Urticarial rash due to Allergy?

A gentleman came to see me this evening with itchy multiple red patches on his trunk, upper and lower limbs. He remembered going to a Christmas event and putting on an old jacket (belonging to his dad). He thinks he is allergic to the dust mites or fungal spores on the jacket, or is it the food served at the dinner?

He was given an injection of Anti-Histaminics to relieve his symptoms and given some new generation oral histaminics to take in the day time and a drowsy 1st generation Anti-histaminic for the severe itch at night. If his symptoms are severe, he may benefit from some corticosteroids orally or by injection (However, care needs to be taken as these should be given to athletes in emergencies only as they are on the Prohibited list and require TUE).

Blister after unmonitored heat therapy

An adult male patient came yesterday with back pain 2 days after injuring his back carrying a light object at work. He did not complain of any 'shooting pain' (radiating pain) to mentioned that the pain did not subside despite placing a hot water bottle (heat therapy) overnight. He had no pain bending forwards (flexion) but pain getting up from bent position (deflexion).

I examined him and found that he had 4 blisters (fluid filled sac in the skin) on his back (see photo) and spasm of his right erector spinae muscle. He didn't know that some of the pain was due to the blisters!

His muscle strain would recover with a week of physiotherapy and some medication for pain and muscle relaxation. He was not advised any treatment for the blister as it would heal on its own. I advised him to avoid using the hot water bottle directly onto skin or longer than 30 minutes to avoid blisters.

Right Axillary Follicular Abscess

Ramli is a 30 yrs old club soccer player who came with painful right armpit (axillary region) painful swelling of 3 days duration. He usually shaves his armpit hair for hygiene purpose but this is the first time he suffered this fate.

I examined him and found several peasized tender, firm swelling in his right axilla but there were no other enlarged lymph nodes. The skin in the groin and axilla is commonly colonised by Staphyloccus Aureus. Minute skin cuts or abrasion could have introduced the infection to the hair follicles. We treated him with a course of antibiotics and some topical antibiotic ointment for 5 days duration. His symptoms resolved quickly as the infection was still at early stage. If the swelling failed to subside, he would have required incision and drainage surgery.

For further reading:-
Folliculitis
Lympadenitis

Tinea Pedis (Athlete's Foot) and Onychomycosis

Tinea pedis (athlete's foot) is a common fungal condition occuring in the feet of athletes or workers who routinely wear their shoes without drying and cleaning them properly. Although it is more common to find the itchy, scaly (not always) and smelly skin lesion in between the toes, they can also infect the sole of the foot. Athletes who have the habit of wearing shoes belonging to their team mates may transmit the disease to others. This condition is easy to treat with foot hygiene, topical anti-fungal creams and occasionally require oral anti-fungal medication.

The nails may also be infected (see 2nd photo) causing Onychomycosis. This condition is more difficult to treat often requiring oral anti-fungal medication, topical anti-fungal lotion after filing the infected nail.

Links of interest:-
Athlete's Foot: MayoClinic.com
Nail Fungus

Sudden Deaths in Soccer: Are we doing anything about it?

There is an interesting write up of the series of sudden deaths in soccer by The Star (Malaysia) on Thursday August 30, 2007.

A history of sudden deaths in football

# Aug 28, 2007: Spain and Sevilla defender Antonio Puerta (pic) died on Tuesday following a heart attack, becoming the latest footballer to die suddenly while playing.

# April 11, 2006: Colombian teenager Victor Alfonso Guerrero, 17, died during a training session for the reserve side of Colombian First Division club Envigado FC. He collapsed and lost consciousness, and died on the way to hospital.

# June 25, 2005: Hugo Cunha, a 28-year-old midfielder with Portuguese top flight side Uniao Leiria, died while playing a match with friends. Cunha suffered a heart attack and was unable to be resuscitated by the emergency services.

# Oct 27, 2004: Brazilian Serginho, 30, collapsed during a Brazilian First Division match between his club Sao Caetano and Sao Paulo and later died. His death caused a huge controversy after the autopsy revealed that his heart weighed 600 grams, twice the normal size. Sao Caetano, the club’s president and the doctor were sanctioned by Brazil’s sporting authorities.

# Jan 25, 2004: Benfica’s Hungarian international striker Miklos Feher, 24, collapsed during a Portuguese Premier League match against Vitoria Guimaraes and never regained consciousness. The autopsy revealed he had suffered from a heart malformation.

