sensation to the thalamus. From the thalamus, the pain sensation reaches the cerebral cortex.

80 % of pain sensation is carried by a pair of the vagus nerve. The right vagus nerve innervates the sinoatrial node, atrioventricular node, and atrial walls. The left vagus carry innervates these structures and also from the rest of the heart. There is a considerable overlap of innervation of the heart from both vagus nerves.

Sympathetic innervation of the heart.

The neurons, that carry the pain sensation from the heat in the sympathetic nervous system, are situated in the Dorsal Ganglion from the 8th cervical to the 3^rd thoracic segment. The axon of the nerve enters the spinal cord via the Dorsal root and makes a connection with the neuron situated in the dorsal horn of the spinal cord. The second order neuron carries the pain sensation upward to Thalamus. And from Thalamus the sensation caries to the cerebral cortex by the 3^rd order neuron.

Nerve supply to the pericardium.

The pericardium has two sets of innervations.

The surface or parietal pericardium is supplied with neurons situated in cervical 3 to cervical 5 segments. The pain fibers travel via the Phrenic nerve.

The visceral pericardium is supplied by nerves that travel to the brain via both sympathetic and parasympathetic nerves.

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Single Pulmonary Nodule

 

Single Pulmonary Nodule.

         PKGhatak, MD

In certain circumstances, a Chest CT scan is obtained as a part of workup - like a seat belt injury in an automobile accident or an undetermined cause of chest pain or shortness of breath, and to the surprise of the patients and doctors, a single pulmonary nodule is detected on the CT scan.

The incidence of an unsuspected Single Pulmonary Nodule (SPN) is 1 million / year in the USA. The attending doctor must give the patient the most recent information about the possible cause of the SPN. In the USA there is a 40 % chance that the SPN is a growth at the initial time of detection. The vast majority of these are benign lesions, if the nodule is less than 3 cm then only about 1 % of all the nodules so detected turn out to be malignant. Whether the SPN is malignant or benign, that depends on many factors including the radiological features of the SPL.

The first question doctor asks the patient is whether he/she had a CT scan of the chest or chest x-ray previously, if so, that x-ray/CT scan must be reviewed and compared with the recent CT of the chest. Say, 2 years earlier CT, the SPN was of the same size - it was most likely a benign lesion.

This is important because no one wants to miss a diagnosis Ca of the lung in a very early stage because the cure rate is 90 % at that stage compared with 30 % in stage II CA lung.

How to define a Single Pulmonary Nodule.

This definition is radiological and strictly adhered to.

These are the features: a discrete, well-marginated, rounded opacity, not exceeding 3 cm in diameter, surrounded by normal lung tissue; away from the hilum and mediastinum of the lung and no sign of pleural effusion, atelectasis and lymph node enlargement.

Nodules over 3 cm are called pulmonary masses. It takes 10 years for a nodule to reach the first 1 cm size.

What are common causes of SPN.

The three most common categories of SPN are benign adenoma, granuloma, and malignant tumor. The percentage of these conditions varies according to counties and even different regions of the same country. For example, in the desert region of the USA granulomas from fungal infections are more frequent than tumors, in developing counties granuloma of Tuberculosis is more prevalent.

What are granulomas.

A granuloma is a localized collection of inflammatory cells surrounded by blood vessels.

Granulomas are of two kinds- Inflammatory and No-Inflammatory.

Infectious causes are Tuberculosis, Histoplasmosis, Coccidioidomycosis, Cryptococcus, Blastomycosis, Nocardiosis, and Hydatid cysts.

Non-infectious granulomas.

Rheumatoid nodules, Granulomatous angiomatosis, Sarcoidosis.

What are benign lung tumors.

Bronchial adenomas, hamartomas, benign tumors originate from cartilage, connective tissues, muscles, etc. And a special group of bronchial adenomas called Carcinoids.

What are the radiological signs of SPN being cancer,

SPN larger than 3 cm in diameter, irregular margin, ground-glass appearance (structure of lung is visible through the lesion), stipple calcification, eccentric calcification; doubling time is short (less than 120 to 600 days). Care must be taken not to call an opacity a nodule if it is located outside the lungs, artifacts, foreign bodies, and nipple shadow.

What are the risk factors for malignancy.

Chance of malignancy increases with 30 + years of smoking history, older age; exposure to radon, asbestos, Nickle, chromium, vinyl chloride, polycyclic hydrocarbon; history of previous malignancy and chest radiation.

