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Having COPD and had two open heart surgeries. Hypothyroid and taking synthroid. Having fluid in lungs. Treatment?

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General & Family Physician
Practicing since : 2008
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Yes... My Mom is 88 years old and has something occurring that is worsening that none of her physicians have been able to figure out. She has COPD and has had two open heart surgeries throughout her lifetime. She has a hypothyroid and takes synthroid for this. Approx. 6 months ago, she was admitted in the hospital for fluid in her lungs. Many consults later, the Cardiologist indicated it was NOT due to CHF, yet the Pulmonologist indicated it was not due to her COPD. The Pulmonologist initially thought it was that her amiodarone, which she began taking several months earlier for an a-fib incident, was blocking her T4, so she was taken temporarily off her diuretics and thyroid pill and then was advised to resume them, in order to systemically get everything in order. This did not work. In the meantime, she got a UTI. About a week and a half ago she got the Shingles. About a few days after that, she now has incredible swelling in her calf and foot, to the point where they are purple. The other foot is swollen as well. We have taken her to the ER numerous times, only to be told that her vitals look great and nobody knows what the heck is going on. She has had a bladder scan, as she goes to the bathroom constantly, and it came back negative. This week she had a venous doppler exam and it came back negative. Her BNP is around 115, which is the best it's ever been. Her kidney tests I believe are good or only slightly declined. Today, she awakened and has gained 3.5 pounds overnight, all primarily in her foot. It is now blistered and she's in a lot of pain and can barely walk on it... We were scheduled to go to the Dermatologist today to determine if maybe she has vasculities, but I don't know if my Mom is going to make it to that, as it's scheduled in the afternoon... I need someone to help my Mom. Can you advise what might be happening? I have numerous more information on her history if needed... Thank you!
Posted Wed, 4 Sep 2013 in General Health
Answered by Dr. Raju A.T 8 hours later

Thanks for your query.

I have gone through the history well.

I suspect the water retention your mother suffering from is a side effect of the drugs she is on. If it was due to any fluid scavenging system in the body, blood tests would have identified or the vitals would show a deviation when the main fluid compartment in the body is disturbed.

Its very common for a drug induced water retention to present in association with circulatory disturbance or inflammation in the lymphatic channels causing purplish swelling specially in the lower limbs.

I would like to be more specific and sure about my theory for that, kindly mention the drugs she is on. Also the recent drug dose changes.

After reading about the drug information you provide, I would be able to rule out the same or consider other possible causes if drugs are not the cause.

Waiting for your response,
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Follow-up: Having COPD and had two open heart surgeries. Hypothyroid and taking synthroid. Having fluid in lungs. Treatment? 5 hours later
The only new meds that my Mom has been put on are amiodarone (January), hydrocodone, acyclovior, and torvadol? (for possible bladder spasms). The pain med and acyclovior are for her recent Shingles that she began taking several days ago, and the Torvadol has just recently been started over the past 2-3 days, since my Mom is having frequent bowel movements and urination...

In addition to this, she's had ongoing variations on dosages ranging from 40 mg to 80 mg of Lasix. She's also been on Spironolactone, Potassium, Aricept, Xanax, fish oil, eye caps, multi-vitamin, baby aspirin. She's been on these for years, in addition to her AdVair that she does twice a day.

I was wondering if this could be due to my Mom's Shingles, since interestingly, the purple calf and foot are on the left side (same as the side of the body of her Shingles, which are on her back, side of ribs and under her left breast). We were wondering if it was due to the recent administration of the med for her Shingles (acyclovior?), but the docs here don't believe so...

Please help us,

Answered by Dr. Raju A.T 36 minutes later

Thanks for your query.

The fluid in the lungs could be due to Amiodarone. Amiodarone is known to cause intestitial pneumonia, sometimes subclinical causing no symptoms. Such inflammation will subside on its own. There could be post pneumonic effusion of the fluid in lung spaces leading to fluid in the lung.

