Episode #359: Fever, Rapid Heart Rate, and Difficulty Swallowing in 22-Year-Old Bodybuilder (Medical Mystery)

18:13Dr. Austin Baraki:Constantly, 24-7, that's not realistic in the same way that you should ideally not have to think about, you know, every calorie that is either entering your mouth or being expended by your body. Like ideally, we can set up your daily habits, your dietary pattern, your food environment, so that you don't need that constant hypervigilance to everything. Kind of a similar concept when it applies to movement. And so these types of pieces of advice, I think are not as helpful as I think that this physician suspected it would be when he provided the quote.

18:43Dr. Jordan Feigenbaum:Yeah. I think the third surgeon is Dr. Patel. He's a spine surgeon at Northwestern Medicine. He often sees patients, quote, running into trouble with activities such as pickleball, paddle tennis, and golf. There it is. He says flexibility is key. So build in a warm-up and stretching routine. For example, with golf, add a low back and chest stretch every three holes. As an avid golfer, no. The dumbest thing I've heard. One, this presupposes that doing regular, we'll call it flexibility exercise, just some sort of guided flexibility training reduces the incidence of low back pain, which is not the case.

19:25Dr. Jordan Feigenbaum:And in fact, when people get a little overzealous with stretching, it may actually cause more symptomology. uh but on the course if i was playing with a person and every three holes they went through this this whole routine i'd be like dude what are you doing yeah like this is ridiculous they uh further say don't overload your carry-on bag uh that's not a motion that most people do every day so be mindful not to overload your luggage i personally never take a carry-on bag on planes

19:50Dr. Austin Baraki:anymore wow that's uh remarkable instead of like maybe get strong enough to wear handling a carry-on is a trivially easy task for you. Just never move anything overhead. This is like the doctor advice,

20:07Dr. Jordan Feigenbaum:like, hey, if that hurt, never do it. Ever. Ever. Whereas we come back from a different perspective. It's like, look, I want you to have, to the extent it's possible, unrestricted movement. You can do whatever you want. Unfettered access to the entire cornucopia of the movement library that so far exists in human history. I want you to be ready and be able to do all that. Fit for duty.

20:30Dr. Austin Baraki:Yeah, I want you to be 70, 80 plus years old and still able to lift your carry-on into the overhead bin with no issues and no assistance from anyone else.

20:38Dr. Jordan Feigenbaum:Have a carry-on, be able to travel, and then two, be able to lift in the overhead luggage. And then finally, and you knew this was coming, steer clear sit-ups. They may put a lot of stress on the discs of your spine. Core strengthening exercises such as planks, Pilates, swimming, and yoga, and also the elliptical machine are a lot healthier for your back in general. So we're personifying the back and back health, spine health. I mean, this is like a low back pain nocebo bingo card. You got like reductionism to just a disc injury despite most of the low back pain not being related to a disc. You've got this biomedical model where, oh, there has to be an injury to the disc, the ligament, something.

21:21Dr. Jordan Feigenbaum:And that's what caused the pain, which, again, most low back pain is specifically not. nothing about doing more movements to like prepare yourself for things that you might face, but instead just avoid more, more things. And then disc, disc, disc, disc, disc. And it's like people already, even if they're not in the fitness space and even if, or even if they've been exposed to some of our material or material like ours, you hear disc, disc injury, disc rupture, it's still kind of triggers this like, totally scary. Don't want that.

21:49Dr. Austin Baraki:Yeah.

21:50Dr. Jordan Feigenbaum:And you got all

21:51Dr. Austin Baraki:of them here. Yeah. I mean, this is, you could, you could, uh, mad lib this as Dr. Miles likes to do and, and fit in, you know, running and your knees, it could be tennis and your elbows or your shoulder. And it's like, yep, all of those sports that provide, you know, uh, deliver a particular stress, a little bit more biased towards a particular body area. People may be more susceptible to discomfort or overuse syndromes in that area. But the solution is not to just withdraw from that activity forever because it has the potential to contribute to some, you know, pain experience, but rather it's like, be mindful of the dosage, be mindful of your tolerance, your capacity.

22:27Dr. Austin Baraki:And if something crops up here are the tools that you can use to self-manage and get better through that, which is what we aim to the messaging that we aim to put out there instead of just never do this thing, because the solution there is just withdraw from all activity because all activity delivers some sort of physiologic mechanical stress to the body somewhere. And it's like, well, if that dose is off, you might get some pain. And that's certainly a good way to avoid, you know, maybe the spine surgeon's operating table for a discectomy. But it's also a great way to end up in the primary care office or the ER with a complication of cardiovascular disease because you develop metabolic syndrome from not, you know, moving for, you know, a large portion of your life out of fear.

23:08Dr. Jordan Feigenbaum:Yeah, I guess my question to you is now, Now, this is – it is theoretically answerable if the data set existed, but I've been actively looking for something like this, and there's just not a lot of data on this. But my speculation here is that if you took two groups of just twins, identical twins, and you split them right down the middle, one group of twins on one side, one group of identical twins on the other side, the one group of identical twins, they do not exercise. They don't lift weights or whatever, any of that. And the other group, well, they are resistance training. They're exercising, whatever.

23:39Dr. Jordan Feigenbaum:and you compared low back pain incidents in both groups, I actually think they'd be pretty similar. The only study that exists like this is mostly on with cardio only, where the one cardio group was doing like six hours a week of conditioning. The other group remained insufficiently active. And the number of injuries, including low back pain, was the same between both groups. And so it's like, I don't know actually that avoiding these things reduces your risk of low back pain. I think, in fact, if you're avoiding all of these things, to include exercise that would directly stress your low back in any sort of way.

24:12Dr. Jordan Feigenbaum:It actually just leaves you under-trained and maybe more vulnerable. Not to say that you need to be like, have the super robust sort of, you know, strength and muscle mass or whatever in order to prevent low back pain, but at least it prepares you for the movement more than sitting on the couch.