# June 26, 2003: Cameroon international Marc-Vivien Foe died while playing against Colombia in the semi-final of the Confederations Cup. The Manchester City player collapsed in the centre circle and all efforts to save him failed. An autopsy revealed he had a disorder of his heart’s electrical system.

# December 2002: Macedonian defender Stefan Toleski died of a suspected heart attack. He collapsed halfway through the first half of his side FK Napredok’s league match against Kumanovo and later died in hospital.

# February 2000: John Ikoroma, a 17-year-old Nigerian youth international, suffered a heart attack during a friendly in the United Arab Emirates. He was in a trial match for Al-Wahda against Kazakh club Astona when he collapsed 20 minutes before the final whistle. He died in hospital.

# 1997: Emmanuel Awanegbo, a Nigerian playing in Germany, died after only 12 minutes of play. The death was attributed to cardiac arrest.

# 1995: Amir Angwe, 29, a striker for the Julius Berger Club of Nigeria, collapsed a minute before the end of an African Cup Winners’ Cup semi-final match with Maxaquene of Mozambique. Doctors believe he died of a heart attack.

# 1989: Nigerian international Samuel Okwaraji, who had signed as a professional for AS Roma in Italy after stopping his university studies in Rome, died during a World Cup qualifier between the Super Eagles and Angola.

This is a reminder to all who conduct sporting competition that efforts are needed to prevent the occurence of sudden deaths in elite athletes. Although elite athletes are routinely screened for medical conditions, some are done without exercise stress test. Some have in the past linked such deaths to fatigue, severe dehydration, doping, alcohol and illicit drugs. In some parts of the world, soccer and field hockey tournaments are still held without cardiac resuscitation equipment to give some hope of saving the athlete in the event of sudden cardiac arrest.

What are we doing to prevent sudden cardiac deaths in our sport?

Knee Gouty Arthritis

Mr Loh is a odd-job worker who came to see me with a painful and swollen left knee this since 3 days duration. He told me that he gets the swelling every time he ate Bak Kut Teh (pork herbal soup). He had been told that he had gout by his doctor but he defaulted his treatment.

I examined him and found that he had a tense left knee joint effusion and restricted joint flexion due to the pain and swelling. He refused to do the X-ray and requested that I remove the joint fluid (he had it done on an earlier episode in a hospital). I aspirated 50ml of bright yellow fluid. He also did not want to send the aspirate sample to the laboratory for analysis. He was also advised to use RICE treatment to assist recovery.



He felt much better after the joint aspiration and was given NSAIDS and told to continue with his gout (Allopurinol) medication with his doctor. He was also advised to avoid high-purine foods.

Stopping Smoking

Cigarette smoking has been known to adversely affect sporting performance. Despite efforts by the honorable Sports Minister to discourage smoking amongst athletes, elite athletes have found it difficult to stop smoking. Despite making sports venues and training centres smoke-free areas, the general public continue to smoke in these places due to lack of implementation of the smoking ban by the health and sports authorities. Recent developments in medicine has shown that new pharmacotherapy may offer better options to assist athletes in this cause.

The efficacy of smoking cessation methods was systematically reviewed by a United States Public Health Services (USPHS) committee during the development of an evidence-based clinical practice guideline for physicians released in 2000. Based on meta-analyses of the existing data, the USPHS panel concluded that 2 smoking cessation methods had the best evidence of efficacy: behavioral counseling and pharmacotherapy (nicotine replacement products -- gum, patch, lozenge, oral inhaler, and nasal spray -- or the antidepressant bupropion*., known as Zyban or Wellbutrin SR). A combination of counseling and pharmacotherapy produced the best results. There was no evidence to support the efficacy of other methods, such as hypnosis or acupuncture. An independent systematic review of this evidence, conducted by a global network of researchers (the Cochrane Collaboration), came to the same conclusions.

In a randomized trial in which bupropion was compared directly with the nicotine patch, patients using bupropion had significantly higher quit rates at 1 year than those using either the patch or placebo. However, nicotine replacement products and bupropion are considered fairly equivalent by most experts, so patient preference and medical conditions should dictate choice of therapy. The USPHS clinical practice guideline states that combining the patch with other forms of NRT resulted in higher quit rates than use of the patch alone, and recommends that combining nicotine replacement products be encouraged if the patient has failed on monotherapy. Ad lib use of nicotine gum or lozenge with the patch may help to reduce acute cravings. Bupropion SR may also be used in combination with nicotine replacement products, although as mentioned above, combining the patch and bupropion has not resulted in significantly higher rates than bupropion alone.