Also Amiodarone can cause bluish discoloration of the skin due to irritation to the blood vessels.

Shingles causing the purplish discoloration can be explained. Usually shingles affects the nerves, also the minute nerves supplying the blood vessels and the subcutaneous tissue leading to swelling and discoloration. The recent weight gain due to fluid retention can be secondary to the viral infection. But I consider Amiodarone to be the prime cause for the lung effusion.

Do discuss the same with her treating doctor.

Please let me know if you have any doubts.

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Follow-up: Having COPD and had two open heart surgeries. Hypothyroid and taking synthroid. Having fluid in lungs. Treatment? 49 minutes later
My Mom no longer has experienced any effusions in the lung; I apologize for the confusion. That has now subsided and we are now onto the calf and foot being incredibly swollen, with rapid changes happening, including seepage of fluid from her skin and she can barely walk on her leg due to the pain. The fluid in the blisters that appear on the skin is clear in color.

She was put on an antibiotic today by the Dermatologist. He has reviewed everything and he now wants her to return tomorrow to run some blood tests and do a skin biopsy.

The other issue is the constant bowel movements and urination. I realize that diuretics can cause frequent voiding, but this goes beyond frequent voiding! It is controlling her life and every half hour she is in the bathroom- The torvodol has helped in that since she's begun taking that, she now has to toilet every couple hours... Interestingly, it appears as though she is incredibly straining to have a bowel movement; it's not normal... It's as though her whole system is angry.

I am concerned about leukemia or something...
Answered by Dr. Raju A.T 16 hours later

need not worry, Leukemia and other blood related cancers may not present this way.

The swelling in the calf alone for sure should be investigated with a skin biopsy but consideration of Lymphangitis also has to be taken in. Lymphangitis can be ruled out on simple physical examination. Most of the symptoms you mention do suit into the diagnosis. Such inflammation of the lymph channels could be secondary to a non specific inflammatory disease, filarial infestation or drug induced.

Let her continue on antibiotics as in swellings like she has there are high chances of getting infected or present with cellulitis.

Please write back if any doubts, also this time attach an image of the limbs affected here. After seeing at the image I could get specific ideas on the cause.

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Follow-up: Having COPD and had two open heart surgeries. Hypothyroid and taking synthroid. Having fluid in lungs. Treatment? 12 hours later
Thanks for your reply, Dr. XXXXXXX ..

Unfortunately, I wish I could send you the photos I have on my phone, but it's a company phone and I believe we are blocked from that functionality...

I wanted to provide you with the latest update. Upon getting to the dermatologist's office today, the physician began numbing a site higher up on my Mom's leg/calf (an area that while affected, it wasn't blistered like other parts of the calf or foot are) to begin to do the skin biopsy, when all of a sudden, he put the needle into her calf, and this yellowish substance started oozing out of her- Many hours later, it is still seeping. As a result, the physician didn't do any skin biopsy. A series of blood tests were drawn, Mom has been put on antibiotics, and we were given specific creams to put on Mom's leg/legs and foot/feet. Right now, her caregivers are only applying the creams on the left leg/foot, but I am going to advise we do it for both, and plan to travel home to check things out tomorrow.

Interestingly, my Mom doesn't have a fever, although her temp has been a bit lower than maybe it usually is, so I'm not sure if that constitutes a low-grade fever or not?... A fever was indicated through my research as a presenting symptom for the possible condition you referenced.

Since your most recent email, I have researched lymphangitis. I live about 3.5 hours from my Mom, but upon last examining her leg last week when I was there for a visit, I did note that there were tiny red spots on the top of her right foot and that on the left calf, which is the one side where the calf and foot are so bad, there were tiny, faint red streaks up and down that leg. My sister said that now today, my Mom's toes are her right foot are starting to turn purple...