24:25Dr. Austin Baraki:Yeah, it may just be trade-offs and shifting risks around. Instead of developing an overuse syndrome from maybe lifting a little bit more than you're ready for too much too soon, it leaves you under-trained and underdeveloped so that turning around to grab something out of the backseat of your car is too much too soon, you know? And so you end up ultimately in a similar place.

24:41Dr. Jordan Feigenbaum:Yeah. If New York Times contacted me and they say, hey, you want to review this just for like accuracy or whatever, I'd be like, yeah, so I think this is mostly harmful, net negative, does not provide a lot of actionable advice for folks that would actually make them healthier. Instead, maybe we should do some stuff on pain education, like what it actually means to have low back pain. What it doesn't mean, it's probably not a disc injury most of the time, unless you have these certain signs. And then which case, yeah, it's okay to be concerned and be evaluated. Let's introduce maybe the biopsychosocial model.

25:06Dr. Jordan Feigenbaum:Let's talk about exercise, like what you can do, find an entry point, all sorts of stuff. But yeah, no, none of that. Let's just – you know what? Let's just talk about not lifting – not having luggage.

25:20Dr. Jordan Feigenbaum:Never BLT. Great sandwich, by the way. And yeah, if you're going to blast this out to like a million subscribers, I think you have the responsibility to do a good job.

25:30Dr. Austin Baraki:Yeah, here's an interesting kind of corollary to this. if we were to translate this into a different clinical setting, instead of talking to a spine surgeon about back pain, for example, let's say you went to an obesity medicine physician about their best tips to manage or avoid, you know, developing obesity. The analog of, I just don't carry a carry on is, yeah, so I just don't eat. I just don't eat. Yeah. That's the analog of this.

25:53Dr. Jordan Feigenbaum:The way that I avoid, the way that I avoid gaining weight is I actually don't take in any energy and it's pretty foolproof. There you go. Yeah. Just don't eat. eat less move more thanks new york times do bad yeah right this podcast is brought to you by butcher box one thing i try to stay consistent with is keeping enough protein in the house so i don't end up ordering takeout a few times a week that sounds simple but between work and everything else the grocery store trip is usually the first thing that gets cut butcher box fixed that for me they deliver grass-fed beef organic chicken wild-caught seafood and more all sourced to the standards they are transparent about every box is customizable so you pick the cuts and the proteins that fit how you actually cook and what you're actually going to eat.

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30:34Dr. Jordan Feigenbaum:Get free shipping on your order and 365-day returns. Now available in Canada and the UK too. That's quince.com slash BBM. Hey, quick interruption. You've been lifting for years. You're consistent. You don't miss sessions, but you still spend a weirdly large amount of time wondering if you're doing the right thing. Is this enough volume? Should I be pushing harder? Is my form falling apart? And how would I even know if it's wrong? Most of you don't need a coach for that. You can run the same program for another few weeks and measure your results. That's free, and you can definitely do that. But here's where it gets harder.

31:04Dr. Jordan Feigenbaum:Plenty of coaches can write a decent program. Plenty can spot an error on video or pull your training back around an injury. To me, that's table stakes. Now, this morning, I watched a deadlift where the guy's back rounded slightly off the floor. You could call that an error and cue it out of him, or at least try. But what's actually happening is he's buying a better start position and paying for it at lockout. And at his leverages right now, that's the correct tradeoff because he's got a meet coming up. Now, if he didn't, maybe that changes the calculus, and maybe we change it to try to improve efficiency long term.

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32:00Dr. Jordan Feigenbaum:Now, through August 20th, you can get 10 % off all of our one-on-one coaching using code SUMMERFIT. That's S-U-M-M-E-R-F-I-T at barbellmedicine.com slash coaching. and you can use FSA or HSA funds as well. If you're on the fence, send us an email, support at barbellmedicine.com, and we'll talk to you about it and see if we're a good fit. All right, let's get back to the podcast. All right, so we're going to get into the mystery case now. Before we do, again, just to remind folks, it's a real case. Any jokes, any humor is purely for the entertainment portion of the edutainment, sort of the word we made up.

32:33Dr. Jordan Feigenbaum:Also, I'll be playing the role of patient. So this is a little twist. Dr. Baraki is going to have to treat me like a patient. So maybe more respect than normal. And I also do have to predict whether or not you're going to get this. And get this, I'm defining this particular type with not only the diagnosis, but why it happened. So a little house type thing. So I'm going to say that you – no, you're not going to get it. Okay. Yeah. All right. So let's get into this. So Dr. Baraki is on call in the hospital, in his hospital, and he gets a chart checking as he normally does, particularly in the emergency room.

33:13Dr. Jordan Feigenbaum:He wants to see, look, I got somebody coming to me. Like, what's going on? I have to go to the ED. And he sees that there is a patient who's been in the emergency room for a couple of hours. It's a 22-year-old male, the four-day history of fevers, difficulty swallowing, and throat pain that's been associated with shortness of breath. And he thinks, man, I'm about to get a page from this. And serendipitously, boom, pager goes off. It's the emergency department. They want Dr. Baraki to come down and see this patient. I am playing the role of the patient. My name is Tork Lewith, and my friends call me T.

33:45So Dr. Baraki, take it away.

33:48Dr. Austin Baraki:All right, T. Did you pull your name from like a Key and Peele sketch? This sounds like one of those kinds of names.

33:52Dr. Jordan Feigenbaum:Exactly. I am a subscriber to the fandom website for Key and Peele's East vs. West Challenge. That's correct.

33:58Dr. Austin Baraki:Perfect. All right, T. Well, tell me in the best way you can, what's going on today and what brought you in?

