* NEW JERSEY MAN ASKS IF HE WILL LOSE HIS THUMB?  READ WHY.

"A few years I had a fungus on my toe.  I had it treated,  and now after having a small accident at work where I cut my thumb, I have contracted a sort of a fungus.  Is it related to my preious fungus or due to my accident.  It does not hurt but have swelling.  Will I lose my thumb?"  ( JS, New Jersey)

Hi JS,

After visiting with you in person, you appear to have onychomycosis (also called tinea unguium), a fungal infection of the nail bed, nail matrix, and or the nail plate.  This infection is most commonly caused by Trichophyton rubrum, which invades the nail bed and underside of the nail plate.   This infection commonly infiltrates the toenails more than the fingernails, and the  fungus most commonly spreads due to exposure to moist environments such as wearing occlusive footwear, walking in gym rooms, spas, or  fitness centers, and not allowing drying of the skin.  

In fact, almost 33% of all skin fungal infections and 50% of all nail disease is linked to onychomycosis.   Fungus in the body may indicate a weakened immune system; thus, your doctor should order tests to check for any immunocompromised states.  In diabetics, onychomycosis may indirectly decrease peripheral circulation worsening venous stasis and diabetic foot ulcers.  

Regardless of the cause, onychomycosis is easily diagnosed, and treatments are readily available.  Although you mentioned applying an over the counter, topical agent to your nails, the spread of the fungus from your toes to your thumb likely suggests that the fungus is in your blood and stronger medicines are needed to kill the fungus.  Commonly used antifungals are terbinafine and itraconazole but doctors may prescribe griseofulvin and  ketoconazole based on the individual patient's allergy and past medical history. 

Your homosexual relations lends credence to the possibility of  you having contracted AIDS and a subsequent weakened immune system.  The weakened immune system lacks the ability to kill bacteria, viruses, and fungus that enter or exist in the blood; thus, pathogens are able to freely float from one extremity of the body to another extremity. 

Set up an appointment with a doctor, let the physician check for any immunocompromised states, have a HIV test done, and upon receiving those results, discuss with your physician the appropriate treatment steps, as needed.   

In the meantime, I humbled by your question and trust.  Happy Holidays.

Respectfully,

Dr. Roshin 

* PHILIPPINE MAN QUESTIONS HIS ANTI HIV VIRUS MEDICATION REGIMEN?

"hello doc.  how are u?  can i call?  just a shortwhile pls.  I WISH TO CALL U COZ I HAVE SOME IMPORTANT QUERIES"  (Mr SPinoy, Philippines)

Dear Mr. SPinoy,

I am glad we were able to chat on Facebook video, this past weekend, November 11, 2016, concerning your antiretroviral therapy (called HAART).  You mentioned that your HAART therapy consists of Aluvia with Efavirenz.  Aluvia is a combination pill of Lopinovir/Ritonavir, and Efavirenz is a non-nucleotide reverse transcriptase inhibitor medicine (NNRTI).   Your inquiry was whether this was the correct medication regimen to continue to take for combating the HIV virus. 

Latest HAART guidelines suggest that if a patient has a CD4 count less than 500, that person could be placed on one of the following three medication regimens.

1) 2 NRTI (nucleoside reverse transcriptase inhibitor)  +  1 PI (protease inhibitor)

2) 2 NRTI + Efavirenz

3) 2 NRTI + 2 PI

NRTI medications include the following not limited to Zidovudine (also called AZT), Didanosine, Stavudine, Lamivudine, Tenofovir), and NNRTI medicines include  Efavirenz, Nevirapine, Doravirine, Etravirine, and Delavirdine.  PI (Protease Inhibitors) are not limited to the following which include simeprevir, lopinovir, ritonavir, boceprevir, darunavir, telaprevir, fasamprenavir, indinavir, saquinavir. 

When I asked what your latest CD4 count and viral load were, you said you will "recheck these levels in December 2016".  You also mentioned that "my Cd4 count go up 100 points since last time."   Although the updated guidelines would  change your HAART therapy, my recommendation is for you to stay on the Aluvia + Efavirenz combination treatment.  Why, you might be wondering?  To become healthier and contain AIDs (Acquired  Immune Deficiency Syndrome) side effects, a physician wants the patient's CD4 count to increase and the viral load to decrease.  Thus, as long as your CD4 count continues to increase and the viral load continues to decrease, STAY on this  antiretroviral therapy regimen.  Furthermore, you mentioned "not having" any adverse symptoms, such as rash, confusion, neurologic conditions...etc., from your present medications; thus, you should  STAY on this HAART protocol.  Your medications are making you healthier and providing you a longer life. 

