Perspectives in Medicine: Diagnostic Challenges

The last perspectives in medicine was about sudden changes.  This post is on more insidious changes and the diagnostic challenge.

There is an interesting challenge that I notice in clinical medicine.  It is a situation when someone’s health is not quite right but the diagnostic test and the clinical condition has not yet materialized to allow the physician to make a diagnosis.  There is certainly a sweet spot in timing of the diagnosis: long enough to discern one cause from another and confirm it;  not too long that a person is left with discomfort or a health risk.

In the inpatient setting, a patient may come in with a nonspecific series of complaints:  fatigue, chills, jaundice.  There may be nonspecific test results: elevated liver tests, a low white blood cell count, low platelets and a high bilirubin.  This very circumstance happened in a patient that I evaluated.  This series of findings is described as a mononucleosis syndrome.    The challenge is that there are many things, infectious, rheumatologic, and neoplastic, that can cause these findings besides Epstein Barr Virus (EBV), the virus that causes “mono”.

The patient developed the symptoms over a period of three weeks.  She noticed jaundice and increased fatigue.  She had no flu-like symptoms, sore throat, lymph node swelling, or sick contacts.  A battery of infectious diseases tests were performed, but none of them singled out one process.  She may have had a positive antibody for EBV, but so does 80% of the population.  The EBV DNA Polymerase chain reaction test (PCR), a marker of active infection, did not detect any copies.  A CT scan showed an enlarged liver and spleen.  Over a period of several days, she improved to the point that she was able to be discharged – without a diagnosis.

We discussed the next steps, which included a liver biopsy.  The pathology of the liver sample suggested a process that is a result of many possible causes.  It suggested a rare finding known as hemophagocytic lymphohistiocytosis (HLH), which is caused by autoimmune, neoplastic, or infectious causes.  No telling findings otherwise were seen.  Fortunately, she was feeling better.

We had a discussion about the results.  I brought up strategy to address diagnostic challenges.

In medicine, seldom is a condition diagnosed on the spot.  An astute physician can evoke a diagnosis like they are conjuring up magic.  One of my mentors in infectious diseases, while rounding with us on a particularly vexing patient, walked in the room, looked at the patient face and skin (he had some ulcers on his lips and a generalized rash), and almost immediately said “he has Mycoplasma.  And that is what he had.  All other tests were negative, but he had the typical X-ray finding of Mycoplasma, a cause of “walking pneumonia,” and all his tests HIV, syphilis, etc were otherwise negative.  We were spellbound, as we reviewed about this less common presentation of Mycoplasma.

A disease process sometimes takes time to present, time to grow and enable a safe way to diagnose it.  Some diseases can be diagnosed fairly reliably by looking at the skin, our bodies largest organ.  In fact, there is an app for that.  The skin houses a network of vessels that mirror what is going on the in the entire body.  Occasionally, systemic diseases can present with skin findings, that facilitate a less invasive way of making a diagnosis.  This includes conditions such as sarcoidosis, T-cell lymphoma, malignant melanoma, metastatic squamous cell carcinoma of the lung, and lupus vasculitis.

When the disease is confined to the deeper vessels and lymphatic system, often there will be nonspecific changes in the GI tract.  The tests may be nonspecific, such as elevated liver enzymes, white blood cell changes, and anemia.  Since there are a multitude of infections that can present similarly, a shot-gun approach isn’t always high-yield or cost-effective.  The radiologic imaging may also be nonspecific, such as a large liver and spleen, and mildly enlarged lymph nodes.  At that point, the next step becomes a decision between watchful waiting or more aggressive, invasive testing.

The imaging and tests can only hint at the possibilities.  Sometimes, there is a need of tissue, and sometimes there is a need to treat while not being completely sure.  It reminds me of a patient that I saw from Africa who presented in the US with peritoneal fluid, lymph nodes, and thickening changes of the peritoneal lining.  These changes usually occur when there is inflammation.  The pathology report of the peritoneal biopsy was that of non-caseating granulomas, a feature of sarcoidosis but certainly not exclusive to it.  She was from a part of Africa, where an article was published on cases of sarcoidosis.

noncaseating granuloma
Noncaseating Granuloma of Sarcoidosis (Ref:  Wickepedia)

It was also a high prevalence country for tuberculosis, which can present as non-caseating granulomas (though are more known for caseating changes).  Her blood test (quantiferon) was positive for tuberculosis, but it wasn’t clear if it was latent infection (and had sarcoidosis) or if this was peritoneal tuberculosis.  I saw her in the hospital; a different one from where she was being seen.  She just had a biopsy there.  I called the pathologist told him that I found it worrisome for tuberculosis.  He looked at the smears before (tuberculosis stains with acid fast stain) and did not find anything.  My call was enough to get him to go back and look.  He called me a few hours later saying that he found “one acid fast bacillus.”  We started her on four drug tuberculosis and after about one week, she had already felt better.  None of the cultures ever grew; none of the genetic tests were ever positive.  Yet, she had peritoneal tuberculosis.

Although ultimately it goes back to the service that physicians provide to the patient, a vague but concerning presentation can get a physician concerned about whether something is missing, and even if he or she is skilled enough.  Hovering around is a concern of malpractice.  As many as 39% of medical malpractice lawsuits come from failure to make a diagnosis, missed diagnosis, or delay.   There is a point when the nonspecific, mild symptoms start to escalate to more specific, acute symptoms.  Ideally, the time to diagnose a disease is before it can cause a threat on health.

Photo by Pixabay on

Fortunately, there are some important aspects to addressing a challenging diagnosis, for patient and doctor alike.  I approached the patient with the diagnostic dilemma with these points in mind:

  •  Go back to the History and Physical Exam

This is one of the physician’s most important tool.  Whenever I get into a situation of a diagnostic challenge, I go back to the patient and really listen to his/her words and determine the development of symptoms.  A dying art in the era of advanced medical technology, a good history can still assist greatly in making a diagnosis; from some estimates, 70-90% of the time.

A follow-up physical examination while reviewing the history is critical.  I often find that the best exam includes a second visit.  It gives clarity on the history:   the patient may have had a chance to think about the symptoms or questions more; the exam may have been changed or a physician may have missed something on the prior exam. There was a time that after a fourth genital exam, in my stubborn fashion, I found the source of the patient’s fever – a penile abscess.