34:04Dr. Jordan Feigenbaum:Well, before we start, are you Austin Barbell Medicine? Yes. Oh my God. I watch all of your stuff. I send your meme all over the place. I'm so happy that you're my doctor because you get it. You get it. I'm a lifter. You know, I'm a lifter, bodybuilder. So not really your cup of tea, but I have been competing in bodybuilding for a few years. Yeah. I don't know. It's really weird. like four days ago, right before a workout, I had my normal pre-workout meal. So, you know, protein shake, uh, and some oatmeal. And I went to the work, went to a workout, uh, it was legs. So I did some squats, some Romanian deadlifts, uh, some hamstring curls and everything was fine.

34:41Dr. Jordan Feigenbaum:Lifted, lifted normally, came home, ate, ate dinner, normal dinner. Um, but that night it was, it was kind of weird. Yeah. I started feeling like not, not so good. Um, I thought, man, kind of maybe have a fever, but I don't have a thermometer. So I actually had to like, you know, Amazon prime that to myself. And yeah, it said 101, which, which I think is high. Um, and then I noticed when I tried to eat again later, cause you know, six meals a day, trying to keep that metabolic furnace going. Yeah. I hear you.

35:07Dr. Austin Baraki:Yeah. Uh, it was tough.

35:09Dr. Jordan Feigenbaum:Like I couldn't really, I couldn't really eat. Like I, it was hard for me to, to chew and even harder to swallow because it was pain, like painful. And so then I thought, Oh, I could just do like another protein shake, Like, you know, I got to get my protein in. But yeah, it was even hard with like to drink like the protein shake, which is which was just liquid. So I didn't you know, I didn't feel like any food was getting stuck or whatever. But I thought, man, this is this is weird. So I just went to bed. But that was four days ago. And every day it's kind of gotten a little worse. Like it's just hard for me to eat because of because the pain I can't really swallow.

35:41Dr. Jordan Feigenbaum:Yeah, I don't know. So so four days now I've had this fever. It's worse at night for sure. and I can't really eat. And I'm really worried that I'm going to lose all my gains because I can't eat. So that's why I came here.

35:54Dr. Austin Baraki:Okay, great. Glad you came in. This does sound like something that needs some medical attention. And you're doing some great acting so far. As an aside, is it fair for me to assume that this patient would be as fluent in their speech as you are right now? Would they be able to speak in complete sentences like this? Or would the symptoms that they're having, the throat pain, difficulty, swallowing things, would that make it so they're not able to speak as clearly, fluently, and breathe comfortably while they're talking? I'm breaking the breaking character here.

36:23Dr. Jordan Feigenbaum:There's no report that the patient had any difficulty speaking or giving a history. So I'll just assume that he can speak normally.

36:29Dr. Austin Baraki:Okay. So that's a first reassuring thing in terms of like, how much of an emergency am I dealing with here? Do I have imminent concerns about this patient's like airway and complications from some sort of infection or something like that in the throat? So moving on. So yeah, I'm glad you came in and important that you notice these symptoms like the fever and difficulty swallowing and things like that. Have you had any vomiting during this period?

36:52Dr. Jordan Feigenbaum:No, I haven't thrown up. I actually really haven't been sick to my stomach at all, which I think is because I haven't really been able to eat anything. So I'm just really hungry, to be honest, but I'm afraid to eat because it hurts.

37:03Dr. Austin Baraki:That's fair. But you have been getting some fluids down, it sounds like, at least shakes, or have you stopped drinking any fluids as well?

37:09Dr. Jordan Feigenbaum:Yeah. Like this morning, I tried to have a little bit of water and it was actually pretty painful to swallow. Like I thought maybe I had like strep throat or something like that with the fever and not really being able to swallow comfortably. So a little bit of water, but nothing, nothing with any calories in it.

37:22Dr. Austin Baraki:So, okay. And before this four days ago, you were, sounds like you were feeling great. Like your normal self never didn't have any signs or issues at that time. Dude, I've been crushing the gym lately. It's been so awesome, but yeah, it's just really weird. Like, I don't know, man. I, yeah. Ever had anything like this before?

37:37Dr. Jordan Feigenbaum:Never. This is the first time.

37:39Dr. Austin Baraki:Okay. And any symptoms anywhere else in your body that you've noticed like pain in your chest or rashes or anything else yeah it is interesting that you

37:47Dr. Jordan Feigenbaum:mentioned that i have like i didn't want to mention because i i didn't really want to worry about it i thought if i didn't think about it i wouldn't worry about it but like i have been having a little bit of chest pain um mostly like if i do happen to eat something or drink something if i get it down it does seem to hurt like uh like right here like right in the middle of my chest yeah um but yeah other other than that it seems to go away a few hours after i try to eat something but yeah, I've had, had some of that too.

38:13Dr. Austin Baraki:Okay. And then any problems? So I mentioned something like any rashes or are you having any problems with urinating, for example? No, I've been going to the bathroom just fine.

38:21Dr. Jordan Feigenbaum:Although probably less, I can think now that I think about it, cause I, you know, I usually, I'm a two gallons a day guy and just, I haven't really been able to do that. So like, I don't know how I probably go in the bathroom less, but no, no issues with that

38:32Dr. Austin Baraki:other than that. Okay. And then last couple of questions I saw from the ER board that, uh, you were having some shortness of breath. Not going to experience back to say?

38:41Dr. Jordan Feigenbaum:Yeah, it's mostly when I'm trying to like eat or drink. Like, I don't know that I'm like choking. Like that's, it's not like that because I don't feel like it's getting stuck per se, but like, it's just not going down how it should. And I feel like right afterwards, yeah, I'm a little short of breath, but otherwise like sitting here, I feel fine.

38:58Dr. Austin Baraki:Okay.

38:58Dr. Jordan Feigenbaum:Any cough? No cough. No. Okay. Gotcha.

39:03Dr. Austin Baraki:All right. Could you, I'll probably come back with some other questions relating to what's going on right now, but I'm curious if you have any other medical problems, anything else that you've ever been told you have, any other things you see doctors for? No, I don't take any medications.

