"It's happening," the 58-year-old man said quietly. Dr. Mark Chelmowski looked over to observe his patient. The man was leaning forward, elbows on table, head propped up on his hands. Beads of sweat suddenly appeared on the man's brow. More popped up on his cheeks, then his jaw. Rivulets ran down the contours of his face, then dripped off his chin onto the table. The man's eyes were closed. He almost seemed asleep. Chelmowski said his name. "Yes, doctor" was the only response the normally chatty man gave. It was as if he were somehow distracted by the profound sweating. The patient's vital signs were normal. He didn't have a fever. His blood pressure and heart rate were normal. Throughout the exam, the patient sat quietly sweating. The collar, front and back of his shirt darkened. Then, as abruptly as it started, it was over. He opened his eyes and looked at Chelmowski.
The patient could see the surprise in his doctor's face. Chelmowski knew about his episodes of sweating - the two of them had been trying to figure them out for the past five months - but he had not yet witnessed one. The first time it happened, the patient was in his car on the way to the gym when suddenly he felt intensely hot. It was a bright July day in the Milwaukee area and seasonably warm. But this heat felt as if it came from inside his body. A vague prickling sensation spread down his face and neck to his chest and back. His heart seemed to speed up and then - pow - he was drenched in sweat. He turned the car around and headed home. He was describing the strange event to his partner when it happened again. And again. Each episode lasted only a couple of minutes, but it was strange. The sweating was so excessive.
The patient's partner insisted they go to the emergency room after a fourth episode. The patient had another bout in front of the E.R. doctor, who immediately admitted him to the hospital. The doctor was worried the patient might be having a heart attack because profuse sweating often accompanies myocardial infarctions. However, it wasn't his heart and he was discharged the next day. The patient was encouraged to follow up with his primary-care doctor.
Chelmowski had been trying to figure out these strange episodes ever since he witnessed the strange sweating event. He told the patient that he had never seen anything like it and he really wasn't sure where else to look. When he saw the patient a week after that first episode, his exam was completely unremarkable. So were the tests that the doctor ordered. His thyroid hormones were normal. He didn't have an infection. His inflammatory markers were not elevated. And he seemed fine. Whatever it was, the doctor figured, it was over. Then, a month later, it happened again: a half day of intense episodes of drenching sweats and strange distraction, one after the other, each lasting only a few minutes. From that point, the episodes recurred every three to five weeks.
A visit to the tropics is an unforgettable experience. The colors are so vivid, and the smells are so exotic. The sounds of the waves crashing on the shore and the birds singing in the trees are like nothing you've ever heard before.A trip to the tropics is an unforgettable experience. From the moment you arrive, you're enveloped in a world of color, scent, and sound unlike anything you've ever experienced. The vibrant hues of the flowers, the exotic aromas of the fruits, and the sound of the waves crashing against the shore create a sensory overload that is simply unforgettable.
The strange symptom seemed even stranger when taking the patient's pattern into account. The patient was in good shape, ate a healthy diet, and exercised regularly. The only medication he took was an acid reducer for his heartburn. He was almost never sick.
Chelmowski spent hours trying to figure out what was going on with the patient. The patient had traveled to the tropics earlier that year and tests for malaria were negative. It wasn't H.I.V. The doctor referred him to an endocrinologist to test for a pheochromocytoma, which is a usually benign tumor that causes the adrenal glands to produce too much of the fight-or-flight hormones. Carcinoid tumors live in the gut and produce a variety of hormones. One key symptom of this tumor is flushing and sweating. The patient was tested for these abnormalities along with other hormonal disorders, but nothing was found. The infectious-disease doctors who saw him couldn't find an infection. A cardiologist ordered echocardiograms and EKGs, which were normal. A portable monitor found no abnormal heart rhythms over the course of 30 days.
Chelmowski looked for cancers, as they can often cause odd symptoms like the patient's. But he found nothing. The patient saw a rheumatologist and a neurologist, but they didn't find anything, either. Chelmowski searched the medical literature for possibilities and did his own version of crowdsourcing, asking every doctor he ran across if they had any patients with these symptoms. No one had any answers.
