June 3, 2011
KevinMD had a guest blogger who questioned the value of needing to treat one million strep throat infections with antibiotics to save one patient from rheumatic fever and heart disease. Typically, we only need to treat a particular strain of strep called Group A beta-hemolytic Strep (GABHS), which produces a particular type of toxin and antigen. However, non-GABHS is often treated with antibiotics, as well as for a significant number of viral throat infections.
This practice is based on studies in the 1940 and 1950s showing that the rate of rheumatic fever in children can be cut 50% from 2% to 1%. Currently, the rate of rheumatic fever in the US is 1 per 1 million people with strep throat. On the other hand, one million courses of antibiotics can cause 2,400 cases of significant allergic reactions including anaphylactic reactions, 50,000 to 100,000 cases of diarrhea and 100,000 cases of skin rash. Here’s another article that states that strep throat risks are greatly exaggerated.
There’s a lot of merit in what Dr. Lundberg has to say, but when I reviewed the symptoms of rheumatic fever, I was shocked to see how all the symptoms sounded like an acute episode of obstructive sleep apnea. Let me explain:
Rheumatic fever typically occurs in children, and usually presents about 2-3 weeks after a strep infection. Children will naturally have large tonsils. If inflamed for whatever reason (virus, bacteria, allergies, etc.), they’ll get larger by definition. Having large tonsils all of a sudden will close off your throat suddenly, preventing you from breathing properly at night while sleeping. This sudden onset of sleep apnea can cause a number of systemic symptoms which are very similar to the classically described symptoms of rheumatic fever:
- painful, tender, red and swollen joints
- heart palpitations
- chest pain
- shortness of breath
- skin rashes
- severe fatigue
- skin nodules.
You may be thinking, how do these symptoms relate to sleep apnea?
If you have any type of infection, you’ll also have fever. Also, having sudden breathing pauses will cause vasomotor symptoms which can also produce fever, chills, hot flashes and night sweats (similar to menopause).
There are numerous reports of rheumatoid arthritis resolving completely with sleep apnea treatment. Obstructive sleep apnea, by definition causes systemic inflammation, which can even affect your joints.
Not breathing well at night can stimulate your heart, causing palpitations. This can also cause shortness of breath.
Numerous dermatologic conditions have also been linked to sleep apnea. Many people report that their psoriasis or eczema improves after sleep apnea treatment.
Sleep apnea causes a hyper-coagulable state. This can cause micro-strokes or throw small clots to the most remote parts of the body (skin).
Sudden onset of sleep-breathing problems can initiate an intense autoimmune response, since sudden stress can stimulate your immune system.
Granted, toxins from a strep infections can aggravate many of these problems. However, heart valve biopsies in patients with rheumatic fever only sometimes show inflammation and scarring, similar to what we may see with autoimmune conditions. Bacteria or toxins are usually not found.
I have to say that there are certain situations where strep must be treated, but the vast majority of people who have strep don’t actually have a true infection, and even if they do test positive on a culture, they could be one of the 15% of normal carriers, who just happened to have a viral infection, or reflux. The words strep throat is definitely over-used these days—oftentimes people with any degree of throat pain will say they have strep throat.
Furthermore, since most adults will have much smaller tonsils, your risk of having heart complications will probably be much lower compared to children’s risks.
To date, I’m not aware of any solid prospective evidence-based study what supports our current guidelines for routine treatment for strep, especially for adults. I suspect a new study in the future will completely reverse the current management of strep. Unfortunately, even if such a study does surface, it’ll be very difficult for physicians to change their ways.
How often do you test positive for strep? If so, how often are you prescribed antibiotics even if it comes back negative?
Click here for a follow-up discussion about the dangers of Strep throat over-treatment.
January 5, 2011
Believe it or not, your skin is considered an end organ, meaning that it’s at the outermost reaches of your blood supply. It’s also a part of your body which can be deprived of blood flow if you’re under stress, similar to what happens to your digestive or reproductive systems.
Psoriasis is a common skin condition that affects about 34 million Americans, or about 3% of the population. It’s characterized by red, scaly patches of skin covered by white flakes. It’s thought to be a chronic autoimmune condition, where your body’s immune system can attack or damage your own tissues.
I’ve written before about strong links between psoriasis and obstructive sleep apnea, but here are a series of studies that further solidifies this connection. Some of the studies I’ve cited before. Others are new:
Metabolic syndrome (Syndrome X) is a combination of high blood pressure, insulin resistance, and high cholesterol levels. Having all three conditions has been shown to significantly increase your risk of heart disease, heart attack, or stroke. Numerous studies show that people with metabolic syndrome can also have obstructive sleep apnea. In fact, syndrome Z has been described as all the features of Syndrome X plus obstructive sleep apnea.
A study published in Archives of Dermatology showed that patients with psoriasis had a higher chance of having metabolic syndrome compared to people who didn’t (40% vs. 23). I’ve written in the past about how chronic physiologic stress due to sleep apnea causes diversion of blood flow and nutrients to the bowels, reproductive organs, and the skin, since they’re considered “low priority” organs. Low blood flow causes a relative hypoxia, creating oxidative stress, and along with a heightened immune system, so it’s not surprising that the skin can show psoriatic plaques.