39:15Dr. Jordan Feigenbaum:I mean, I haven't seen my doctor since like I was a kid, but you know, I don't take any medications. I don't have any medical diagnosis that I know about. And I called my mom. I was like, hey, have you ever like had this? She said, no, you need to go to the ER. So ultimately kind of went to the emergency room.

39:30Dr. Austin Baraki:Yeah, probably pretty good advice right now. Okay. And aside from the medicines, what about supplements?

39:35Dr. Jordan Feigenbaum:I mean, yeah, a little bit. I listen to your guys' podcasts. I'm a huge fan. Love your guys' stuff. Now, you probably won't like this because I've been taking a multivitamin for some years, but it's the same multivitamin and whatever. And then, yeah, I take pre-workout. But again, big fan. So it's third-party tested. So I'm pretty clear on that. But yeah, pre-workout, for every workout. I don't take it on my off days when I just do some walks because you've got to stay lean. You've got to get ready for this next bodybuilding show.

40:02Dr. Austin Baraki:Okay, very good. And then my last question, at least right now, before I'll break character and give some thoughts, is tell me about your sexual practices.

40:14Dr. Jordan Feigenbaum:Oh, yeah. Like I broke up with my girlfriend a few months ago. She just didn't get it. You know, like I was in the gym twice a day, and she said I didn't have like time to spend with her or whatever. So, yeah, not really active, I guess, for the last few months. But, yeah, no problems down there. You know what I'm saying? Never had any sexually transmitted infections. Not that I know of, no.

40:34Dr. Austin Baraki:Okay. All right. Very good. So we'll, I guess, pause here if that's acceptable. Is that the idea that you had for this kind of podcast? Yeah. All right. So we have this 22-year-old kid who is seemingly previously completely healthy without any known medical issues, coming in with four days of fever and this syndrome that is really centered around the throat relating to swallowing with some other associated symptoms that so far I'm interpreting as mostly kind of consequences of that initial issue. So for example, he points out that the shortness of breath that he's experiencing is really just associated with when he's trying to get stuff down.

41:07Dr. Austin Baraki:The chest pain is just associated with when he's trying to get stuff down. And so I'm not interpreting those as like separate symptoms of shortness of breath or chest pain like we have maybe in some of our other mystery cases. It is really quite centered around the mouth throat type area and associated with a fever, which is evidence of inflammation. And so I think that, you know, at the moment that leaves me in a position where I'm kind of comfortable applying a label to this patient, like a working diagnosis of acute pharyngitis. Now, acute pharyngitis is not what I would call like a final diagnosis or a terminal diagnosis.

41:41Dr. Austin Baraki:It's a description of a syndrome. You can get pharyngitis from all sorts of issues. They can be due to infections, lots of different viral infections and bacterial infections. He even mentioned one himself, like strep throat. But more often, this is due to all sorts of different viruses. Mononucleosis, all sorts of things can be associated with pharyngitis and throat pain. And again, there's a long list of bacterial infections. And part of the reason I asked about sexual history and practices, for example, is that gonorrhea can cause a pharyngitis. And that's also why I asked about urinary symptoms.

42:11Dr. Austin Baraki:So there are some reasons behind asking those questions. This is a demographic where that would be not too unusual of a presentation of gonococcal pharyngitis, for example. But it seems to be relatively low risk, even though I didn't go into as much detail on sexual history on this podcast as I would in person with a patient like this, just for the sake of our audience. And since I don't think that's where you were leading me. But aside from infections, there are other things that can present with pharyngitis, you know, this kind of inflammatory syndrome centered in the throat. There are cancers, lymphomas and leukemias can present that way.

42:45Dr. Austin Baraki:There's all sorts of autoimmune conditions that can do this. The most characteristic is called Stills disease, one of my favorite and most interesting kind of diagnoses that I've caught a couple times over the years. This can also show up with certain forms of like drug-induced hypersensitivity syndromes can present this way. And so that's kind of why I asked about supplements as well. If there's some sort of a, you know, drug contaminant or something like that, that can manifest in this way. And then thyroid disorders can be in the neck, but kind of patients can interpret it as being in their throat.

43:13Dr. Austin Baraki:So thyroiditis and things like that, which we would look for some signs of when we move forward a little bit. So I think that first and foremost, with these types of cases, acute pharyngitis for a couple days, fevers, difficulty swallowing, the first thing we need to think about is, is there an infection in the throat? And more importantly, is there an infection that requires kind of more urgent evaluation? So does this patient have like an abscess, like a peritonsillar abscess or some pocket of pus or something that can be potentially threatening to their airway, their ability to breathe and speak?

43:42Dr. Austin Baraki:That's why I was paying attention to those things. Once people are no longer able to swallow their own saliva, for example, and they start drooling, it's like, okay, this is getting real bad. And so a lot of these patients, you know, will certainly move on and get some vital signs and in a physical exam, take a look in the throat, feel around the neck. But a lot of times patients like this end up, in addition to getting some initial basic labs, if they're in an emergency department setting, they might get a contrasted CT of the neck if there is sufficient concern to look for things like that. And it's not just a run-of-the-mill presentation of something like strep throat.

44:13Dr. Austin Baraki:A lot of the times these are just viral, you know, sore throats, but this patient has persistent fevers for a few days, he does not have a cough, and all of those are things that can fit with strep throat, for example. So that's, you know, among the more likely diagnoses that I'd be thinking about first, while also knowing that this is a mystery case, and it's probably something a little bit more interesting, but trying to make it as realistic to what would happen in real life. So that's kind of my initial thoughts here. So if it's okay, I'd like to move on. And if you are able to, you know, pull data and give me a sense of what are your vital signs, patient, and tell me about your physical examination of your throat and neck and things like that.

