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Dr. Andrew Rynne

Family Physician

Exp 50 years

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Overweight. Have breathing difficulty, sleep apnoea, GERD and edema in legs. Required treatment?

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Dr. Shashi Dangwal

Pulmonologist

Practicing since :1979

Answered : 1126 Questions

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Posted on Tue, 5 Feb 2013 in Lung and Chest disorders
Question:

I am a 40yr old male - rather overweight 6ft2in 113kg - howewver I am still quite fit and play football 4 times a week - I used to be a pro soccer player (goal keeper).

I smoked in the Army but not heavy and I was a heavy drinker but not currently the only family history is Ulcerative Collitus, Bowel Cancer and Nephritus

History - this all seemed to start back in 2006 after a trip to Thailaind and Germany and after I got vacinated because of the outbreak of German Measles at that time - at this time I was also exposed to
a sex worker who had HIV - I was given Anti Retro Virals for 2 weeks and never caught the disease. IT all started with a strange feeling of not getting enough air, I got a lot of joint pain in my
feet,
but as my Uric Acid levels were high they assumed gout, this continued for over 12 months -
I had fluid removed from sore joints and uric acid crystals were found, treatement for gout was started - this did not reduce my Uric acid levels - it continued to get so bad I could not walk,
they did an MRI and a Rheumo said that the damage seen - florid synovitis (or what have you) and other connective tissue issues, looked like it was more than gout.. in the end Prednisone
was administered and within a day I could walk freely with no pain...
The difficulty breathing got worse and worse, I was sent to a sleep specialist, they diagnosed me with Sleep Apnoa and I
have used a CPAP since, during the night of my sleep study, my O2 sats dropped to dangerously low levels - after I started getting pain in the chest I was sent to another rhuemo who thought it
might be Arthritic - but he ruled out Arthrius as the cause, I have been tested for Lupus, XXXXXXX R Facter, sarcoid etc etc I do have bad psoriasis but was told that it was unlikely to be psoriatic
arthritus -
they decided to do a Pulmonary Sprial Angio, which found some dark pathces on the bottom of my lungs, but nothing exceptional, and enlarged lymph nodes (pre tracheal) but nothing significant,
certainly no clots etc, as the pain worsened I had a cardio stress test...and this was fine, they ended up stopping the test as i could run for so long, they then did a spirometry test and it
was ok too, I have now had a total of 6 CT scans, a Galuim scan and MRI, several XXXXXXX tests and 2 cardio stress tests as well as ultrasounds of heart pressures - the most they have ever found
was patchy infiltrates, some fluid like signs (possibly from being stationary) and minor dependant basal atelectasis in the base of both lungs - each time they have assumed inflamation.

The galium scan revealed considerable bowel retention, I had a Endoscopy, which showed mild Gerd symptoms but no hernia - I have since had another which revealed the same with more Gerd,
I decided to see a general physician - they tried prednisone which worked for the first few months, but I grew very fat and it seemed to wear off- they tried methtrexate which did not help -
during this time I caught food poisening and had a vasal vagal black out while driving and was in a serious accident but not injured -

I had a PH Test done to measure acid reflux....
this found that acid was coming up at night and staying up - they decided to do a Fundiplication which did not go well, it took 3 hours and my heart stopped - whenever I drink water now,
it does not go down for ages, it sits high in the chest and I can hear it sloshing around - the strange need to burp has stoped however and I fart a lot more...Since the antiretrovirals my tryglicerides and chol
have climbed even on 80mg liptor -

I have elevated LFT's but this is suggested of fatty liver or the lipitor, My chest became more uncomfortable and i could feel fluid inbetween the lung and
chest wall, but no one could hear any friction rub and it did not show up on CT's - I had a bronchoscopy which was normal and more recently have had two more -
the first of which revealled squamos metaplasia (but no cancer cells yet) and abnormal cell growth in one lung, the second one revealled infections and more metaplasia now in both lungs
as well as chronic inflamation - there were abnormal areas to sample from.