Here’s a study showed that women who drank more than two alcoholic beverages per week had a significantly higher risk of psoriasis. Alcohol relaxes your throat muscles, aggravating sleep apnea.
Researchers from harvard showed that comorbid conditions such as cardiovascular disease, depression, diabetes, obesity, and hyperlipidemia all increased over time. Not too surprising if you already have sleep apnea.
Pregnant women with psoriasis were found by Harvard and Mass General researchers to have higher risk of pregnancy-related complications, including spontaneous abortion, preterm birth, preeclampsia, placenta previa, and ectopic pregnancy. Gaining weight can aggravate sleep apnea. Studies show that CPAP can help with preeclampsia.
People with psoriasis were found to have increased risk of depression (39%), anxiety (31%) and suicidal thoughts (44%). Sleep apnea can cause structural, metabolic, and biochemical changes in your brain due to hypoxia.
And lastly, young adults who are obese were found to have a higher risk of developing psoriatic arthritis later in life. Obesity is a major risk factor for obstructive sleep apnea.
Perhaps psoriasis should be placed on the ever-growing list of complications of obstructive sleep apnea. What do you think?
December 26, 2010
Women who drink 2 or more times per week, particularly nonlight beer, are found to have a higher risk of developing psoriasis. This study out of Harvard University showed that the risk increased by 1.72 times normal. One hypothesis that was proposed was that non-light beer is made from wheat products, and that wheat contains gluten, which is a common component that provokes an autoimmune response in Celiac disease.
I’ve written before about how sleep apnea could cause psoriasis in men, and this situation can apply to women as well. Sleep-breathing problems at night, whether or not they’re apneas, can cause a low-grade physiologic stress response which heightens your immune system. When your body’s immune system is in a constant state of stress, it can easily attack normal tissues or proteins. Furthermore, when your body is under stress, certain parts of your body (like your skin, digestive or reproductive organs) will be deprived of blood flow and nervous innervation. Hypoxic states can cause oxidative stress, which has been shown to be linked to autoimmunity, atherosclerosis and even cancer.
Knowing how prevalent obstructive sleep apnea is in our population, this connection is not surprising. Is there anyone reading this blog that had their psoriasis go away completely after your sleep apnea was treated?
August 16, 2010
How is psoriasis connected to obstructive sleep apnea? You may think I'm crazy for even making the suggestion, but if you look at the studies, the results don't lie—you just have to connect the dots.
I've always wondered about this link, since almost every known medical condition is proven to be or possibly associated with obstructive sleep apnea. I was reminded about this connection when I read about golfer Phil Mickelson's psoriatic arthritis. I already commented on the association between sleep apnea and arthritis, and this time, I'm going to show you that psoriasis may be connected as well.
First of all, numerous studies have shown that people with psoriasis have a much higher chance of having cardiovascular disease. There are other reports that psoriasis is associated with an increased incidence of cancer, lymphoma, obesity, metabolic syndrome (also known as "Syndrome X"), autoimmune diseases (Crohn's disease and diabetes, etc.), psychiatric diseases (such as depression and sexual dysfunction), psoriatic arthritis, sleep apnea, personal behavior issues, chronic obstructive pulmonary disease (COPD). If you have severe psoriasis, the likelihood that you'll have a heart attack is 3 times normal. Your chance of dying overall is almost doubled than if you didn't suffer from this condition. Average life expectancy is about 3 to 5 years shorter for someone with psoriasis.
We also know that obstructive sleep apnea can cause metabolic syndrome, hypertension, diabetes, high cholesterol, inflammation, heart disease, heart attack, and stroke. Your risk of dying early increases 45% if you have severe obstructive sleep apnea.
There's even a case report of someone with severe psoriasis who was completely cured after undergoing gastric bypass surgery for obesity.
Here's my take on the connection between obstructive sleep apnea and psoriasis: The chronic stress response and repeated episodes of hypoxia deprives the skin of vital blood flow and nutrients. Sympathetic activity overload preferentially shuts down certain parts of the body that are considered unessential, such as the digestive system, reproductive system, and the skin. In addition, chronic low-grade stress also causes your immune system to overreact and cause inflammation, inducing various self-destroying tendencies that are common with autoimmune conditions.
What do you think about this possible connection? I'd like to hear your opinion.
March 19, 2009
Skin disease is one area that I haven’t covered so far, but data from three large clinical trials suggests that having psoriasis significantly raises your risk for heart disease and stroke. Looking at this issue through my sleep-breathing paradigm, it all makes sense. Not being able to achieve deep efficient sleep can cause a low-grade physiologic stress response, which does two things: It constricts blood vessels going to end organs and parts of the body that you don’t need when you’re running from a tiger. This includes the bowels, the reproductive organs, and the skin. Less blood flow in general leads to poor healing and poor functioning. Chronic low-grade stresses can also ratchet up your immune system which ends up attacking it’s own body parts. In light of these possibilities, it’s not surprising at all that people with psoriasis have increased risk of cardiovascular disease.