  • Communication

It is important to keep the channels open and to feel comfortable to discuss any questions or concerns.  I like to reassure the patient that I will continue to search for a the person can contact me and inform me of their health.  We can keep visits at closer intervals to review progress.

  • Go toward the place where there is the greatest change

A blood test can sometimes show changes, for instance in the white blood count or the liver tests.  A patient may have localizing symptoms, for instance, localized abdominal pain.  If there is a concern, an imaging test may be ordered, such as a CT scan.  Where an abnormality is encountered is the place that a more invasive test can be used to assist in the diagnosis.  This often requires a scope or interventional radiology to take a sample.

  • Watchful waiting requires diligence

If a person is not suffering from severe symptoms, they may be safe enough to monitor over time.  This requires careful planning and setting goals.  This could be ensuring that the patient is seen frequently or receives additional testing, such as an imaging study or diagnostic test, in a timely fashion.  In the infectious diseases clinic, I once diagnosed a patient with atrial fibrillation, but needed to confirm it on an ECG, which we didn’t have.  I sent him to the cardiovascular lab; it was closed.  He wasn’t able to get the test for one week, which confirmed the clinical exam.  Was that too long to wait?  Maybe.

  •   Consider collaborative discussions and second opinions

Occasionally bias can obfuscate the ability to draw objective conclusions.  There are always going to be knowledge gaps, as well.  I used to think that being a specialist would have a more confined and manageable knowledge foundation than a generalist.  I though wrong.   It is just as complex and ever-changing.

It’s common that a patient’s information is discussed by multiple providers involved.  In fact, it is a disservice to not have this collaboration otherwise.  It isn’t unusual and sometimes helpful to walk down to the radiology reading rooms, review slides in microbiology or the biopsies with a pathologist, or to scrub in on a surgery.  These perspectives enhance care.

I discuss cases with other infectious diseases specialist as well, if I can’t find a satisfactory answer from my knowledge base or from a brief literature review.  Sometimes, one can be treated while closely watching and considering other causes.  Other times, it is necessary to wait until a definitive diagnosis is made.  It all depends on the acuity.






Adaptive Gardening After a Stroke

All anti-depressants do not just come in a pill so I am glad I found a way to garden after my stroke.  However, each year I forget the tricks I discovered so I took photos and described them.

At first I pulled plants out of their containers one-handed.  The moist dirt balls broke apart.  I learned to let the plants dry out a little.  The photo shows a child size spade I slide down the sides of each container to loosen the roots.

I use a big plastic pot that is lighter than clay.  After I partially fill the pot, I put a ring on top of the dirt.  I made this ring out of a disposable plastic cutting board.  The ring keeps plants away from the rim and gives me something to lean the 1st row of plants against.  A small cup helps me fill the narrow space between the ring and the edge of the pot.  I make sure the plants are touching each other so they grow into a thick ball that prevents water evaporation.  I drop fistfuls of dirt in the small spaces between the plants.  Then I pull out the ring.

I use my hemiplegic (paralyzed) hand to hold the watering can still so it will not tip over as I fill it with the hose.  I use the garden hose to wash off the dirt I have spilled on my concrete patio.
I lower the pot onto a bench and carefully slide it next to the chair I sit in to watch the sunset and drink a cup of coffee.  I also get to enjoy these beautiful flowers every time I come home.
P.S. Rebecca you only need four 4-packs.

Aphasia: 10 Insensitive Reactions to Someone Who Has It

Aphasia is not having a senior moment every once in awhile. Rather, aphasia is the loss of ability to comprehend or express speech caused by brain damage, one of negatives for winding up with a malfunctioned brain from stroke and Traumatic Brain Injuries (TBI). Sometimes you get better with aphasia from stroke or TBI, but few get better completely.

I make a self-deprecating joke with aphasia when I often say, stumbling to find the exact word, “This here is aphasia in action,” naming it before people think I’m slow. But naming it or not, aphasia really sucks.
I’ve come up with a list the insensitives among us say when, after a few seconds, they lose my thread and start talking about something else. I want to say, “C’mon, guys, can’t you wait while I think of the word,” but I never say it. Why bother? I saw that now. But early on, I wanted to change the world’s thinking about aphasia. What a dud I was.
Here’s the list of the top ten reactions people have for those with aphasia:
1. I can’t understand you.
This statement cuts right into my soul. You’re speaking English. I’m speaking English. “So what’s the problem?” I say silently. To my ear, it sounds good enough, but to the person’s ear, it sounds incomplete, which it probably is. But even though….
2. Supplying the right word
Oh, no! I want to be part of the conversation, and if you’d just hang on for a sec or three, the word will come to me. Or they won’t.But my aphasia is different from some, because the word that I’ll come up with, though in the ballpark of correctness, a word I’ve rarely used before. Example, we took a ride to the coast and when we arrived, I described the houses as “ramshackle.” I never know what’s going to come out of my mouth because I lost the filters when I had a stroke in 2009.
3. People finishing your thought
I can honestly say, “What the F is wrong with them?” Sheesh. Give a gal a chance. They think they’re doing me a favor, but the exact opposite happens. I resent them, and fairly soon, I want to leave the room.
4. Speaking sentences that NO ONE understands
I’ve improved, but early on in the first three I spoke sentences that even after I was finished, couldn’t understand. People just stopped listening soon after.
5. Making up words
I used words, back in the beginning, that weren’t really words at all, like “clockfer,” “greenac,” and “withand.” I know that I said them because early on (wanting to escape the aphasia which I still have not done completely), I used to tape conversations on my phone and recognize the errors. I was embarrassed but given the condition I was in, a little empathy please?
6. Inability to understand someone else’s conversation
In the first year after my stroke, I went to an art lecture on Picasso, and with the visuals right there in front of me, I had severe trouble following that talk. I hadn’t heard of aphasia, but I’m satisfied that other people had trouble following other lectures at first with strokes, too. But people were annoyed that I “didn’t get it.” Remember when I said strokes suck?
7. Pronunciation suffers
On the first round, even after eleven years, I still, like a little child, say “bisquetti” for spaghetti when I don’t remember to slow down my speech. It is also useful to say every part of the word in isolation and put it all together, slowly at first. Thus, I had the inability to pronounce words correctly, and some words not due to muscle weakness or paralysis because I could pronounce them if I slowed the heck down. Some people laughed. It wasn’t funny though.
8. Loss of reading and/or writing skills
In some patients with aphasia, reading and/or writing skills (usually both at first) are lost. This means that the patient is no longer able to comprehend written language or even express themselves through writing, all of which are necessary to communicate to emotion, language, and information using symbols, and even emojis. You can imagine what that loss does for self esteem. They have to start over. I’m extremely fortunate, as a writer, I didn’t have that affliction.
9. Spontaneous speech is rare for aphasiacs
I gave a speech to a stroke support group a year after the stroke in the Hershey Medical Canter in Pennsylvania, and though it appeared spontaneous, I simply read off the bullet points so fast, it seemed that the neural pathways were on fire for somebody in the back row who was simply listening and not watching the presentation. Spontaneous speech, also called off-the-cuff, is speech that happens without any planning having taken place, and the majority of aphasics, though they want to do it, simply are unable.
10. The facial expressions
I saw the frowns, and sneers, when I talked to people, even now, if the minds are already made up that this is a person (me) whom they won’t understand. I detest it though I can’t have any control over so I don’t worry about it like in the early years. I can try and talk slower and who cares what they think? If they call me slow and dimwitted, who cares?
Alexander Hamilton said it best: We must make the best of those ills which cannot be avoided. He may have been talking economics, but I’m talking stroke and TBI. Different causes; same result.