My O2 sats were tested and remained lower than 91 they decided to test my O2 blood gas which was also low
and then performed a shunt study which proved I have a shunt, I was sent to cardiologist who performed more stress tests and untrasounds and said my heart was fine -
a buble study was done with no sign of a shunt. The feeling of being unwell and wanting to pass out continued but joint pain had gone away for some time -
I tried more aggressive treatments for gout - higher doses of allupurinal and other gout meds and anti inflamatories and am currently on Sulphasalazine -

I had strange issues where a bursa on my elbow
would get bumped at sport and my whole arm would get infected for some reason causing eodema. Recently I had a lot of eodema in my legs, especially when sitting for more than 1 hour.

I started to cough up more blood and was finding blood on the pillow in the mornings, it was bright blood and I dont get nose issues, but I got ear and nose checked anyway as I constantly have
a post nasal drip - it was all fine - it was suggested I mght have a pumlmonary eodema but the amount of CT's I have had to date should have shown it by now, The crackling noise at nght on exchale is
causing a lot of stress for my partner as she can hear it quite well - I have grow pretty tired of all the guessing
and personally I was prepared to let it all go as I was sick of the radiation exposure, but it just seems to get worse and now I have pain on both side of the chest when breathing XXXXXXX and it feel heavy
on the left side.


my O2 sats are now down to 92 when lying down, yes it changes a little when lying down
I went to have another PH study done, but they could not get the sensor into my gut - I seem to have a sore upper gut all the time, I tried foods without gluten and this helped for a little bit but
as soon
as I excercised it got worse again - I have tried fluid only diets which help the pain just under the bottom of my ribs (around the upper gut) but does not help with the breathing issue, I have tried a
Asthma challenge test which showed I do not have asthma - the fluid in chest feeling seems much much worse and the feeling of being unwell is terrible, my hands keep swelling up and occasionally my legs
still get oedema - if it would just stop at this level I would feel ok, I have always had a lot of lipomas in the chest and I had one removed by a doctor who to be honest was very sheepish about it all
and swore when he removed it as if he was frightened (this was when it all started too) but these lumps seem to be a lot more and I seem to have quite a few in the abdomen below the ribs.

Thats about all I can tell you - I am NOT a hyperchondriach (spelling) it has just been 6 or more years so I know a thing or two about the issues - there is definately something wrong, but I cant work it
out and neither can the Doctors, so I am asking if there is something else I could try - my bet would have been Psoriatic Arthritus but they say it normally is not in the chest wall and it does not lower
O2 or make you feel unwell - it just causes pain.
The only other thing I could think of is a GUT issue - but not sure how else I can test this. - Could this be a connective tissue or autoimmune issue?
doctor
Answered by Dr. Shashi Dangwal 7 hours later
Hello XXXXXXX

I`ve gone through your entire medical history 2 to 3 times. It seems to be rather complex.

I may not be able to comment on systems other than chest and you should consult the concerned specialitist about issues related to other systems. However i have made certain observations about Respiratory system which are as mentioned below:

1. You are overweight.

2. You have sleep apnoea.

3. You have GERD and post nasal drip.

4. You could be prone to develop allergy or asthma like symptoms.

5. The fluid like sound you are talking about could be due to basal atelectasis which is common in overweight people.

You have undergone almost all the tests to rule out major diseases like pulmonary involvement in thromboembolism and shunt in the heart and all seem to be negative.

I will suggest that you

1. Try and reduce weight.

2. Continue using CPAP at night and even at day time while resting or if you are having breathing difficulty.

3. Get treated for GERD by PPIs like pantoprazole or lansoprazole and prokinetics like itopride.

5. Use inhalers like seroflo250 and duolin 2 puffs 3 times a day along with a tablet of montair lc and one tablet of doxyphyllin400 twice a day.

6. Be physically as active as you can be.

7. Continue and follow up on your gout treatment.

You are not very specific about your coughing up blood and neither have you quantified it. In my opinion, you can undergo bronchoscopy and bronchoscopic biopsy again a little while later to know the status of the metaplasia. Though metaplasia is not same as dysplasia which may be a sign of malignancy but some time a metaplastic area can undergo dysplastic changes.

Another point i would like to make is that pulmonary involvement in collagen vascular diseases have to be kept in mind. You may discuss it with your treating physician or pulmonologist.

I hope this may be of some help to you.

Take care.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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