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NYT: “A Prescription for Youth”

Dovetails exactly with my feeling about day in and day out cycling as I age.

A Prescription for Youth (New York Times, Jan 13, 2015)

Active older people resemble much younger people physiologically, according to a new study of the effects of exercise on aging. The findings suggest that many of our expectations about the inevitability of physical decline with advancing years may be incorrect and that how we age is, to a large degree, up to us.

The Joy of 50 Years: Neuropathy, Gut Ache, Gallbladder Polyps

In spite of the nerve damage (Metronidazole (Flagyl) antitiotic reaction (autonomic neuropathy), I had an exceptionally strong training week around the last week of the year. A full week of very strong 2+ hour rides felt great. The Bad makes the Good even more delicious.

I had hoped that given a few weeks my body would steadily heal the nerve damage. But while the initial symptoms abated, it now seems to be regressing: no overt tingling but low level pinprick sensations in hands, a feeling of weakness in forearms, odd little sharp pains in wrists and forearms as far as the elbow, gritty feeling toes that have blotchy discolored purple areas. Not so pleasant, but all pales in comparison to the prospect of no improvement, or the disheartening prospect of worsening symptoms, or a propensity to further damage by unknown future agents.

Blood sugar

Equallly worrisome is that my blood sugar which for 12 years tested (fasting) in the low 80's to 90's historically, was tested in late December at a whopping 120 (14 hour fasting), then retested in January at 111 as a 3-month average (blood test for average glucose based on red blood cells).

I seem to be a statistical data point in a case-plot band to doctors, who seemingly consider a radical outlier (in standard deviation terms) as “normal”, because it falls just short of diabetic. Perhaps damage from the Metronidazole might not be limited to neurological effects. Or it could be something else. But my glucose was normal (85) in May 2014 in the midst of the right side gut ache issue, so that suggests some other precipitating cause. Like the neuropathy, the future prospects look uncertain. And I have felt like I’ve been carrying extra fluid for some months now; this might be related to blood sugar.


12 year of blood glucose tests (fasting)

Right side gut ache / bloating vs gallbladder

The right-side gut ache (now a 9 month ordeal) for which I took the damned antibiotic is back with a vengeance for over a week now along with uncomfortable bloating and an enervating energy drain. So while I’ve continued training, my power meter reading say it lops off 10-15%. I've had to cut back, but that isn’t solving anything—I just feel marginal when I don’t get exercise. Recovery is also impaired; whatever the root cause, that right side gut ache and bloating is exacting a significant “energy tax”.

Because the right side pain increased to a level that could not be ignored for long, I went in for an ultrasound for the gut. As an “incidental finding”, 3mm polyps were found in my gall bladder. All doctors I consulted indicate that that gall bladder ought to come out, even forgetting other symptoms. And all agree that it might have nothing to do with the right side ache / bloating symptoms, or that it might be the root cause. No one can say.

“There are multiple gallbladder polyps measuring up to 3mm. No gallstones or sludge. No gallbladder wall thickening or pericholecystic fluid to suggest cholecystitis”.

So next up is Laparoscopic Gallbladder Removal (Cholecystectomy). I’m going to find a very experienced surgeon, as I don’t want the common bile duct damaged or bruised.

Another possibility

Besides the gallbladder, another possibility for the right-side ache could be sphincter of ODDI disfunction.

Individuals with sphincter of Oddi dysfunction present with abdominal pain resembling that of structural or inflammatory disorders of the gallbladder, biliary tree or pancreas. Among other characteristics, the pain is typically in the upper part of the abdomen or in the right upper quadrant of the abdomen, lasts 30 minutes or longer, and is not associated with a structural abnormality that could lead to these symptoms.

Functional disorders of the gallbladder, bile duct and pancreas have been defined and classified by the Rome criteria for functional gastrointestinal disorders.[2] The criteria outline three variants of functional disorders of the gallbladder, bile duct and pancreas, termed functional gallbladder disorder, functional biliary sphincter of Oddi disorder and functional pancreatic sphincter of Oddi disorder. All of the following criteria need to be met for as part of the definition of a functional disorder of the gallbladder:[2]

  • the pain must be located in the upper part of the abdomen and/or the right upper quadrant of the abdomen
  • episodes of pain must last at least 30 minutes
  • the symptoms must be recurrent, and occur at differing intervals
  • the pain must incrementally increase to a "steady level"
  • the pain must be severe enough the patient's daily activities are affected, or that the patient must attend the emergency department
  • the pain must not be relieved by any of bowel movements, change in posture, or antacids; and,
  • other structural disorders that could explain the symptoms must be excluded.