One Ingredient “Ice Cream”

What if I told you that you could make gluten-free, dairy-free, vegan ice cream?

Banana ice cream
(credit: the Kitchn, Leela Cyd)

The secret ingredient is *drumroll* the humble banana!

This fruit is packed with nutrients, antioxidants and fiber. They are a great source of potassium and carbohydrates to fuel the body while still remaining a low-calorie food.


credit: Pexel

Also, as it turns out, when you freeze bananas and puree them in a blender, something magical happens. Due to their naturally high pectin content (a type of fiber), pureed bananas obtain a texture similar to custard-y ice cream!

The steps are simple:

First, cut your ripe bananas into coins and then freeze them. Once frozen, put the coins into a blender or food processor. Blend them, while scraping the sides down often, until you achieve a smooth, ice cream consistency. If the bananas continue to stay in chunks, you can add some milk or soy milk tablespoon by tablespoon until it blends smoothly. Scrape out and enjoy!

Some delicious add-ins to experiment with:

  • Peanut Butter (for a little kick of protein)
  • Cocoa Powder
  • Chocolate chips
  • Honey
  • Cinnamon

The post One Ingredient “Ice Cream” appeared first on Your Health Forum.

Pepe Finds His Way E-book

In this book, Pepe says “I think it’s worth a try.”  In this simple sentence lies the bridge toward new behaviors.  Pepe steps out of his comfort zone by changing his diet, managing his feelings, and walking with his family.  He takes one step at a time in forging a path toward improved health.  From these changes come more opportunities, as Pepe plants the seed for his future self.

Whether you are a child who has some challenges with your health or are interested in learning some skills that can strengthen a feeling of wellness, Pepe Find His Way provides tools that are sure to be useful.  Please be sure to enter your email on the right to become a member of Your Health Forum for access to more books, carefully researched articles and virtual and physical community events.


Christopher M. Cirino, DO MPH

Founder Your Health Forum


Attached is a free download of the book Pepe Finds His Way.


Eggplant Mini pizzas

What a great way to use eggplant in place of dough for snacks that are healthy AND   tasty!

Actually considered a fruit, the eggplant was originally from China and made its way East. It is popularly used in Middle Eastern and Greek dishes. At one point from the 14th century to the 1700’s in Italy, eggplant was not regularly eaten. A member of the nightshade family, it was believed to be a cause of fever, epilepsy and insanity. Not to mention it has a very unappealing, bitter taste that requires soaking prior to cooking.

Eggplant has a lot of fiber and is packed with vitamins and minerals like potassium, Vitamin B6, Vitamin A, magnesium and folic acid.  It is a versatile food and is a great staple for a plant-based diet.

In this recipe provided by Lucia of Lalu, Inc, the eggplant slices become the small snacks in the form of pizza. If you are a fan of Eggplant Parmesan, you’ll like this preparation! This could even be the kids go-to snack. It might be fun to have the children design their own mini-pizzas with their favorite pizza toppings.

Hope you enjoy it! Don’t forget to check out the website of Lalu, Inc. for recipes and nutrition information in Spanish and English.

New Facts on COVID-19: “Don’t Come In Unless You’re Short of Breath” Doesn’t Apply Anymore

I had an annoying, dry cough in the beginning of February. Then the cough roared like a hungry beast. No fever. Just the cough, with shortness of breath and fatigue that escalated quickly over a two-week period. Was it COVID-19, I asked myself repeatedly? I don’t know now, and maybe I wouldn’t ever know, unless the testing starts very shortly to all people, rich or poor, healthy (for the asymptomatics amongst us) or sick, despite what Jared Kushner, as a spokesman for President Trump, says about enough tests now. I haven’t had one at the peak of coughing/shortness of breath/fatigue. Have you? Just to make sure?

But with Trump in charge, forget that option. “Coming up shortly,” or “Within the next two weeks,” or, my favorite, “Soon” is Trump-speak, when most people, after the passage of time, forget he made those promises in the first place. But I remember. You can count on that.

WIRED had an article written by Megan Molteni who says that scientists are running like crazy to comprehend why some patients also develop neurological ailments like confusion, stroke, seizure, or loss of smell. Stories of other, stranger symptoms like headaches, confusion, seizures, tingling and numbness, the loss of smell or taste have been going on for weeks.

“The medicines we use to treat any infection have very different penetrations into the central nervous system,” says S. Andrew Josephson, chair of the neurology department at the University of California, San Francisco. He is saying that most drugs can’t pass through the blood-brain barrier, a living wall around the brain. He also says if the coronavirus is penetrating the barrier and infecting neurons, that could make it more difficult to find appropriate treatments.