Not to throw a wrench into this whole situation, but about 5 weeks ago my Mom was hospitalized and to make a long story short, the healthcare staff inappropriately did an emergency spinal tap for possible spinal menangitis on a patient that was sharing the room with my Mom, while my Mom, sisters and I were in the room! The initial stain/tests came back positive for a bacterial infection but there was no propholactyc (spelling) treatment for it. We were never given the cultured results, and were only told that we'd hear back only if something more than what the initial stain revealed was present.

Can the Shingles virus present a skin infection elsewhere? I noted that possible causes for lymphangitis include the chicken pox virus, and it was after she had her Shingles break-out that the swelling in her legs began...

Thanks for relieving my concerns on the leukemia situation...


Answered by Dr. Raju A.T 34 hours later

Yes, shingles infection can cause lymphangitis.

Let the reports of the tests come, we may get a clue into the exact cause.

Do get back to me as soon as you get the reports.

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Follow-up: Having COPD and had two open heart surgeries. Hypothyroid and taking synthroid. Having fluid in lungs. Treatment? 33 hours later
Physician clinics take too long... Significant changes are happening rapidly to Mom so I advised my sister to take her to University of Michigan Hospital, as situation is out of many docs' league locally near where my Mom lives...

Things are so bad; I feel bad we didn't take her sooner to U of M. She's already had a venous doppler which came back negative- They now are doing an arterial doppler... It's obvious there's significant infection. I can visually see puss pockets everywhere, along with the fluid oozing out of large bumps coming out of her foot and leg. Looks like the other leg is getting it now.

U of M has run battery of tests. The results we were expecting today from the local doc which were drawn Friday morning of last week never were received by doc yet, so Mom had to go through another battery of probably the same tests at U of M tonight. Good news is that someone finally is giving her an IV of antibiotics, after 3 prior unhelpful visits to another Emergency Room! Thank God she's getting some help. Makes me wish I had gone to med school so that I could care for her more in a way that would make a positive difference for her...

The docs are looking at XXXXXXX proteins, etc...

Will keep you posted.
Answered by Dr. Raju A.T 14 hours later

Good to hear that your mother is well attended now.

Also she is on IV antibiotics which could cure serious condition like cellulitis.

Anyway lets keep a watch on the tests and procedure they perform.

Thanks for keeping me posted.

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Follow-up: Having COPD and had two open heart surgeries. Hypothyroid and taking synthroid. Having fluid in lungs. Treatment? 7 hours later

I just wanted you to know that the medical team is still sorting through information, however, the docs feel as though my Mom's scoliosis (she was born with a somewhat significant lower curvature of her spine) is causing fluid retention/build up in her leg, thus increasing inflammation and causing capillaries to break/bleed.

A surgeon is being consulted with tomorrow, as though it is high risk to cut those two larger bumps on her leg and foot open, the thought is that it may be necessary as otherwise, the blood has nowhere to go...

When my Mom began having strange symptoms, her one doc had requested we take her off of her diuretic for a period of time (I think it was 4 days?) as well as her synthroid, as he believed that her T4 was being blocked by the amiodarone... The physicians at U of M indicated that being off her diuretics for a period of time probably didn't help matters, as it relates to her leg.

Just wanted you to know as I believe that perhaps what I share may be helpful for you someday in the future for someone else...

Have a good evening,

Answered by Dr. Raju A.T 16 hours later

Thanks for the information.

I would like to know the blood reports, if possible do mention only those which are out of range. I just want to correlate with and provide my opinion.

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Follow-up: Having COPD and had two open heart surgeries. Hypothyroid and taking synthroid. Having fluid in lungs. Treatment? 5 hours later
Thanks for your response... Although I guess I can see how my Mom's scoliosis is causing issues, I do find it odd that it would create such a severe reaction, since she's lived with this her entire life... It may have degenerated a little more, but it still seems odd to me...

We are still awaiting the blood results that were done last week, sadly... in the meantime, numerous tests were taken regarding her coagulation, and that came back fine.