44:48Dr. Jordan Feigenbaum:Sure, yeah. So let's give you some data here. So vital signs are significant for an elevated heart rate to 110 beats per minute. His fever in the emergency room is 101 degrees Fahrenheit. Otherwise, normal. Blood pressure is normal. O2 sats are normal on room air. As far as the physical exam, the patient does appear non-toxic, well-nourished, and he is alert and oriented. His head and neck exam, no lymph node swelling, no thrush, no focal deficits. The actual pharynx looks pretty normal. His cardiopulmonary exam is also normal. He's moving all of his extremities well. No rashes or lesions noticed on a skin exam.

45:26Dr. Jordan Feigenbaum:For labs, he did have a chemistry run sent in the lab, which is normal except for his creatinine was 1.5. They also did a D-dimer, which was 595 nanograms per milliliter. Austin, hey, what's a D-dimer?

45:40Dr. Austin Baraki:Sure. So a D-dimer is a kind of a breakdown product of blood clots. It is involved in the coagulation and kind of a cascade at the tail end once things start breaking down. So this is kind of a crude marker of like, there is some kind of clotting happening somewhere in this patient's body. And I imagine, you know, I don't think that I would have sent this in this patient necessarily, but I wonder if they heard that he had chest pain and shortness of breath and sent a D-dimer, which is actually, I would say, a little bit unexpectedly elevated in this patient. I would expect it to be lower than it is.

46:13Dr. Austin Baraki:So now the question becomes, what do we do with this thing, which is a common conundrum that people end up in when they order this kind of a test. I will also say it is interesting. It's reassuring. I was expecting, you know, it was plausible that we might find some swollen lymph nodes in this patient's neck, or if we found thrush, that would definitely open up a significant concerns about this patient's immune status because he has no other reasons to have oral thrush. The fact that his throat looks visually completely normal is not shocking, but I was expecting to see something there given the severity of his symptoms.

46:45Dr. Austin Baraki:And so if he's telling me he's having a lot of pain with swallowing and he's having this chest pain associated with swallowing, it's making me wonder, is this not so much a case of pharyngitis, but does he have potentially esophagitis? So is there something going on a little bit lower that I can't see just looking in his mouth? And esophagitis has its own list of possibilities. Acute esophagitis is a little bit more unusual. It can be due to certain infections like candida and viral infections and things like that. But it can also be due to just like irritants to the esophageal kind of mucosa of the surface.

47:15Dr. Austin Baraki:If people have swallowed something, whether it be foreign bodies or somebody tries to self-harm or accidentally drink some bleach or something like that, that can irritate the esophagus and cause a lot of pain with swallowing and pain in the chest after eating. So now I'm kind of entertaining. Is it pharyngitis? Is it esophagitis? Am I completely off base? And I need to start looking completely someplace else in the patient's neck area to try to find where is the actual problem here?

47:37Dr. Jordan Feigenbaum:Yeah. Other labs that were ran, infectious panels. So he's negative for HIV, for cytomegalovirus, CMV, and negative for herpes simplex virus, HS. Yes. Some imaging was also performed that you have access to. He had an EKG performed that just showed sinus tachycardia, but otherwise normal complexes. And he had a CT chest done, I guess, because you run that D-dimer, you got to get a CT chest. Yeah, that's what happened. Showed no pulmonary embolism, but there was some circumferential distal esophageal thickening. So we'll pause there. Austin, do you have any further thoughts on this particular patient?

48:12Dr. Austin Baraki:Yeah, still a bit puzzling. If I go through these labs, his creatinine of 1.5 could be because he's not eating or drinking very much for a couple days, or could be if he is well muscled, the test for that would be give him a little fluids, especially since his heart rate's up, which could also be due to the fever, but see if it gets better. But I'm not terribly concerned about that right now. The fact that he's HIV negative is helpful because again, esophagitis, infectious esophagitis and things like that are definitely something we see more often in patients with compromised immune systems. Not much to say about the EKG, not terribly surprising.

48:45Dr. Austin Baraki:And so now we have this thickening of his lower esophagus. The question is, A, what could that be? And B, does that fully explain his presenting symptoms? I would say that it could explain some of the symptoms. So what kind of things can happen in the esophagus that results in this kind of visualized thickening on a CT scan? You can have kind of long-term thickening if there's some sort of like pre-cancerous, cancerous type process developing, which in general, we don't really see in 22-year-olds. It's something that can usually takes quite a bit longer to develop. There are, you know, some infections that can happen in the esophagus that I alluded to earlier, not so much something that I would expect to see just on a CT scan or just in the lower esophagus.

49:31Dr. Austin Baraki:And there are some kind of autoimmune inflammatory things that can lead to esophageal thickening, but those also don't tend to show up so abruptly like this patient's situation did. The last thing is that I wouldn't expect something in the distal or the lower part of the esophagus that's right before it enters the stomach to cause tons of throat pain or pain with swallowing. Usually that might cause some feeling of food getting stuck in the chest as it's trying to move its way down the esophagus and get in there. And so I'm a bit puzzled as far as how related this is. it can explain some of the symptoms, but I'm still reaching a little bit to try to figure out why is he having a fever?

50:07Dr. Austin Baraki:Why does his throat hurt so bad? And so the next things that I'd be thinking about here is do I need actually dedicated neck imaging because a chest CT doesn't actually get a totally sufficient assessment of the soft tissues of the neck? And do we need to ask a specialist to send a camera down whether to look in his throat and or in down his esophagus to see what we might find down there. I think those are probably the next couple steps. This patient would, at this point, probably get admitted to the hospital to undergo some of these things, and because he was actively fevering when he came in, and try to figure out what's going on here.

50:42Dr. Jordan Feigenbaum:Yeah. So they did send a camera down my throat, I guess. This is an esophageal endoscopy, and that showed severe punctate ulcerations, linear ulcers, and scattered linear gastric erosions. A biopsy was sent that showed severe chronic inflammation of the squamous mucosa with basal cell hyperplasia and lots of eosinophils. You can also talk to the patient again if you prefer because at this point, I'm going to have to ask you for a diagnosis and a cause. So that's the information that you have unless you want to talk to the patient again. Okay.