When the virus first started in Wuhan, China, health records indicate that 214 patients admitted to the Union Hospital of Huazhong University of Science and Technology, 36.4 percent of the patients showed signs of nervous-system-related issues, including headaches, dizziness, confusion, strokes, prolonged seizure, and a slowly disappearing sense of smell, some before the fever and cough were apparent.

“We’ve been telling people that the major complications of this new disease are pulmonary, but it appears there are a fair number of neurologic complications that patients and their physicians should be aware of,” says Josephson.

Without that information, datasets in particular, there’s no way to know how to interpret reports on patients, and “single cases are tantalizing, but they can be fraught with coincidence,” says Josephson.

COVID-19’s horrendous death toll, 61, 656 as of this writing, is other-worldly, science fiction-like worthy, and not many autopsies are being done. Only some pictures of the lungs, but a good chance that there’s some viral invasion of the brain.

A paper in the New England Journal of Medicine examining 58 patients in Strasbourg, France, found that more than half were confused or agitated, with brain imaging suggesting inflammation.

“You’ve been hearing that this is a breathing problem, but it also affects what we most care about, the brain,” says Josephson. “If you become confused, if you’re having problems thinking, those are reasons to seek medical attention,” he added.

Viruses affect the brain, explained Michel Toledano, a neurologist at Mayo Clinic in Minnesota. The brain is protected by something called the blood-brain-barrier, something that Josephson says, too, which blocks foreign substances but could be penetrated if compromised.

Since loss of smell is one of the symptoms of COVID-19, some have hypothesized the nose might be the pathway to the brain. But in the case of the novel coronavirus, doctors hold on to current evidence that the neurological impacts are more likely the result of overactive immune response rather than brain invasion.

Jennifer Frontera, who is also a professor at NYU School of Medicine, explains documenting notable cases including seizures in COVID-19 patients with no prior history of the episodes, and new patterns of small brain hemorrhages.

“We’re seeing a lot of consults of patients presenting in confusional states,” said Rohan Arora, a neurologist at the Long Island Jewish Forest Hills hospital, adding that more than 40 percent of recovered virus patients. “Returning to normal,” added Arora, “appears to be taking longer than for people who suffer heart failure or stroke.” [Apparently, Dr. Arora hasn’t worked extensively with stroke patients. After 11 years, I’m still recovering. Just sayin’.]

Anyway, good advice if you have any of those symptoms–headaches, dizziness, confusion,  prolonged seizure, and a disappearing sense of smell–go to the doctor. Many doctors are seeing patients through tele-conference now. If you had a stroke as a result of COVID-19, you probably have already gone to the hospital where there are tests but not too many of them.

One more thing. How about Trump supporters try injecting or swallowing disinfectants to see if they work or this headline: Online demand for hydroxychloroquine surged 1,000% after Trump backed it, study finds. I say that statement with sarcasm, but unlike Trump, he said it confidently when he recommended Lysol, Clorox, and hydroxychloroquine, despite his walkback when people were alarmed and others broke into peals of laughter. It’s on tape, Mr. President.

Ways to Move Toward Health and Away from Severe COVID-19 Infection

It is our first month into social distancing measures.  We have had a few months to see and read about how the pandemic affected some countries, challenging the health systems of Italy and China.  We now witness the effect of the pandemic in New York City, while the case loads increase in other cities.  Hospitals have struggled to find beds, personal protective equipment, and ventilators.  Healthcare workers are being stretched to their breaking point to care for sick patients.


As of April 15, of the 644,089 cases in the United States, 28,529 people have died from COVID-19.  It is a sad reality that more people will succumb to this infection.  


We grapple with the paradox, that some will develop severe disease, while the majority of people will have only mild disease.   A closer look at the risk factors of those most affected by COVID-19 does allay some fears.  As with all infections,  advanced age (>65 years, especially >75 year of age) is the greatest risk factor.  Nevertheless, we are more than chronologic age.  Underlying conditions often increase with age, including obesity, hypertension, diabetes, lung disease, and immunocompromising conditions are important underlying risk factors.

What explains these exceptional cases, e.g. a thirty year old female with no other health problems who dies from COVID-19 after having a severe presentation?  The news media covers these cases, because they are mysterious and show that this process can be severe.  We learn about the way the body interact with the virus, and we begin to realize that a person with “who was otherwise healthy” was a person who has risk factors that haven’t been determined.  Recent studies have brought light to genetic susceptibility for more severe infections, such as single gene polymorphisms and HLA variance.

Unfortunately, news reports can stoke further fears.  We as humans are wired to consider these exceptional cases over what is more likely, a cognitive distortion known as catastrophizing.  Our minds weigh risks and predict ways we should react to this unseen, approaching threat.  It is as if our brain fixates on these negative outcomes to trigger an action.   A result of this is to go into “fight, flight or freeze mode,” and, since we can’t fight an invisible enemy, it often manifests as “waiting out the pandemic.”  Enter some new routine like netflix binge watching, eat your cravings, nod off and repeat.”  These behaviors put us as risk for becoming unhealthy.

There are some active ways that we can become more resilient through this and protect ourselves from severe disease.  Although we are not able to change our age, inherited chromosomes, and there is no fountain of youth.  Nevertheless, we can protect ourselves from severe infections through daily healthy decisions.  The burgeoning field of epigenetics shows that diet, stress and sleep affect genetic expression and our immune systems.

What follows are some strategies to protect one from more severe COVID-19 disease during the pandemic:

  1.  Get plenty of sleep.
  2.  Keep physically active.
  3.  Keep stress levels low.
  4.  Keep a healthy weight.
  5.  Eat a nutritious diet.
  6.  Avoid or limit medications that can affect the immune system.
  7.  No smoking or use of alcohol, marijuana and other drugs.

1.  Get plenty of sleep.  “Sleep helps healing”

Photo by Dominika Roseclay on

The quarantine has altered, sometimes drastically, our normal routines.  As we adjust, some people working from home may compromise a healthy duration of sleep to get more work done in the evening.  Others may look at the schedule change as a vacation and become more lax with their routine.

Sleep deprivation can lead to impairment of immune activation, of both innate and adaptive immunity.  There are likely hormonal factors (e.g elevated cortisol) that contribute to these changes.  Decreased sleep leads to impaired activation of the immune system and increased inflammation.  In one study, pro-inflammatory cytokines IL-6 and TNF-alpha receptor 1 were increased after four days of sleep deprivation.