In the end, visit with your doctor, seek counsel, and make a decision that is best for you.  I am humbled by your trust in my opinion.  God Bless you and God Bless the Philippines.

Respectfully,

Dr. Roshin

*

       * PHILIPPINE MAN MAY HAVE POTT'S DISEASE?


“ahh ok sir.  u know about spinal cord disease???  we need an ortho doc.but we only a poor family....his bedridden for almost 6mons.  I'll send u the result of MRI.”  (Ms. Lovely, Philippines)

Hi Ms. Lovely,

After spending almost a month in correspondence with you and after scanning numerous imaging and test results you sent, I believe the 32 year old man you referenced with your question, may have either Pott’s Disease or a leukemia.  Pott’s Disease is a form tuberculosis that effects the spine causing tuberculous arthritis of vertebrae joints.  A leukemia is a cancer of the blood, involving white blood cells.  Allow me to explain.

When I asked you has the man had tuberculosis in the past, you said, “n0 sir.”  Yet, judging by this  man’s MRI report (L3-L4 and L4-L5 dessication / posterior disc bulge at L3-L4 / L4-L5 posterior disc herniation causing mild spinal canal stenois), blood results (extremely high monocyte count with low lymphocyte count), and an apparent effect on the adrenal gland (sodium and potassium levels abnormal),  tuberculosis must not only be considered, tuberculosis tests (Mantoux test, PPD) must be ordered by his doctor.   The PPD will confirm active or past exposure to tuberculosis.  If the PPD is positive, you and this man’s contacts must all be tested for tuberculosis.  The other factor that may lead credence to Pott’s disease is that his blood test showed low levels of hemoglobin and hematocrit, which could have been caused by loosing blood orally or rectally.  Multiple medication regimens will treat tuberculosis. 

This man’s monocyte count was 19.1% (2-6% normal range) and lymphocyte count was 4.9% (20-30% normal range).  His hemoglobin was 113 g/L (135-180 g/L normal range) and hematocrit was 40.9% (44-54% normal range).  Pott’s disease, also known as tuberculous spondylitis, is a combination of osteomyelitis (bone inflammation) and arthritis, frequently involving multiple vertebrae of the lower, lumbar spine which may cause vertebral collapse and compression fractures.  The MRI report appears to reflect many of the signs and symptoms you mentioned in our discussions on Facebook.  With urgency, please locate a doctor who will test this man for tuberculosis exposure.  If you require assistance with the location of a Philippine hospital or clinic, simply ask, and I will make contact with doctors in your country. 

Due to the unusual and abnormally, very high monocyte count ( a type of white blood cell), a leukemia should not be ignored.  A hematologist ( a blood specialist) should be considered for making an absolute confirmation of a leukemia diagnosis.  Chemotherapy is a treatment option for leukemia. 

I am humbled by your trust.  Please write and let me know what evolves from our discussion.  A 32 year old man, bedridden for sixth months, is crying for help, and I pray and hope my suggestions, through your efforts, will reverse his health and life’s fortunes.  God Bless the thirty-two year old man,  God Bless you, and God Bless the Philippines. 

Respectfully,

Dr. Roshin

*

* PUERTO RICO:  How Do I Protect Myself From The ZIKA Virus?

Use Insect Repellent

Use EPA-registered insect repellents* that contain at least 20% DEET (products include Cutter Backwoods and Off! Deep Woods) for protection against mosquitoes, ticks, and other bugs. Other repellents protect against mosquitoes but may not be effective against ticks or other bugs:

• Picaridin (also known as KBR 3023, Bayrepel, and icaridin); products include Cutter Advanced, Skin So Soft Bug Guard Plus, and Autan
• Oil of lemon eucalyptus (OLE) or para-menthane-diol (PMD); products include Repel Lemon Eucalyptus
• IR3535; products include Skin So Soft Bug Guard Plus Expedition and SkinSmart
• Cover Exposed Skin                                                                                          Consider using clothing and gear (such as boots, pants, socks, and tents) that are treated with permethrin (an insecticide). You can buy pre-treated clothes or treat your own clothes. If treating items yourself, follow instructions carefully. Do not use permethrin directly on skin.

Respectfully,

Dr. Roshin