51:20Dr. Austin Baraki:Well, at this point, I'm curious, of course, always going to be how the patient's feeling and what his trajectory was like if he's been admitted to the hospital. Has he had persistent fevers this whole time or what else could be going on?

51:33Dr. Jordan Feigenbaum:Well, nursing staff reports. So they started – because he hadn't been able to drink or anything, you started him on some IV hydration. And the fevers, the tachycardia, the elevated creatinine all resolved with the IV hydration. But yeah, what's up with this endoscopy report, you know?

51:52Dr. Austin Baraki:Sure. Yeah, so that endoscopic description is something that does raise concern for an inflammatory esophagitis. And so that again, kind of like when I said pharyngitis, is not a terminal diagnosis, but rather kind of a working diagnosis. And a lot of different things can cause inflammation in the esophagus to include infections and autoimmune conditions being the top two things that I would think about. This did not have the classic appearance that I would expect from something like candidal esophagitis, which is something that is kind of like having thrush, except all the way down your esophagus.

52:26Dr. Austin Baraki:Herpes viral esophagitis can cause punctate ulcerations. CMV esophagitis can cause linear erosions in the esophagus. Severe reflux can cause linear kind of erosions and ulcerations in the esophagus. And so I'd be curious if this patient has maybe a history of like reflux type symptoms that he's never thought much of or didn't tell us about, or if anything else, if this rings a bell, if we're talking about heartburn, or I always go back and grill patients in this demographic about, are you sure you're not taking any other new or different supplements, or have you been trying anything new or different lately to see if anything else rings a bell or comes to mind for them?

53:03Dr. Jordan Feigenbaum:Man, Austin Barbell Medicine, that's crazy. You know, you mentioned that. I feel like an idiot. It's like, I've never had heartburn, at least what I think it feels like, but I'm telling you, man, like, you know, I've been taking this pre-workout and it gets third party tested. So it's like really good, you know, so I listen to your podcast, but like, after I took it four days ago, it did, it felt like, I don't know. Like I felt like my chest was on fire. I don't know. Like I've never felt anything like that. But, you know, I just, I got to get my workout. I didn't want to go do not train. You know, so like, so whatever.

53:35Dr. Jordan Feigenbaum:And it kind of went away for when I was working out, but then yeah, like right afterwards, it was kind of hard to eat, but I still got it down and it just kept getting worse. and I had the fever and well, you know, the rest of the story. But yeah, that's, that's the only thing I can tell you, man. Sure.

53:48Dr. Austin Baraki:Okay. So I have a couple, you know, kind of, I guess, final, final thoughts here. One is, I think in the endoscopic report, you mentioned lots of eosinophils. That is a very unusual and unexpected finding for most forms of kind of inflammation in the body. There is a diagnosis called eosinophilic esophagitis. It is most often, you know, thought of as an autoimmune type condition where these particular types of immune cells are activated and cause inflammation and esophageal symptoms. Again, they don't tend to present this abruptly in most patients with like fevers and all of a sudden developing the syndrome.

54:22Dr. Austin Baraki:It's more often people having what I would call more like subacute to chronic kind of symptoms associated with eating, swallowing. Sometimes this can lead to the development of things like strictures and stenosis in the esophagus that do lead to food getting stuck and things like that. So I'm curious about the potential diagnosis of eosinophilic esophagitis in this patient. But the other thing is we do have this unusually abrupt onset, and we have this temporal association with this patient's new supplement use. And so could it be either that there is some ingredient in the supplement that can potentially trigger an eosinophilic response, an eosinophilic esophagitis, or does the pre-workout product itself contain some sort of kind of mucosal irritant, as I mentioned earlier, the most extreme examples, like when people drink bleach and end up with severe caustic esophageal injuries, is there something in this product that is leading to this kind of like irritant, inflammatory kind of mucosal response?

55:19Dr. Austin Baraki:For him to have fevers for days afterwards, unless he's been continuing to use this, even in that situation, is like a little surprising to me. But I think that it's hard to ignore the temporal relationship there between this new exposure and this syndrome. So I'd be probably doing two things. I'd be asking for him to provide the information about this product that he's been using and then start aggressively searching all of the ingredients and what is known or reported out there about it. I would also probably be looking for, are there any kind of case reports of this kind of thing happening before?

55:54Dr. Austin Baraki:Maybe I'll come across the very case report that you are pulling this from. And then definitely be talking to the pathologist who kind of reported the results of the endoscopy, talking to the gastroenterologist who performed it about their thoughts, particularly because like a gastroenterologist is somebody who would see a lot more cases of eosinophilic esophagitis than I would. I'm aware of it and I see a handful of cases a year, but I'm not an expert in that condition, particularly with this type of presentation. So that's kind of where I am right now.

56:21Dr. Jordan Feigenbaum:Yeah, I'll give you one more shot as the cause and such because, you know, yeah, You do get to talk to the gastroenterologist and to the pathologist and get a little report here. They're calling this an esophageal ulcer. They're like, the esinophils are kind of funky, but this looks like, smells like an esophageal ulcer. We don't know why, but that's what it looks like. We're calling it an esophageal ulcer. It's up to you, Doc. Figure out why does this patient have an esophageal ulcer out of a 22-year-old? What the heck?

56:53Dr. Austin Baraki:yeah so uh this is where i'm probably at the you know i'm getting stretched at the limits of my typical experience so an acute febrile syndrome with a presumed acute esophageal ulcer you know this is something that i would be starting to do some searching and talking to some consultants and and some some friends to seek out why so abrupt why febrile and uh yeah that's i think i'm kind tapped out at this point. So yeah, what you got?

57:19Dr. Jordan Feigenbaum:All right. So this particular patient had an esophageal ulcer. That was the diagnosis. And the clinical team who wrote up this report concluded that it was from dry scooping his pre-workout. Had you asked the patient how he was taking the pre-workout, he would say that he was dry scooping it. Effectively, he had ran out, patient reported, would have reported that he ran out of the solvent that he was previously using to dissolve his pre-workout, and he was just dry-scooping it for weeks leading up to this particular instance where he had some – felt like heartburn to him, and then subsequently he had a fever and everything else and had some difficulties eating and drinking.