A good night’s rest improves the body’s adaptive immune response, which allows T cells to work better at going to infected sites and lymph nodes.  Adequate sleep ensures that cytokines, which are cell signaling agents, function adequately to interact with T-helper cells.

Sleep disorders such as sleep apnea or primary insomnia can decrease efficiency of sleep and lead to health risks. It is important to discuss with your doctor if you have frequent sleeping problems, whether it is getting to sleep or staying asleep. Other signs can include decreased restful sleep, feeling tired early in the day, “caffeinating” possibly more than 2-3 cups reaching for alcohol or sleeping pills at night. Other signs include lower extremity swelling, frequent nighttime urination, dry mouth in the night, night sweats and morning headaches.

Action:  As for the quarantine, ensure that you are sleeping a consistent duration at consistent times.  Refer to the prior articles on sleep for more details (The Scoop on Sleep, Sleep Disorders Patient Education).

2.  Keep physically active

Photo by Alexy Almond on

Regular exercise strengthens and conditions the body and provides richly oxygenated blood to all of its cells..   Physical activity leads to a reduction of the stress reaction and enhances sleep. Rapid increases in Natural Killer (NK) cells were found after exercise secondary to norepinephrine release.  Exercise essentially lowers systemic inflammation.

Regular activity requires increased effort during this time of quarantine, as devout gym-goers have lost their routine.  A consequence of closing the gyms and other exercise centers during this time of social distancing could be an increase in physical deconditioning, falls, and weight gain.  These could exacerbate chronic health conditions in some people.  It is therefore important to attempt to maintain the intensity of your exercise regimen while at home.  Kenneth Powell et. al. have published a general guide to exercise, which supports that “some activity is better than none and more is better than less.”

Action:  Set aside some time each day to walk or job outside, to stretch your back and legs,  and to do some mat exercises with light weights at home.  There are multiple online options and apps, if your looking for some motivation.

3.  Keep levels of Stress Low

Photo by Tausif Hossain on

Stress hormones, such as cortisol, epinephrine and norepinephrine,  are released in a fight or flight perceived or real situation or with sleep deprivation. These hormones can lead to T-cell dysfunction and leukocyte adhesions molecules which allow T-cell to traffic to sites of infection. Exercise and meditation will likely reduce one’s reaction to stress and lead to decreased cortisol secretions.


Stress attenuates the immune system.  In studies of medical students undergoing a short-term 3-day period of examinations (J. Glaser and R. Glaser), there were levels of decreased natural killer cells, a part of innate immunity, during the times of the exams.  The researchers found less gamma interferon activity and T-cell response in test tubes.  Even with chronic mild stress or depression, there may be an impact on the lymphoctye-T cell response to mitogens (things that normally activate the immune system directly).

What can we gather from this information?  The immune system reacts to hormones that are produced in the stress state, inlcuding cortisol, norepinephrine and epinephrine.    Immune cells possess receptors that interact with these hormones.  Self-management of stress with resilience practices such as physical exercise and meditation reduces the severity of this impact and keeps the immune system functioning at its maximum.


4.  Maintain a healthy weight.

Photo by Lisa Fotios on


Healthy Weight is a Full System Benefit.  Obesity is a chronic disease.

A healthy weight allows that body to function optimally and prevent multiple insults, including infections.  It allows for an effective immune system to neutralize infectious particles and reduce the severity of disease process. As one becomes more overweight, the body becomes taxed by its attempt to compensate. This impacts the way the immune system functions as well. There was an association with high Body Mass Index results (BMI>35) and increase need for being hospitalized in the ICU or even death during the swine flu outbreak in 2010.

In a recent publication (Petrilli et al.) that evaluated the risks in 4,103 patients with COVID-19 disease in New York City, a body mass index (BMI) of greater than 40 correlated with a six-fold higher risk of severe disease (OR 6.2, 95% CI, 4.2-9.3).  The only other risk factors that were higher was age >= 75 (OR 66.8) and age 65-74 (OR 10.9).

Let the message be clear:  obesity is a chronic diseaseObesity can lead to acute and chronic inflammation.  Occasionally, as an infectious diseases doctor, I have been asked to see someone for a chronically elevated white blood cell count.  One common link is that the majority of these patients were significantly obese.  Increased adipose tissue leads to a build-up of inflammatory hormones (adipokines), such as leptic, IL-6, tumor necrosis factor and resistin.  Macrophages are recruited into adipose tissue and continue the response and inflammation.  There may be some localized oxygen delivery issues into fatty tissue as well, known as hypoxia.  There are impacts in both innate and celluliar immunity.  An already taxed body cannot develop a robust immune response.

We cannot talk about the parts without talking about the whole.  Obesity leads to multiple systemic decompensations as the body attempts to compensate.

1)  Increase adipose tissue leads to tissue hypoxia, macrophage infiltration and a pro-inflammatory state, as discussed.

2) Sleep deprivation from obstructive sleep apnea leads to cortisol hypersecretion, which is a potent immunosuppressant.

3) chronic hypoventilation of the lungs increases the risk of pneumonia.

4) aspiration of gastroesophageal reflux leads to an increased risk of pneumonia.

5) Long-term obesity can lead to liver and spleen disease, which impairs the immune system substantially.

6) Impaired glucose metabolism can lead to deficiencies in innate (antimicrobial peptides, natural killer cell activity) and acquired immunity (T-cell and B-cell immunity).


5.  Eat a nutritious diet.

top view photo of vegetables
Photo by Ella Olsson on


A healthy diet provides the ingredients through which a robust immune system is established.  Every food that enters our digestive system requires the body to incorporate it through metabolic pathways.  Ultimately, the metabolites of the food reach our vascular system, a network that connects to every cell in the body.  Our immune system operates from this pathway

Certain foods can rev up our inflammatory response, which might disable as strong of an immune response to infection.  Examples of these foods include ultra-processed high carbohydrate foods, refined flour, snack foods, French fries, fried foods, sodas, and red meats.  Studies have shown increased levels of known markers of increased inflammation, including IL-6, IL-7, and TNF-alpha.  A host of chronic medical conditions, including autoimmune disorders, irritable bowel syndrome, psoriasis and other dermatitis, diabetes, cardiovascular disease, degenerative joint disease, Alzheimer’s disease, and even anxiety and depression have been associated with inflammation.