These meta-analyses also found that physician advice to quit improved adult cessation rates, and the addition of brief counseling (less than 3 minutes) was even more effective. Effectiveness further increases with greater counseling contact time, including proactive telephone counseling. (adapted from a Medscape CME article).

4 weeks treatment with Bupropion costs RM300 to the athlete. It is estimated that the treatment would last 7 to 12 weeks to be effective. Nicotine patches are often not a treatment of choice as the profuse sweating of athletes may affect the effective use of the patch.

Disclaimer: Athletes are advised to seek your doctor's advice before taking these medication.

*2008 Update: In the WADA 2008 Prohibited list bupropion is considered as a Substance under the WADA Monitoring Programme 2008.

Team Physician 'trouble' in Field Hockey

You are required to arrive at the game venue earlier than everyone else to prepare set up your things and prepare the drinks. Prior to that you make sure that your medication and taping inventory in your bags (and trolley) are updated and your water and ice supply is ready. Ensure that you identify yourself to the tournament medical officer (if available) and assess the availablity of medical assistance in case of emergency. For best practice, organisers need to have an emergency service crew and ambulance on standby for the match. They should also have an AED and spinal board ready for cervical fracture immobilisation and evacuation.

Once the athletes arrive, you give them their sports drink bottles, review the injury status (and any other medical condition), tape the joints and assist in stretching. We watch the athletes warm-up (and join in if possible, as you are required to run on the pitch in the event of injury) and do their sports-specific drills before the match. You have to have your rigid tape and powder ready in case some of the sticks needed minor adjustments for grip. You may also need to have self-adhesive tape (e.g. Powerflex or Coban) to hold the shin pads and support the wrists (also prevent sweat from wetting the sticks). You need to ensure that you have 4-5 bags of cube/crushed ice for injuries. Have your Ethyl Chloride spray, scissors, suture set, tubigrip, gauze, povidone iodine ointment and surgical spirit ready in case of cuts, abrasions, lacerations and contusions. The coach and manager will need you to give your injury status report prior to selection of the team.

During the match, you need to be watching the match at all times. Ensure that there is free flow of sports drinks and mineral water for athletes (and officials). Athletes coming in and out of the pitch are 'checked' to ensure that are rehydrating well and injury free. You need to assist them in RICE treatment if there are injuries. Assess the injury and give an immediate injury status report to the coach as he may need to return to play. The decision to play should be based on medical facts and not on the need to play. Clean and dress bleeding wounds immediately and you may need to suture the patient on site if you are able to get a relatively clean environment with your sterile equipment. (to be continued)

Montelukast Option for Asthmatic Athletes

I have been treating asthmatic elite athletes with Montelukast (Singulair)for at least 4 years as a single monotherapy drug. Most of these athletes who had Intermittent Asthma and Moderate Persistent Asthma were well controlled with the medication and needed few rescue medication with Salbutamol Inhalers. Salbutamol, other beta-agonist and Corticosteroid inhalers/turbuhalers require Therapeutic Use Exemption.

The new guidelines for asthma treatment is available here. Athletes should discuss the options of treatment with their team doctor or Family Physician. Find out about the Doping Prohibited List 2007.

In a recent clinical trial, the authors suggested that Montelukast provided significant protection against Exercise Induced Bronchoconstriction (narrowing of the airways) having an onset within 2 h following a single oral dose and lasting for at least 24 h. This medication could be useful for athletes who have asthma as an option for prevention of asthma and better control of symptoms.

Rt Big Toe Gouty Arthritis

Mr Lim came in walking on his heel with a painful and swollen base of the right big toe (see photo) yesterday. He could not remember having any falls or trauma to the toe but had a little too much beer, seafood and peanuts for the past week.

I was keen to find out whether he had any insect bites or previous injury but he had none. I took a blood sample for his uric acid levels and sent him off with an NSAIDS for 5 days. Had to give him some gastric preventive medication i.e. Proton-Pump Inhibitors to prevent any gastric side-effects. Also warned him not to take NSAIDS on his own as it could cause hypertension or heart problems if given indiscriminately.

True enough his serum uric acid levels came back elevated. He was advised to avoid excessive intake of protein and beer. If he had recurrence in his condition, he may have to be on medication to lower the uric acid levels e.g. cholchicine or allupurinol.