Nodule size and a chance of malignancy.

 5 cm nodules have a 60 % chance of malignancy, nodules 8 cm are 80-90% malignant.

What lab tests are required to diagnose benign lesions.

Serology test for collagen vascular disease, Rh factor. Serology for fungal infections, and fungal antigen tests where possible. Angiotensin converting enzyme for sarcoidosis., p ANCA and cANCA for angiitis. For Pulmonary Tuberculosis - interferon gamma release assay.

Follow up CT scan when initial CT and other tests are inconclusive.

For less than 3 cm lesions yearly CT scan. If stable for 3 years, then no further scans.

For 3 to less than 5 cm lesions 3 to 6 months interval CT scans.

For 5 to 8 cm lesions an initial biopsy is called for.

How to proceed with SPL.

If history, radiological scans including PET scans, and various blood tests are inconclusive then a Biopsy of the SPL is called for.

To improve the chance of a better yield by biopsy and with minimum damage of normal lungs, these important additions have taken place.

Skinny needle biopsy (SNB) with fluoroscopy, ultrasound, or CT guidance. Video-assisted thoracoscopic biopsy, GPS guided biopsy.

Bronchoscopic biopsy has also evolved into endobronchial ultrasound (ERUS) biopsy, electromagnetic navigation bronchoscopic biopsy.

At the present time, these modalities of SLN biopsy produced 80 % improvements over skinny needle biopsy.

What to do if SPN is a biopsy proven malignant tumor.

Surgical resection is the treatment of choice.

If the patient is not a candidate for surgical resection but has biopsy proven malignancy, then the following options are available.

External radiation therapy, Stereotactic radiosurgery, Percutaneous radiofrequency ablation.

Single Pulmonary Nodules are mostly asymptomatic when initially detected for unrelated health reasons or during lung cancer surveillance programs for chronic smokers, and the patients are more anxious than sick. A timely investigation and proper counseling must be provided. Most SLN are benign but benign lung tumors can cause pneumonia, lung abscess or hemoptysis and in rare instances turn malignant over years if not properly followed.

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Psoriasis

PKGhatak, MD

Psoriasis is a skin disease that manifests as red, itchy scaly patches. Psoriatic lesions commonly appear over the knees, elbows, trunk and scalp. Psoriasis patches can range from a few spots of dandruff-like lesions to scaling lesions covering a large area of the body.

Types of psoriasis:

For descriptive purposes the psoriatic lesions are called:

Plaque psoriasis, Nail Psoriasis, Guttate psoriasis, Inverse psoriasis, Pustular psoriasis, Erythrodermic psoriasis, and Psoriatic arthritis.

The most common type of psoriasis is plaque psoriasis.

What causes psoriasis.

It is a multifactorial disorder caused by an interaction between Inherited Genetic Mutations and environmental risk factors. The abnormal Immune reaction manifested by very rapid turnover of skin cells, dead skin shedding lags behind the new cells generated resulting in itching and redness of the skin.

What are the risk factors.

Some of the known triggers are – Streptococcal infection of the skin and throat, dry and cold weather, cuts and bruises of the skin, insect bites, stress, certain medications like - antimalaria drugs, High BP drugs, lithium, etc., sunburns, and rapid withdrawal of prednisone.

Is vaccination safe in Psoriasis.

Childhood vaccination should proceed as usual. All vaccinations, skin injury, and surgery may produce a flare up of psoriasis, this is known as Kobener Phenomenon.

What genetic mutations are associated with Psoriasis.

Genome-wide association studies have identified more than 60 susceptibility regions, those genes are related to Thymic 17(Th-17) cell action. Interleukin -36(IL-36) is an important amplifier of Th- 17 signaling.

In addition, Linkage analysis identified 9 different regions - known as PSORS 1 to PSORS 9 - associated with psoriasis.

In North American PSORS 2 is identified as a common variant and psoriasis is inherited as an Autosomal Dominant condition. Mutation of CARD 14 gene identified as the molecular defect underlying cause of psoriasis. Card 14 encodes an adaptor protein that is highly expressed in skin cells known as keratinocytes.

In worldwide studies, PSORS1 locus maps detected an association of PSORS1 to the Major Histocompatibility Complex (CHC) on chromosome 6p21.