A whole foods, plant-based diet is protective of inflammation and can “boost” the immune system.  Vegetables are replete with vitamins and fiber that protect the body and optimize its functional state.    As a general rule of thumb, mix up your diet with a rainbow of colors, vegetables, healthy grain fibers, nuts and fruits.  Keep well hydrated with water.  A healthy, well-balanced diet would include all of the nutrients, vitamins, and anti-oxidants to keep the immune system functioning at its best.


Vitamins and Nutrients

Although nutrient supplementation has not been studied rigorously in trials, there is support for vitamin D supplementation in infections.  Vitamin D has a known role in the innate immunity including its role in inducing cathelcidins and defensins.  Vitamin D is also involved in adaptive immunity and affets expression of T helper cells.  During the winter in northern hemisphere countries, relative insufficiency of vitamin D results from decreased sunlight.  So, it might be reasonable to take a vitamin D supplement available over-the-counter.

Zinc may be associated with inhibiting replicase (RNA-dependent RNA polymerase), an enzyme associated with viral replication of COVID-19, in an in vitro study.  Studies have shown that chloroquine (and likely a related drug, hydroxychloroquine) may allow the zinc to enter into a cellular membrane (known as an ionophore). Whether this equates to some benefit as a supplement is not clear.

Vitamin C has an important role in the immune and vascular systems.  A deficiency in vitamin C, a common occurrence in the age of maritime exploration, can lead to collagen defects that increased vascular fragility, delayed wound healing, bleeding, and even atherogenesis.  Vitamin C has multiple effects on both the innate and adaptive immune system, including antioxidant properties, leukocyte (White blood cell) signaling (that improve wound healing), T-cell maturation and antibody generation.  While vitamin C deficiency is exceedingly rare in modern times, fad diets and extremely limited diets seen in economic hardships, marginalized populations, and homelessness require its consideration.  Interestingly infections could precipitate scury in already at-risk populations.  Vitamin C stores are not long-lasting, so a diet replete with plenty of citrus foods will ensure that you are protected.

Action:  Incorporate a palatte of plant-based foods in your diet, such as vegetables, unprocessed grains, and fruits.  These foods will provide an abundance of nutrients, vitamins and fiber.  Supplementation with a multivitamin may be useful, but let it not replace the source.  The food will fuel your system and lead to vascular health and a robust immune system.


6.  Avoid or limit medications that can affect the immune system.

Ask your doctor if the antibiotics or other prescribed medication is necessary.  Ensure that you are taking the lowest, effective dose for the shortest time necessary.                             Photo by Anna Shvets on


We live in a pill-taking society.  More than a third of patients ages 62 to 85 take at least five prescription medications.  What the pharmaceutical industry is studying for a “desired effect” or drug indication is an effect that causes some degree of destabilization in an already taxed system.  Although, in the short run, these drugs may mitigate risks of a chronic disease, a pathway toward optimizing one’s health has the strongest benefit.

Medications can have direct or indirect effects on the immune system. Medications such as prednisone, cellcept (mycophenolate), imuran (azathioprine) can have a direct effect on the both innate and adaptive immune system, by impairing both B-cell (think antibodies) and T-cell (think killer T-cells) function.

Newer medications, known as monoclonal antibodies are directed toward T cell receptor (CD-3) and IL-2a and are associated with some degree of immunodeficiency. There may be an increased risk of activating TB in someone who has latent TB infection as well as Staph aureus infections possibly and other fungal infections.  Whether an agent (Actemra, an IL-6 inhibitor) that is effective for rheumatoid arthritis may benefit those with severe COVID-19 is the subject of one study.

With the COVID-19 pandemic, several medication concerns have been raised.  Some researchers hypothesized, that since SARS-CoV-2 enters Type 2 pneumocytes using ACE2 receptors (also found in the vascular system), medications that may lead to more expression of these receptors could cause a more severe presentation of COVID-19.  These medications include ibuprofen, a type of diabetic medication (thiazolidinedione class) and ACE inhibitors, a type of blood pressure medication.  Although more research is necessary to clarify this risk, the conditions themselves (high blood pressure, diabetes and heart disease) treated with these medications are risk factors for SEVERE COVID-19 disease.  As for now, I would not advise someone to stop a medication to treat the condition that, if not treated, could increase the risk of severe disease.  As for ibuprofen, infrequent use is probably with limited risk, but I wouldn’t recommend using this medication regularly anyways.

Action: Medications are a short-term measures that cause decompensation (ie. side effects) to get a desired effect.  When one has a diseased condition, there is a state of decompensation that often affects multiple systems.  The pathway toward disease mitigation (and health optimization) requires a healthy lifestyle.

7.  No smoking and marijuana and limit excessive alcohol intake

If you are a smoker, NOW is the best time to quit.  COVID-19 is a respiratory tract virus.  In an recent article, a greater association of death and severe disease in smokers was found in multiple studies out of Wuhan, China.  Zhang et al., found a 2 fold risk (Odds ration 2.23) of severe disease in smokers in a total of 140 patients, 58 patients had severe disease and 82 had non-severe disease.  With severe:  3.4% were current smokers and 6.9% were former smokers; With non-severe: 0% current smokers and 3.7% former smokers.  Liu et al.  found a high proportion of smokers with smoking history  (27.3%) who had a adverse outcome compared with 3% smoking history in those with improvement.

A smoker also has a three-fold higher risk of bacterial pneumonia than a non-smoker, and a two-fold higher risk of getting influenza. Tobacco paralyzes respiratory cilia (tiny hairs) movement, limiting the body’s natural ability to clear bacteria and other particles away from the lower respiratory tract.

It appears that therecommendations for alcohol 60% or stronger alcohol-based hand sanitizers were misconstrued as a way to treat the virus directly in the throat.  As the COVID-19 cases surged in Iran, 44 people died from methanol poisoning after false rumors of its benefit as a “miracle cure” in treating the disease emerged.   Keep the alcohol use for the hands, not for the system.  There is likely no completley safe level of alcohol, with increasing toxicity with dose.