Forefoot contusion after supper!

The local council is going to get a complaint from this patient. He was walking back from 'Mamak' (a spicy, not so fancy, local fast-food) when he accidentally stepped into a pothole in Subang Jaya last Saturday.

He had a painful swelling on the dorsum of his right foot (see photo) and could only walk on his inner side of his foot. He had a painful gait when he walked into my clinic yesterday. I was getting a bit worried as he could not put weight on the side of the foot. After examination, I felt that he could be spared from an X-ray as most of the pain came from the superficial swelling and not the 5th metatarsal (common site of injury for such falls). I once had a 50 year old colleague who fractured her 5th metatarsal in the same manner walking along the pavement! Her risk was higher as she was having Osteoporosis.

Told him to do the RICE treatment (see first-aid) and gave him some Arnica gel and oral NSAIDS. He was advised to avoid excessive walking for another 5 days and return for a review if pain and swelling persisted.

Ingrown Toenail

Anthony is a 10 year old basketball player and cyclist who weighs 60 kgs. He came this afternoon with a recurrent left big toe painful swelling since 1 year duration. He has seen several doctors but he said, "Nothing they did worked!".

I examined his toe and found that the swelling was already resolving. There were signs that probably it was oozing pus over the past few days. Somehow he came in as he felt it was "too much of a hassle".

I got him to agree not to trim his toenails so deep. I was also concerned whether he was diabetic as he had a strong family history of diabetes in his family. I gave him a course of oral antibiotics and an antiseptic for dressing. Told him to bring his footwear for examination and stay off playing games until it healed. I thought, who would stay with this for a whole year?!!

Multiple Joint Pain and Bodyache

Chong was a regular gymnasium user who was as fit as an elite athlete. He did 2 hours of regular workout including 30 minutes run, core stability exercises, moderate weight training and an occasional dance routine at a popular gymnasium. At 40 years of age, he could run faster than most men half his age.

He came in a day after his hard workout thinking that he probably overdid it. Most of his joints were aching and his muscles were sore. For some reason or other, he was still sweating profusely. "Doc, I think I shouldn't have worked out so much last week!", he said. I smiled, saying "Told you you needed to recover after each exercise session!". He wasn't quite impressed as usual. In went the mercurial thermometer. "Ahhh! 38 degrees centigrade. You're down with fever!", I said.

"How many days have you been feeling feverish?", I asked. "Three", he answered. He also had a rapid pulse rate and a slight raise in the Blood Pressure. Hess test (a special test to check for petechiael rash) was positive. "Let me send a blood sample to check for your blood counts. The last thing we want is dengue fever", I said. "You need to rehydrate a little more than usual and take a day off. I will call you in a few hours time". It took the laboratory an hour to fax me the result and true enough his white cell count and platelet counts were low. He was lucky that the levels were not critical and it resolved the next day.

Where is the medical team?

"Where is the medical team?" Shouted the spectators in the far side of the Cheras Badminton Stadium. The officials pointed to the table where the medical team was seated. There were three doctors watching the match although only one was officially on duty. The rest of the medical team consisting of a nurse, a medical assistant, a physiotherapist, an ambulance driver and 2 students were seated just behind the doctors.

Two of my doctor colleagues immediately ran up the stairs to reach the patient. But since they were not dressed in their uniform as I was, nobody could recognise them. The crowd was not helpful. They blocked the access route to the stands just to catch a better glance at the women's doubles finals match between China and Indonesia. I didnt have much of a choice. Everyone was gesturing to me to attend to the patient although I was the last doctor standing for the competition. I had to leave my post to run after my other colleagues.

True to my suspicion. The patient was an epileptic male who was poorly controlled on medication . He just had a tonic-clonic convulsion on the stands possibly due to the hot, humid and extremely noisy environment with every spectator banging away on the sponsored plastic air-balloons. There was not much we could do but to ensure that the patient was comfortable and did not choke on his own tongue or secretions. He was slightly dazed when we got to him and it took three men to carry him up the stairs and down the stairway into the medical room. We were relieved to see that he was better. His mother was not perturbed by the incident and wanted to return to the game immediately. She was not sure what medication the son was on. Neither could she tell us more about the condition. To our surprise, she refused our offer to take the son to the nearest hospital by ambulance. I informed my colleague that we could not have the patient return to the spectator stand without risking another episode that we may not be able to manage. Finally, the patient's mother relented and took the boy home.