Metronidazole / Flagyl antibiotic: Beware Neurological Damage (autonomic neuropathy)

I’m publishing this with the goal of cautioning others who might run into something similar, because all drugs have risks, and some doctors see patients as statistics. One must be fully informed in one’s own medical decisions.

See Apparently Infection After All (Dientamoeba) and On Flagyl (Metronidazole), Dientamoeba Killed (not).

Never in my life have I had any peripheral neurological symptoms.

At day 10 of 14 of the course of Metronidazole, I developed, simultaneously, irritated swollen toes that felt almost like slight burning. The hot/burning sensation went away about a week later, but the toes have never been quite the same, still having odd purple patches in them and sometimes sensations of slight burning. The dermatologist I saw suggested a neurological issue (simultaneous synchronized perfectly symmetrical infections make no sense).

About 10 days later, I developed tingling in hands, weakness in forearms—scary stuff indeed since it would mean financial ruin quickly enough if my hands became more impaired, not to mention the rest of my life. I thought it could have been overuse injury (keyboard), but this makes no sense, because there are zero signs of carpal tunnel, or a pinched nerve, and sensation (pinprick tests) overall is normal (doctor exam). And in context of the “toes” we’re talking extremities (feet and hands). It all adds up to neurological.

As this was just written, I finished a 6-day course of MethylPREDNIsolone (a steroid course of 6/5/4/3/2/1 pills per day). The MethylPREDNIsolone eliminated the tingling within 8 hours, but the feeling of weakness in hands/forearms resumed on the last day (1 pill). According to the literature below, I have the hope of recovery which may take months, if indeed recovery is in the cards.

When I was with the gastroenterologist prescribing Metronidazole, my explicit question of “are there any risks” was summarily dismissed with “NO”. I don’t know if this doctor was uninformed, incompetent, or merely uninterested. But all drugs have risks and while doctors can make mistakes, they should also damn well be the experts. Still, I have to take responsibility for not being skeptical enough with this doctor, who always left me feeling like I learned nothing from him at each expensive visit. This same doctor could not be bothered to return my phone call on the “toes issue”: I had a call back a whopping 36 hours later from a nurse who seemed incapable of comprehending my symptoms. Never heard back from the doctor himself on the toes.

Autonomic neuropathy

So I went googling and found Metronidazole: newly recognized cause of autonomic neuropathy. Note the case cited involves “burning pain in feet”, which is/was precisely my first symptom also and the term “erythematous” describes exactly what happened to my toes.

Primum non nocere.

How could a competent doctor prescribing Metronidazole answer with a terse “NO” when asked if there are any risks with an antibiotic that is clearly dangerous?

The core problem is that doctors make the same cognitive errors as layman, e.g. once having learned The Medical Truth, it forever is so, because all evidence to the contrary cannot be seen once the cognitive context of “rare” is assimilated. E.G, peripheral neuropathy is “rare” by cognitive committment (no doubt from one dubious paper written long ago and studied once in medical school, buttressed by tens of thousands of cases where doctors never bothered to inquire or follow up as to side effects). Note that the doctors in the literature I have seen would all be highly unlikely to consider my case even possible (“large doses”, “extended use”, etc—do the google search). Will I win the lottery next? One praiseworthy exception is the neurologist from Duke University kind enough to call me and discuss the symptoms (I initiated contact); she felt that side effects were under-reported.