Signs and symptoms of psoriasis.

Psoriasis is a chronic remitting skin disease, generally worse in the winter months and improves in summer. About 8 million people in the USA have psoriasis; 40 % of them may also develop arthritis.

Psoriatic skin lesions appear as red patches of skin with thick silvery scales. Psoriasis may appear as raised red or pink plaques with silvery scales called guttate psoriasis. Guttate psoriasis is common in children. In addition, the flowing symptoms and signs may be present.

Dry, cracked skin that may bleed or itch.

Itching, burning, or soreness.

Thickened, pitted, or ridged nails.

Swollen and stiff joints in Psoriatic arthritis. The clinical picture of psoriatic arthritis resembles Rheumatoid arthritis; arthritis may precede skin lesions and over time becomes resistant to therapy.

Treatment of Psoriasis.

It can be discussed in three categories.

1. Topical 2. Phototherapy, 3. Systemic.

Topical.

Emollients.

Local skin emollients are moisturizers and are effective in early cases involving limited areas of the body. It retains moisture in the skin thereby reducing itching and scaling.

Hydrocortisone cream/ointment.

Steroid creams of various strengths are available by prescription and the over the counter1% hydrocortisone creams are useful for reducing irritated skin lesions and reduces flaking and itching.

Vitamin D analogs.

It slows down skin cell production and has an anti-inflammatory effect. The ointment can be used on the scalp, trunk, limbs are other areas.

Calcineurin inhibitors.

Several compounds are available. They reduce immune reactions. And produce remission of skin lesions, and is useful in lesions over sensitive areas of the body and also the scalp.

Coal tar.

Heavy oil obtained from coal processing is effective in psoriasis. The mechanism of action is unknown. The oil has an odor and can stain clothing and bedding.

Dithranol.

It is used only under medical supervision. Dithranol ointment can be applied over a wide area and allowed to act for 10 to 60 minutes then washed off. It may burn the skin if used inappropriately.

Phototherapy.

Special light therapy centers use various forms of light therapy. A wide area of the body can be treated. Each session lasts only a few minutes but is repeated 3 -4 times a week and stretched over 6 to 8 weeks. UVB light is invisible to the eyes and is commonly used in phototherapy. Phototherapy can be combined with Dithranol and Coal tar skin ointment.

Phototherapy is effective when other treatments fail.

PUVA.

Psoralen is combined with Ultra Violet A light.

This combination makes the UV A light pernitrates deep into the skin. It is useful in cases where other forms of therapy have failed. But repeated use may cause skin cancer.

Systemic therapy.

Drugs are classified as Non-Biological and Biological agents.

Non-Biological.

All these drugs are useful in reducing skin cell proliferation, controlling inflammation, itching, and scaling. Many of them also have significant side effects that require regular follow ups.

Methotrexate.

Initially, the methotrexate is administered IM injections, then switched to oral therapy. Usually given once a week, periodic blood count and renal function are checked for side effects.

Cyclosporine.

This medication is an anti-rejection drug; newer drugs of this category are Sirolimus and Tacrolimus. Drugs are given orally and also locally on the skin as an ointment. Blood levels of these drugs are checked to adjust the dose to keep in the therapeutic range. All of these drugs are useful in suppressing immune reactions.

Acitretin.

It is a retinoid compound and be taken orally. It is widely used but also has side effects including liver damage.

Apremilast.

Apremilast is a Phosphodiesterase inhibitor and the pill is taken by mouth daily. It is effective in both skin lesions and psoriatic arthritis.

Dimethyl fumarate.

This drug is primarily used in Multiple sclerosis. It is also used in Psoriasis.

Biological agents.

Bioactive immunosuppressants are given by injections. Each drug is administered by a given protocol. If significant improvement of psoriasis is not seen in 8 to 12 weeks, then these drugs are discontinued. Since these are used in advanced and resistant cases, the outcomes of use in psoriasis are also variable.

Commonly used biological drugs are -

Etanercept. Administered weekly by IM injection.

Adalimumab. Given every 2 weeks by injection.

Infliximab. Given by intravenous injection.

Ustekinumab. This drug can the given subcutaneously or by IV infusions. Usually given every 4 weeks. It is effective in severe plaque psoriasis.

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Psoriasis  usually appears as red or pink plaques of raised, thick, scaly skin. However, it can also appear as small, flat bumps or large, thick plaques