The immune system is affected from alcohol beginning with the gut microbiome and the gut barrier.  As a result of this disruption, the liver becomes inflammed with increased fat deposition, or “fatty liver.”  There is an increased risk of pneumonia, by increasing the risk of aspiration, altering ciliary function (an innate protective mechanism in the lungs), and altering the function of immune cells in the respiratory tract.  The bone marrow can be injured at higher levels.

Action:  Every substance that you put in your body has to be metabolized by the body to protect it from harm.  Known toxins like smoking, alcohol and drugs impair the immune system as it impairs all aspects of a healthy body.  Abstinence from these substances will provide optimal protection from a severe COVID-19 infection.


If you already have a chronic condition, there are ways to improve the situation…

Oftentimes, multiple chronic conditions emerge in the diseased state.  Whether you have hypertension or diabetes, there are often some other emerging problems.  Many times, a healthy weight can provide protection from these conditions.  If your weight is not optimal, even beginning toward this direction can provide great benefits.

When we think of weight loss, we have to think of all of the systems in play.  In many ways, a healthy is like being in an orbit.  It is generated by largely a plant-based diet, an active lifestyle with daily exercise, and a low stress state and resilient mind.  Action towards improving one of these areas generally begins to extend to the other areas to lead to a balanced state.

Action:  Begin by adding plant-based foods in your diet.  Think of the natural source of food (rather than various stages of processing).  Developing a new routine is not always easy, but it always starts with a decision to take it one day at a time, one moment at a time, and one bite at a time.  The impact on your diseased state can be dramatic and liberating.



Reference links:

Iris Briand RDN


Eyedrops After Cataract Surgery

People who do not have someone to put drops in their eyes four times a day need help.  Task modification helped me succeed after my recent cataract surgery.  It is easy to drop and difficult to squeeze the stiff sides of a tiny 5 ml bottle.  I am glad I found the Autosqueeze Eye Drop Bottle.  The big wings are easy to hold and require only a gentle squeeze.

Before I lie down on my bed I gather two bottles of eye drops and a Kleenex tissue.  I put a pillow on my chest (not stomach) and put my sound elbow on the pillow.  This support makes my hand remain steady instead of bobbing around as I hold the bottle in the air.  To stop myself from blinking I distract myself by looking through the opening formed by my thumb and index finger instead of the bottle.  I try to get the drop in the inner corner of my eye.

When I put the cap back on I need to stop my hand from bobbing up and down and accidentally touching the tip of the bottle.  I keep my hand still by pressing my elbow firmly against the pillow.

Nurturing the Resilient Spirit: Ways to support Mental Wellness During the COVID-19 Quarantine

Summary:    The COVID-19 Pandemic is an unprecedented event that requires a rift in the societal fabric in order to stop its spread.  This forced isolation, along with the threats on financial and health security, can create pressures on those already with a history of depression and anxiety and lead to challenges in those that don’t.

Here are seven tips to nurture your mental wellness and create resilience during this uncertain time of social distancing.  Not only will these strategies help you to maintain some normalcy through these times, they just might help you excel.


The COVID-19 pandemic has been responsible for widespread upheaval.  Literally overnight, we have been asked to change our behaviors, stay at home other than essential trips out, and wait for this pandemic to pass.  Trips, social events, religious gatherings, and restaurants have been canceled or closed.  We have been asked to work from home and hold teleconferences instead of physical meetings.  For many of us, these are the very ways that we define our social and support network.

Constant reporting of new case numbers and new virus-related deaths has been both emotionally distressing and overwhelming throughout the world. When paired with shelter-in-place orders and the inevitable time spent confined at home, this unprecedented global event has placed tremendous stress on some of the population’s most vulnerable. Current events are making it harder for everyone to protect and promote mental health. Absent of key resources and often unable to receive the same support and social engagement that’s typical of their daily lives, those with diagnosed and chronic mental health issues are finding themselves in an increasingly dangerous space. The good news is that even in times like these, there are still multiple ways to create the conditions for resilient mental health.


Who’s At Greatest Risk Of Experiencing Mental Health Issues During The COVID-19 Pandemic?

Right now and for the foreseeable future, everyone is at risk of experiencing deep depression, anxiety, and stress. So much of what’s going on in the world is impossible for people to control. This sense of helplessness invariably fosters feelings of hopelessness, even in many who have formerly enjoyed consistently good mental health, general mood balance, and overall high life qualities.

However, there is also a very large number of people who are especially prone to mental distress at this time. This includes people who by choice or by circumstance were already spending significant amounts of time alone and in virtual isolation such as: elderly adults with age-related mobility issues, those with agoraphobia or fear of leaving the home, and disabled individuals who largely live in confinement. Those at greater risk for mental and emotional distress at this time additionally include people who are presently battling drug or alcohol addiction, those who have dealt with substance abuse or addiction in the past, recent divorcees, widowers, those grieving close friends, and those with a history of trauma and who may also be living with post-traumatic stress disorder.

Stressors to Mental Health During Quarantine:

A recent review article from Lancet by Samantha Brooks et al. entitled The psychological impacts of quarantine and how to reduce it discussed several risk factors that provoked a greater risk of mental health issues.  It is with hopes that identifying the triggers to depression and anxiety can help us to construct ways to mitigate these risks.

  • Longer duration quarantine (>10 days) or duration uncertain:  Associated with poorer mental health, e.g. PTSD, avoidance behavior and anger.
  • Fears of Infection.  In one review, those who were concerned tended to be parents with young children or pregnant women.
  • Frustration and Boredom.  A change in usual behavior even routine things like shopping or social networking can create a sense of boredom and isolation.
  • Inadequate Supplies Concerns. This includes the ability to get regular medical care and prescriptions.
  • Inadequate Information.  In studies, participants raised the greatest concerns when there was unclear messaging from public health authorities or a concern for lack of transparency.  Some concern with adhering with quarantine protocols was a predictor of post-traumatic stress disorder in one study.
  • Financial Factors.  Many people have been asked to modify their work routines such as working from home and, in certain cases, have even lost their jobs.  Those with a lower financial safety net, such as those with high debt to income burden, are particularly at risk.


The seven simple strategies that follow can benefit anyone who’s feeling the pressure of world and economic events, and who’s struggling to maintain mental health in the face of prolonged and mandated social distancing and social isolation.