To us (her family), we've noted that over the past six months, it seems as though when she bleeds, she does so to the point where it doesn't clot for a long time, but the tests show she's ok in that arena...

I will keep you posted,

Answered by Dr. Raju A.T 59 minutes later

I too feel the same. I am not convinced by the logic behind scoliosis causing the swelling.

Since she is in the university, let them handle the case and I would like to be aware of the ongoings so that I could in parallel study her condition.

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Follow-up: Having COPD and had two open heart surgeries. Hypothyroid and taking synthroid. Having fluid in lungs. Treatment? 30 minutes later
Thanks for your response... So, a plastic surgeon just came this eve to see my Mom... She was shocked to see that the large bumps/areas where the blood is pooled were not covered, nor did they have Silvadene or antibiotic ointment on them. She indicated that when blood is pooled like that under the skin it destroys/tears down the skin. She was also shocked to know that after days in the hospital, the primary doc had told us that they didn't think hematology or rhumatology consults were needed... I believe she intends to talk to the primary doc on her case to ensure these consults happen. I am hopeful by this!

When Mom sits down on the toilet her toes on the other foot look blue... It doesn't visually look that way when she is still laying down. She was having sharp-like nerve pain in her foot today (the one that's really swollen)... :(

I pray someone can help her and that they don't send her home... They talked about sending her home because per usual, her tests come back negative, but she can't keep living like this, and I hope it can be figured out!

Answered by Dr. Raju A.T 3 days later

With this newly discovered sign (When Mom sits down on the toilet her toes on the other foot look blue), I too suspect scoliosis causing nerve compression in the lumbar region to be a possible cause.

I too hope they consider the seriousness of the symptoms and send her home only after completely treating her.

Above answer was peer-reviewed by
Follow-up: Having COPD and had two open heart surgeries. Hypothyroid and taking synthroid. Having fluid in lungs. Treatment? 1 hour later
I'm here at U of M Hospital; have been living in a hotel that's right on-site... Yeah, my Mom's left foot today turned extremely red/violet-ish in color when only having her foot down a short time.

The docs at this teaching hospital still don't know what is causing the possible hematoma like bumps... At first, they said compartmental bleeding due to nerve compression. Then we were told rheumatological vasculitis. Now we are being told there's a possibility of almidosis?? (this isnt' spelled right). Her blood work revealed abnormality of a certain type of protein. The Rheumatologist is requesting a skin biopsy but dermatology doesn't think it will yield anything different and therefore, they don't want to do it.

Mom does have fluid in one lung, although she's lost 4 pounds since yesterday... Thank God. They have her on incredibly high dosages of Lasix.

Rheumatology wants her to go off of her baby aspirin for good... We are concerned as a family as she takes this for all of her cardiac issues... She has had a double bypass and a pericardectomy, in addition to a stroke and a former heart attack, and a-fib...

I hope they can help my Mom... I feel so helpless as one who Loves her, watching everyone swirl in activity, yet few if none really knowing what's going on yet... :(

Answered by Dr. Raju A.T 4 hours later

It could be Amylodosis which you trying to spell. I do not think it to be related to the present problem though it could be an associated illness.

Lasix at this time is very vital requirement as she is a cardiac patient. Though getting off aspirin is XXXXXXX but necessary at this point.

Its good to read that your mother is being well attended by different specialists now.


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Follow-up: Having COPD and had two open heart surgeries. Hypothyroid and taking synthroid. Having fluid in lungs. Treatment? 2 days later

Mom's skin biopsy was negative... They will be doing a biopsy of her fat in the area of her stomach tomorrow, in the hopes that it will assist with ruling things out.

So far, no hematology consult, which I find odd, especially in lieu of all the bruising and bleeding that already resulted in the two hematomas.

Answered by Dr. Raju A.T 16 hours later
Brief Answer:
Thanks for updating

Detailed Answer:

If the disturbance in circulation causing the symptoms she has is due to scoliosis, the skin biopsy or the fat biopsy is expected to be normal.

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