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DR. STEMMLER’S MONTHLY TEACHING ROUNDS

JANUARY, 1999

CLINICAL STORY OF THE MONTH

(Copyright Stemmler, 1999)

Even in his late seventies, Mr. M. U. belongs to one of the fittest men in my practice. With the joy of a child and that wonderful smile of a life well-lived, Mr. U. has never needed me for anything serious. A marathon cyclist and enthusiastic roller blader, he would sometimes come for a "physical". "Check me out, Doctor. I feel great, yes Ma’am I’m still doing my 100 miles. And every so often we all go to San Antonio or Austin." "On your bike?" I wanted to know, in disbelief. "Yes Ma’am, we do. Yes, Ma’am!" And then his smile would light up again. And that highly contagious chuckle. On occasions, he would see me for a small injury, have a few acupuncture treatments, and cycle on. Perhaps I wouldn’t see him for years thereafter. Yet the last time he came, it was for something that really concerned him. For about five days prior to seeing me, he had experienced unbearable pain, like "knives cutting through" the right side of his face and scalp. His right eye was red and teary, and it was not focusing well. Every so often, Mr. U. would feel an "electrical discharge" in the affected area which, although it only lasted for a few seconds, would be totally incapacitating.

When I examined him, I noticed that the whole area was very tender to touch, so I tried to be extremely gentle and careful with my palpation. On a closer look, the skin appeared to be pinkish red, like trying to erupt into a rash. The diagnosis was straightforward: Herpes Zoster (Shingles) of the face. I was hoping that the globe of his eye would not be involved; this was usually a serious complication that could lead to blindness. But even though the eye was red and teary, I fortunately did not see any redness on the tip of his nose, a sign that indicates eye globe involvement. There is a little nerve connection between the nose and the eye, so when the eye is affected the nose, in a sense, becomes the alarm bell. His history of five days of pain and no rash, and now a rash which would probably develop in the next 24 hours, was typical for shingles. Most of you may have known somebody with shingles, complaining of pain around one side of their chest. That is when one or more intercostal (between the ribs) nerves are irritated by the Varicella-Zoster virus. It is there that shingles present more commonly, but shingles will also occur in the face, along the 5th cranial or trigeminal nerve. The rash is typical: lots of little blisters filled with fluid sit on a reddened base. Mr. U.’s skin showed only the beginning of the redness, but no vesicles yet. In just a few more hours the vesicles would form, giving the rash a pearly appearance. After making the diagnosis, I gave Mr. U. an acupuncture treatment, a Chinese herbal combination and Famvir, and antiviral agent used to treat shingles. Over the last few years, I had treated several patients with acute Herpes Zoster with a combination of Chinese and Western medicine, and I had always seen the rash resolve in 24 hours or less, instead of five days or longer. And, as far as the pain was concerned, not only would it resolve faster, but I had never seen patients develop a "post-herpetic neuralgia" (persistent pain long after the infection is gone), a complication that is fairly common in the older population. Mr. U. felt better immediately after his first treatment. The "electrical shocks" ceased, even though the skin was still quite sensitive. As expected, the blisters formed during the night, but only a few, contrary to a whole array of them, as it usually occurs. And – surprise!, the blisters were all dried out by the next morning when I saw him in follow-up. And not a single new blister ever erupted. His rash had only lasted for one evening. Mr. U. had no more "electrical shocks" and he felt very relaxed. Since his right eye was still inflamed, I decided to make sure there was no involvement; I had him see an ophthalmologist for a thorough exam. The ophthalmologist concurred with the diagnosis of Herpes Zoster and thought the red eye was a reaction to the illness, but the globe was free of disease. Yet his experience could have been quite different. Prior to coming to my office, Mr. U. had seen two other physicians. Two days before, his HMO doctor had diagnosed his pain as "an inflamed nerve" and Mr. U. had been sent home on ice packs and Advil. Since he had obtained no relief with such an approach, he decided to consult a holistic ophthalmologist, who took a look at him, checked his vision (which turned out to be blurry then), and sent him home on shark cartilage and Echinacea Golden Seal. Apparently a slit lamp exam (that weird binocular apparatus ophthalmologists use to look inside your eyes) was not done. Mr. U. went home and decided to see me that same afternoon. After our first two treatments, I saw him a few more times over a 3-week period and then he was off on his bike again. We talked to him two months later and he was again roller blading and cycling along remote Texas roads. So what can we learn from this story?