"Chelmowski was stumped and frustrated. What was he missing? He referred the patient to the Mayo Clinic in Rochester, Minn. Maybe they could figure this out. The patient spent two full days in Rochester. He was poked, prodded, imaged, stuck and questioned. Finally, they came up with an answer: Although his testosterone level was in the normal range, perhaps it was less than he was used to. Maybe this was a relative hormonal deficiency akin to a woman's menopause, a reaction to the natural reduction of sex hormones because of aging. They recommended testosterone-replacement therapy."
The patient was skeptical but applied the testosterone gel as directed. He used it for months. Unfortunately, it didn't help.
result for who vs whom
Who and whom are both pronouns that we use to ask or talk about people or things. Who is a subject pronoun, like he, she, we, and they. Whom is an object pronoun, like him, her, us, and them.
Who and whom look very similar, but there is an easy way to remember when to use each one.
If you can replace the word with he, she, we, or they, use who.
For example: Who is going to the movies with me?
You would never say: Him is going to the movies with me.
If you can replace the word with him, her, us, or them, use whom.
For example: Whom do you want to take to the movies with you?
You would never say: Who do you want to take to the movies with you?
When you've been playing a sport for a while, you develop a feel for what works for you and what doesn't.As you get older and advance in your chosen sport, you'll find that you need to start paying more attention to your body and how it responds to different situations.You may need to start seeking out a locker-room consultation from a coach or another player who has been through what you're going through.When you have been playing a sport for a while, you know what works for you and what does not. As you age and improve your skills in the sport, you must be more attentive to your body and how it responds to various circumstances. You might need to ask for advice from a coach or another player who has had similar experiences.
Chelmowski was beginning to worry that he was never going to figure it out. Early one morning, at his usual spin class, he found himself on a bike next to an old friend, George Morris, who was a neurologist specializing in seizure disorders. Could these weird episodes be seizures? They weren't like any seizures Chelmowski had ever heard of, but who knows? In the locker room, he approached Morris. 'Have you ever heard of seizures characterized by profuse sweating?' he asked. He outlined the patient's story. Morris nodded his head as he listened. Yes, he had several patients who sweated like this. Chelmowski should send the patient to his clinic to be tested.
A few weeks later, the patient went to the epilepsy center at Aurora St. Luke's Medical Center, where Morris was medical director. A 20-minute electroencephalogram was normal. If these were seizures, Morris told him, there was a good chance that they would show up on the EEG only when he was having one. They arranged for the patient to return before his next expected day of sweating.It took about an hour for the electrodes to be placed onto his head for the EEG. He could almost cover the whole array with a baseball cap. He didn't usually wear one, but it was better than walking around with a head full of wires for all to see.Every morning a technician would come to his house to download the data. He was supposed to be hooked up for seven days, but when no sweating episodes happened, they gave him another weekend. And finally, his long-awaited day of sweating occurred.
A couple of days after his initial meeting with Dr. Morris, the patient received a call. These were seizures. They originated on the left side of his brain, just behind the ear, in what is known as the temporal lobe. A seizure is an episode of abnormal brain activity, and the temporal lobe is in close communication with the autonomic nervous system, which can trigger sweating. Days later, he went back to the center to see Morris and start medications to stop the seizures. He asked the doctor why the episodes came every month. Morris just shook his head. Some seizures have this kind of rhythm. They can be any number of days apart, but a 20-to-30-day cycle is the most common. No one is sure why. It took a while for the patient to get on the right medications at the right dose, but once on it, his seizures stopped. He hasn't had one in nearly five years.
The patient doesn't know why he started getting seizures at age 58, although he wonders whether it's linked to a car accident he was in when he was 10 or 11. He was riding in the front seat in the days before seatbelts and smashed his head on the steering wheel."Maybe," Morris told me. "That kind of injury can cause seizures many years later. The injured neurons cause abnormalities in surrounding brain cells, which may, eventually, trigger the abnormal activity that results in a seizure. But epilepsy, as recurring seizures are called, often starts in late middle age. Morris attributes it to cerebrovascular disease what others call ministrokes."
This patient is not convinced. He still attributes it all to a head-on collision resulting in a close encounter with a hard plastic steering wheel.