My prescribing doctor remains totally clueless in never having recognized the symptoms. Thus it is not reported, thus the other 1,000 or 10,000 cases or whatever are never reported, thus people are damaged by ignorant doctors who all agree on the rarity. Self-fulfilling. Don’t look, and don’t ask—why bother, it’s so damn rare. To wit: it’s night-time because it’s dark inside? No, it’s just that the window blinds are closed! It’s professionally negligent that my doctor never inquired as to the symptoms I reported, never asked how I fared on the antibiotic (which he prescribed for 2 weeks, which is double the usual time). He’ll no doubt just go on prescribing an antibiotic with side effets since there are “NO” risks (his answer to my question of risks).

Four doctors (prescribing gastroenterologist, two internists, one dermatologist) all failed to put the symptoms together when informed of the drug and the burning toes, yet there it is plain as day in case literature, if one bother to search. [To her credit, the dermatologist’s first reaction was that it looked neurological, but specialists box themselves into their own field, but this was the clue I needed to figure it out]. What does that tell you about the general diagnositc capabilities of doctors? Their willingness to ignore symptoms in the context of a powerful antibiotic? The lack of follow up by the prescribing doctor even in the face of a highly unusual symptom? I found it in under 2 minutes once I started thinking in neurological terms (google “metronidazole neuropathy”). Why can’t a doctor, theoretically trainedto diagnose, have a little question mark go off? I’d consider myself incompetent to let such things pass on my watch, were I a doctor.

Abstract
Metronidazole is a commonly used antibiotic prescribed for the treatment of anaerobic and protozoal infections of the gastrointestinal and genitourinary tracts.

It is associated with numerous neurologic complications, including peripheral neuropathy. Neuropathy is typically detected in patients on chronic therapy, although it has been documented in those taking large doses for acute infections.

Numerous case reports have been published describing motor and sensory neuropathy, yet autonomic neuropathy has not been described with metronidazole use. A previously healthy 15-year-old girl presented with complaints of burning pain in her feet following a short course of metronidazole for vaginitis. She could obtain pain relief only by submerging her feet in ice water. Examination revealed cold and swollen lower extremities that became erythematous and very warm when removed from the ice water. Temperature perception was reduced to the upper third of the shin bilaterally. Deep tendon reflexes and strength were preserved.

Nerve conduction studies demonstrated a peripheral neuropathy manifested by reduced sensory nerve and compound muscle action potentials. Reproducible sympathetic skin potential responses could not be obtained in the hand and foot, providing evidence of a concurrent autonomic neuropathy. A thorough evaluation revealed no other cause for her condition. Repeated nerve conduction studies and sympathetic skin potentials returned to normal over the course of 6 months, paralleling the patient's clinical improvement. Metronidazole is a potential cause of reversible autonomic neuropathy.

See also

When reviewing the literature, it becomes clear that Metronidazole (Flagyl) has severe life changing risks.

Search for Metronidazole neuropathy:

A prescribing doctor failing to mention such risks (especially when explicitly asked about risk) walks a dubious line on professionalism and ethics. My hands are irreplaceable, both professionally and for my life itself. I was not given the information needed to make an informed decision, even when I asked about risks. Only time will say whether I have permanent damage, but my experience has been that most injuries always carrying nagging issues later in life.

Art B writes:

Just a thought, when a doctor prescribes a medicine, go to the Pharmacist and discuss the side effects and dangers. Doctors are NOT as up-to-speed on the drug's risks as is your Pharmacist.

WIND: good advice.

Dan M writes:

Hell, I knew Flagyl was problematic 35 years ago.

I worked with Flagyl for six years, extensively, in reptiles. A far different
vertebrate, to be sure, but I knew that mammals processed the stuff
more efficiently than reptiles, which is the reason we calculated the dosage
down to the gram and the minimum time period. And I knew if we
went overboard on it a big part of the bad results could be neuro.

I just didn't put the two stories together. My apologies. It should have
been me telling you it was probably the Flagyl.

Telmin was another we had to measure for dosage very, very carefully,
but it had another range of side effects. I always had alarm bells in my
head when the recommendation was either of those drugs.

WIND: my just prior internist (not the gastroenterologist) did not put two and two together either (“I’m taking Metronidazole and I have these burning toes”). These doctors just don’t have quick minds even when the obvious is laid at their feet. I just can’t see being a physician (myself) and not being very concerned if any patient reports a highly unusual symptom while taking a drug. I have a word for that kind of care, but I won’t print it here.


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