57:59Dr. Jordan Feigenbaum:He was started on a proton pump inhibitor, a PPI, and his diet was advanced while he was in the hospital. The patient was able to tolerate a normal diet before discharge. He was continued on the PPI for eight weeks. At four weeks, they did another endoscopy on this patient, and it was basically normal at that time. So they're calling it an esophageal ulcer, secondary to dry scooping his pre-workout supplement.

58:23Dr. Austin Baraki:Well, that is very interesting. It is puzzling in a bunch of ways. If he's doing this for weeks and then presenting that abruptly is interesting. That presumably is when the ulceration like reached some sort of a critical threshold. Persistent fevers, though, is a little surprising in that context, if there was never any sort of infectious complication that was identified. A lot of good teaching points from this, I would say, even for like general medical trainees and students, you know, about the differential diagnosis of both pharyngitis and esophagitis in a patient like this, as well as autoimmune, I suppose, getting into eosinophilic esophagitis as well.

59:06Dr. Austin Baraki:dry scooping your supplements leading to ulceration. That is wild. So nice find. Good case, I suppose. When it comes to patients who use certain types of drugs, I'm certainly in the habit of always asking them how they administer them, right? Because different drugs administered by different routes, whether inhalation or injection or anything like that can lead to dramatically different complications. The route of administration of a pre-workout supplement is, although I guess that's the same route, but just like the method is not something I've ever thought to ask specifically. Are you raw dog in the supplement as they say, or are you actually dissolving it?

59:45Dr. Austin Baraki:Maybe I'll have to think about asking that when that becomes relevant in the

59:49Dr. Jordan Feigenbaum:future. Yeah, there were a few other case reports I found on some strange ways, not only just dry scooping, but also other ways that people have used a pre-workout supplement. Some people have snorted it and had, you know, nasopharynx, you know, inflammation and other issues related to that makes sense uh i also thought like what if you ever made like a like a pre-workout suppository like and you'd have a whole nother potential list of complications or like a like a what if you made like a like a dip kind of thing you know like buckle absorption yeah you could and there are

1:00:18Dr. Austin Baraki:mechanistic reasons why you could promote all of these things to say why they're so much better because they're bypassing enteric or enteropathic circulation and all sorts of things like that and and people who don't know any different would be like sure that sounds awesome let's do it yeah

1:00:31Dr. Jordan Feigenbaum:Yeah, so let's talk about esophageal ulcers and dry scooping. So it's pretty interesting stuff here. And I think, I don't know, I did think this case, like obviously this person was probably terrified and reasonably, you know, rightfully so. But I kind of found this when I'm like, bro, you were dry scooping and had – anyway. Okay, so an esophageal ulcer is a, you know, discrete break in the tissue lining the esophagus. And we say mucosa is just the cells that are lining the organ in this case, the esophagus. The main cause, most common cause is GERD, so gastroesophageal reflux disorder, usually from the lower esophageal sphincter.

1:01:07Dr. Jordan Feigenbaum:That's this like little muscle that separates the esophagus from the stomach. It's either weak or it's inappropriately relaxing. And so you get this sort of caustic, acidic contents of your stomach, the gastric juice, interacting with the mucosa, the tissue of the esophagus. and that can lead to an esophageal ulcer. So you get an injury that way. The second most common cause is drugs. Most commonly would be like a non-steroidal anti-inflammatory drug, something like that, ibuprofen or antibiotics, specifically like doxycycline. That's pretty common. But the GERD causing this like 60 % to 80 % of cases, drugs about 20 % of cases, lots of different drugs.

1:01:49Dr. Jordan Feigenbaum:Almost any drug could theoretically cause this. But as far as supplements go, There have been documented case reports of like L-arginine and caffeine causing this stuff, particularly in powder form. The ingredients of this particular individual's pre-workout included malic acid, which also has been associated with acid-induced injury. The pH of malic acid is 2 to 3. Citric acid, pure citric acid has a pH of 1.5. It's very, very acidic, right? Water 7 is neutral. Citric acid, 1.5. That's very, very acidic. Tartaric acid was also in the supplement. That is a pH of 1.6. Interestingly, there was a study that was conducted with the purpose of analyzing the pH, so how acidic the thing was, of energy drinks and pre-workout beverages.

1:02:33Dr. Jordan Feigenbaum:Now, of the 20-something pre-workout powders that they analyzed, the way that they did the studies, they mixed them with water, which would make these things less acidic because water is neutral. pH is 7. And the pH ranged from 3 to 4 when mixed with water.

1:02:50Dr. Austin Baraki:Yeah. Yeah.

1:02:51Dr. Jordan Feigenbaum:So imagine if it was not mixed with water.

1:02:55Dr. Austin Baraki:Sure.

1:02:56Dr. Jordan Feigenbaum:likely lower with being dry scoop and the transit is likely slower because now instead of it being the smooth sort of thing it you know tends to go your esophagus is you know we call it peristaltic contraction which is basically like a rhythmic beating of the esophageal muscle to move stuff from top to bottom get into your stomach well powder is going to flow a lot more slowly and expose that mucosa that tissue a little bit longer compared to something mixed with with water. And so probably direct caustic exposure damaging the tissue here. I suspect that his lower esophageal sphincter was intact and working fine.

1:03:30Dr. Jordan Feigenbaum:He just, you know, had been dry scooping this stuff for a while. And yeah, after a while caused this ulcer that led to these sort of symptoms.

1:03:37Dr. Austin Baraki:Yeah, I had mentioned a couple times the idea of a caustic, you know, irritation. Those are typically like more basic compounds. This is like, it definitely seems on the more acidic side. And And it makes me think of like if you were to take a drug that is normally known to cause like pill esophagitis and you try to crush it and you'd end up with like powdery form of the pill, it'd probably, you know, do the same thing. So this is effectively that. Yeah, super interesting.