#1 Diagnostic Accuracy

An early and correct diagnosis is the most important factor affecting a disease course and prognosis. And only with an accurate diagnosis can the right treatment be promptly started. Chinese medicine is defined as Bian Zheng Lun Zhi, which translates as: "Identifying patterns and determining treatment", or "Planning treatment according to diagnosis". Such a definition summarizes the sharp focus of Chinese medical doctors have when evaluating a patient.

#2 Pitfalls of being "either, or"

The patient first saw a Western contractual physician, who had limitations of time and practice guidelines imposed by a management company. Such a physician can no longer rely on personal knowledge, experience and intuition, therefore risking to make errors in clinical judgement. The "holistic" doctor, on the other hand, may have had removed himself too much from all that is mainstream, relying solely on his "holistic doctor’s bag"; using approaches that may work often, yet not always. It is easy to become overconfident, wanting to treat everything naturally. But, unfortunately, those dreaded chemicals can be useful, lifesaving, and even eye saving at times. And patients should always be offered the best of everything, as long as it is reasonably safe and justifies the benefits from the treatment. Furthermore, physicians have the responsibility of informing and offering choices, advising and guiding, but never denying what is available to others at the time.

#3 Prodromes of Illness

Many diseases come after an announcement, or prodrome: migraines have "auras" (flashing lights and such), feeling "under the weather" may precede a flu or other febrile illness, and shingles often presents with pain days before its typical rash appears. Patients have even been operated on during their prodromal phase! (suspecting gallbladder disease, for example) Recognizing what is to come is just as important, and often more important, than diagnosing the disease itself. The Chinese classics of the 7th century talk about three levels of medical expertise:

Superior treatment: treating an illness before it appears.

Mediocre treatment: treating an illness when it reveals itself.

Inferior treatment: treating an illness once it has manifested itself.

 

#4 Using Only One Set of Tools for All Jobs

Treating Mr. U. only with an antiviral agent and pain medicines, may have helped the disease’s symptoms, but at a much slower pace. And the dreaded "old age" complication of chronic pain after the illness is resolved, would still be a threat. Steroids are often used to ward off this complication. But they present two new problems: (a) steroid’s side effects (bleeding, cataracts and glaucoma, high blood pressure, diabetes, osteoporosis and infections) and (b) they only ward off the possibility of chronic pain in a rather modest number of cases. Treating only with Chinese medicine might work by itself, especially if sought in the early stages. But there is still not enough clinical research available to determine who will respond with this treatment alone and who needs a more complex intervention. I hope that in the future we will be able to determine the best treatment for each patient.

#5 Combining Eastern and Western may Work Better than Eastern or Western Alone

Over the last twelve years I have treated a significant number of patients with Herpes Zoster. Before drugs like Famvir were on the market, Herpes Zoster had to just follow its course. Then, when drugs like Zovirax came out for Herpes Simplex, we just used a higher dose of this drug to treat Herpes Zoster, although it was really not as specific as the newer drugs. During those earlier times, I was fortunate to be able to use Chinese medicine and see rapid recoveries I had never seen before. Today, with more specialized drugs for Herpes Zoster, the combination seems magnificent to me. Shingles is still a fairly common and nasty viral infection, which can affect everybody, but has a predilection for people over 50. It is uncomfortable and difficult to treat with Western medicine alone. And its complication, post-herpetic pain, can last from months to years, and be devastating and disabling in my own clinical experience.

I am happy to report that the course of illness and prognosis for a disease like shingles has changed. The combined use of Chinese and Western medicine makes shingles a much easier to treat disease, without the dread of chronic pain or the need of steroids and potent analgesics.

And one further piece of good news: even if post-herpetic pain develops or is already an established condition, Chinese medicine also has much to offer to bring such chronic pain to an end.

Christina Stemmler MD


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