  1. Get Outside And Get Moving


Most shelter-in-place orders that are presently being enforced are not intended to prevent people from going outside entirely. Instead, these orders have been designed to limit gatherings and activities that bring large numbers of people together. Moreover, in addition to not restricting solitary outside activities, or outside activities involving two people or fewer, many of these orders have been issued by municipal bodies that are actively encouraging people to get outside and exercise. The general understanding is that too much time spent indoors and leading a highly sedentary lifestyle is not beneficial for anyone at any time.

Pick a time each day to get outside and get moving. This can be as simple as taking a short walk around your neighborhood or going for a ride on your bike during the early morning hours or late afternoon. Although there are fewer recreational areas still open for enjoyment, there is also far less traffic on the streets. You can use this as an opportunity to better appreciate your neighborhood without the hustle and bustle of moving vehicles and busy consumers.

A short walk or bike ride will lift your spirits and give you the opportunity to re-center your thoughts. It can also make you feel more connected to the world around you. Outside exercise can even be as simple as taking your yoga mat out into the yard or onto a patio or balcony.  It might be a good time to get outside to a local park and practice the calming art of Shinrin-yoku, or forest bathing.   In addition to benefiting from conscious and structured movement, you’ll have the benefit of fresh air, sunlight, and a restored sense of normalcy.


  1. Continue Interacting With Others Via Social Media And Other Online Platforms


Now is a great time to start making use of social networking platforms. If you haven’t leveraged them before, these are great spaces for reconnecting with distant family members, childhood friends that you’ve lost contact with, and loved ones that you normally communicate with in other ways. Video chat platforms such as Skype can give you the benefit of both speaking to and seeing the people who normally fill your life, and who provide you with the social stimulation and engagement that’s absolutely essential for maintaining good mental health.


  1. Brighten Each Day With Exploration, New Learning, And Other Enriching Activities


For many, the COVID-19 pandemic has provided a very bittersweet silver-lining; massive amounts of free time. For those who are no longer working or having to physically commute long distances to their jobs, as well as those who are no longer attending in-person classes at school, this event offers countless opportunities to engage in new forms of learning and exploration. If you’ve ever wanted to make your own sourdough starter, crochet a blanket for a brand new or aging family member, teach yourself a new language, or pick up the cello, piano, or guitar, now is a great time to do it. These activities are personally enriching. More importantly, efforts to promote personal growth often give people greater hope for the future.


  1. Engage In Art Therapy


Now is also a time to break out your adult coloring books, or, better yet, start with a tabula rasa mentality and create your own work. Art is one of the most therapeutic activities that you can engage in. It’s immersive, cathartic, and relaxing. When you’re focused on drawing or coloring in the lines, choosing complementary colors, and achieving a very specific aesthetic, you cannot simultaneously dwell on all the outside problems that are beyond your realm of control. Creating art in any form can be both meditative and restorative. This is additionally a good time for art appreciation. Take advantage of online museum tours, free or discounted art or cooking classes, and other arts-related resources. Use online videos to start practicing and exploring martial arts, or start reading and writing poetry. Keeping a journal is also a great way to begin organizing your thoughts, analyzing your own emotions, and venting about your personal discomfort among other things. If you ever dreamed of writing your memoirs, the present moment is offering the perfect opportunity.

For those of you interested in using this form of expression and participating in an ongoing exhibition of art inspired by these current times, see the art that is posted on Instagram Hashtag #Cov19_art. I would like to compile the art, poetry, photography and writing into book that documents the psyche of these times and celebrates our perseverance.


  1. Unplug And Unwind


For all the resources, information, and assistance that the Internet is able to provide during this crisis, it can be just as harmful as it is beneficial. This is especially true when people spend too much time on the web, and when they spend too much time immersing themselves in activities and ideas that foster stress. While staying informed is vital, you must limit the amount of news that you’re reading. Nothing is currently so dire that it requires minute-by-minute updates. Set a special time for logging in and gathering essential information from trusted news sources. Then, set a special time for turning your phone off, logging off your computer, and turning off your TV. Whether you have diagnosed mental health issues or believe yourself to be in excellent mental health, too much information can lead to overload and can leave you feeling deflated, detached, depressed, or excessively anxious.


  1. Make Sure That You’re Getting Enough Quality Sleep


Getting poor-quality or insufficient sleep at this time is a bad idea. Not only will this undermine your efforts to maintain good mental health, but it can also lead to a flagging immune system. If you had a nighttime ritual before, try to stick to it. Moreover, don’t try to mute your emotions or lull yourself to sleep with increased indulgence in alcohol. Some areas under quarantine are reporting as much as a 40 percent increase in alcohol consumption since the institution of stay-at-home orders. Rather than promoting good sleep, alcohol actually reduces overall sleep quality, and shortens the amount of time that people are able to remain asleep.

Try reading a book or meditating before going to bed, taking a warm shower, and turning off all electronics and Internet-connected devices. If necessary, sip a warm cup of chamomile tea or a large mug of warm milk and honey. Making deep and restful sleep a top-priority is one the best things that you can do to promote physical and mental health at this time.


  1. Practice Mindfulness And Conscious Directing Of Your Thoughts


No other world event has highlighted the value and importance of mindfulness than the COVID-19 pandemic. With so much going on around you, it can be difficult to not let feelings of anxiety and panic set in. There is enough fear and stress in the present movement to exhaust anyone’s ability to mentally process current world circumstances. As such, there is no need, reason, or benefits in worrying about possible problems that might lie far ahead in the future. Practice focusing on the moment. Enjoy what you have you right now and work on fostering a mindset of gratitude. If you’re tired of being stuck alone at home, remind yourself that there are some people who have no homes to take shelter in. Give yourself permission to only worry about and deal with the problems that you’re immediately facing. Practicing mindfulness can help alleviate negative emotions about past events, while also limiting anxiety about what the future might hold.


The state of your mental health should be a key concern right now. Actively promoting good mental health and proactively protecting your general sense of well-being is critical. With greater mood balance, proper stress management techniques, and a focus on enriching and expanding yourself, you can successfully survive the mental and emotional ravages of this global pandemic, and any other unexpected life events.