1:04:00Dr. Jordan Feigenbaum:Infections can also cause this, like you'd mentioned, not only herpes, HSV, CMV, HIV, a bunch of other types of infections as well. You can get radiation, you know, that could cause esophageal ulcer, various autoimmune diseases, various cancers, genetic conditions. The lists are long. But most commonly, drugs and GERD. Symptoms, heartburn, chest pain, usually not related, so non-cardiac sort of chest pain, although there was a case report from dry scooping of an ST elevation myocardial infarction, a STEMI, so a heart attack. A healthy 25-year-old man from dry scooping.

1:04:34Dr. Austin Baraki:I'd be more concerned about what ingredients were in that.

1:04:36Dr. Jordan Feigenbaum:Yeah, exactly. But, yes, you can get this heart pain, this non-cardiac chest pain. You can get difficulty swallowing, so that's called dysphagia. You can get pain with swallowing. We call that odynophagia. You can get nausea, vomiting, lack of appetite. Usually when people have problems swallowing or it's painful, their appetite tends to go down. It's like a learned sort of response. You can get bleeding if the ulcer is actually bleeding. So hematemesis, if you're throwing it up. Melana. So if it ends up in the stool and it's not a – we call it a brisk bleed. So if it's relatively slow, it can be dark in the stool.

1:05:08Dr. Jordan Feigenbaum:But if it's fast and a lot of blood is coming out, it can be bright red. We call that hematochesia. So you guys are learning a lot of medical terminology here. As far as evaluation goes, yeah, the upper GI endoscopy for both diagnosis and treatment can be very useful here. Or people can do an esophagram or barium swallow, for example. As far as treatment goes, if it's bleeding, the main thing, you got to stop the bleeding, protect the airway. Those are the like two, you know, most important things are off the bat. If it is gastroesophageal reflux disease or GERD, a proton pump inhibitor or other medications can be useful.

1:05:39if it's an infection you got to treat the uh the the thing appropriately whether it's an

1:05:44Dr. Jordan Feigenbaum:antiviral or antibiotic or fungus antifungal although then you have other questions how did this thing end up there yep uh if it's a caustic sort of cause first thing you got to remove the caustic agent secure the airway you got to make the patient npo so nothing by mouth due to risk of perforation particularly if it's actively bleeding and you can advance the diet it's tolerated there's a whole what's the scale it's like a zagram or something like it's a predictive model of how severe the ulcer is. Anyway, that's well beyond my training, but I did read that. I go, cool. Learned something else today.

1:06:16Dr. Jordan Feigenbaum:As far as complications that we would be worried about here is, yep, bleeding, perforation, if it goes untreated, stricture, which is a narrowing of the esophagus. So that sometimes requires a stent or surgery to correct. So dry scooping, you're like, all right, Jordan, nobody dry scoops, dude. Like, what are you talking about? One, It's super popular on TikTok and social media right now. A recent study out of Canada analyzed nearly 3 ,000 young Canadians who worked out and used a pre-workout. 17 % reported dry scooping in the past year. It's a big pearl here. It's a fair amount. Yeah. Big take home.

1:06:52Dr. Jordan Feigenbaum:Don't dry scoop. Just add some water. Just add some water. Not difficult. Yeah, or like don't take a pre-workout. Like whatever. Like we obviously make a pre-workout. I think that if you're trying to get the most out of your training, both performance-wise in a session and get the most gains from every session, sure. A multi-ingredient pre-workout supplement, which is – use the acronym MIPS, could be useful. Just don't dry scoop it. And make sure there's no, like, bleach in it also.

1:07:19Dr. Austin Baraki:Yeah, generally would avoid highly caustic agents. But so, yeah, I suppose this practice involves just trying to swallow dry powder completely, which is, I don't know. I can't believe people actually do this, especially at that rate. I will take creatine oftentimes in powder form, but then it is getting washed down with a substantial amount of water afterwards rather than trying to dissolve it in a glass first. But just straight dry powder trying to like choke that down seems, I don't know, very unpleasant to me.

1:07:53Dr. Jordan Feigenbaum:Yeah, I would be very curious of like the transit time of like pure powder. So no liquid at all. Also like choking hazard potentially versus like you did the scoop and then like a small little bit of water, right? Okay, what's the pH there? What's the transit time? And then like, okay, per manufacturer's instructions, like 12 to 16 ounces of water, mix it up, you know, whatever. Then what is the pH and what's the transit time there? I mean obviously the pH as measured by that other study was somewhere between three and four. So still pretty acidic. But because it's liquid, it's just not in your esophagus for very long.

1:08:23Dr. Jordan Feigenbaum:Right. saliva has likely made this a little more basic, a little more neutral, and then it just gets into the stomach and you've got nothing to worry about. But if it's staying there for a while, particularly like these granules of whatever, I mean, it seems plausible. It seems plausible.

1:08:41Dr. Austin Baraki:Good find, man. I learned today, and I think our audience probably did too. Maybe if there's any of that 17 % in our audience, maybe they will rethink this practice if it's something they do habitually.

1:08:53Dr. Jordan Feigenbaum:Yeah, stay off TikTok also. Generally good advice. Yeah, right. That is a wrap here on the Barbell Medicine podcast, where we bring modern medicine to strength and conditioning and strength and conditioning to modern medicine. I'm your host, Dr. Jordan Weigenbaum. Special shout out to Dr. Austin Baraki for blessing us with his clinical acumen, also for tolerating my acting chops. They are rudimentary at best. Before you guys go anywhere, please leave us a five-star rating and a review. It really helps drive traffic to our podcast so we can keep bringing you all the latest nuance in health and fitness from everyone here at barbell medicine we'll catch you next week and every week right here on the barbell medicine podcast