Category: Interesting Cases

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Overactive thyroid can affect your eyes.

According to Thyroid Foundation of Canada website, it is estimated that 200 million people in the world have some form of thyroid disease. One in every three Canadians (about 10 million people) has a thyroid disorder. Of those, as many as 50 per cent are undiagnosed.

The normal function of the thyroid gland is to secrete hormones. These hormones have multitude of functions and are vital to metabolism in adults and for normal growth and development of children.

Underactive thyroid (hypothyroidism) causes many symptoms like weight gain, lethargy, cold intolerance, menstrual irregularities, depression, constipation and dry skin. Deficiency of thyroid hormone in children leads to dwarfism and mental retardation.

Overactive thyroid (hyperthyroidism) results in palpitations, nervousness, tremor, heat intolerance, weight loss, muscular weakness and usually there is a presence of goitre.

Hyperthyroidism can be caused by a number of conditions, including Graves’ disease, toxic adenoma, Plummer’s disease (toxic multinodular goitre) and thyroiditis.

Graves’ disease accounts for at least 90 per cent of all patients with hyperthyroidism. It is a condition where eyes are affected. A condition called exophthalmos – protrusion of the eyeballs. Graves’ disease is an autoimmune disorder in which antibodies produced by your immune system stimulate your thyroid to produce too much thyroid hormone.

These antibodies mistakenly attack your thyroid and occasionally the tissue behind your eyes (Graves’ opthalmopathy) and the skin, often in your lower legs over the shins (Graves’ dermopathy). Scientists aren’t sure exactly what causes Graves’ disease, although several factors, including a genetic predisposition, are likely involved.

The disease has a genetic component, although not every member of the afflicted families will suffer this condition. It is more common in females than in males.

In Graves’ eye disease, the eyes are painful, red and watery – particularly in sunshine or wind. The eye lids and tissues around the eyes are swollen with fluid. The eyeballs bulge out of their sockets (exophthalmos). Because of eye muscle swelling, the eyes are unable to move normally and there may be blurred or double vision. Some patients have decreased colour vision as well.

Fortunately, the eye changes tend to “burn out” within a period of about 24 months and, in most cases, there is a satisfactory end result even without any treatment. The double vision and the bulginess usually do not disappear completely.

Unfortunately, there is no satisfactory treatment to prevent Graves’ eye disease. Because hyperthyroidism seems to influence the eye disease, it is very important to treat the hyperthyroidism quickly and effectively. In most patients, the eyes tend to get somewhat better when the thyroid abnormality has been treated.

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Skin Blemishes of Breast

Skin Blemish of Breast
(click to enlarge)

Skin lesions and blemishes are very common. Most of them are benign and have no malignant potential. But some can be malignant or potentially malignant. Some areas of the body are easy to examine but other parts of the body are not clearly visible. One such area is lower part of a woman’s breast.

Many women are very particular in doing breast self-examination but forget to do visual inspection of the nipples, areola and under surface of the breasts where moles can be missed.

Moles that are of medical concern are those that look different than other existing moles or those that first appear after age 20. If you notice changes in a mole’s colour, height, size or shape, you should have these moles checked. If the moles bleed, ooze, itch, appear scaly or become tender or painful then it is time to have them removed and checked for cancer.

The following ABCDEs are important signs of moles that could be cancerous:

Asymmetry – one half of the mole does not match the other half.

Border – the border or edges of the mole are ragged, blurred or irregular.

Colour – the colour of the mole is not the same throughout or has shades of tan, brown, black, blue, white or red.

Diameter – the diameter of a mole is six millimetres or larger.

Evolution – moles which have changed over a period of time.

Remember, there is a forecast for a sizzling summer this year. So, we should continue to remind ourselves to protect the rest of the body from sunburn. Use of sunscreen is one way to do it. There is a lot of misconception about what kind of sunscreen to use and how to apply.

Sun Protection Factor (SPF) 30 provides 30 times greater sun protection than unprotected skin when exposed to damaging sun’s ultraviolet B (UVB) rays. This does not mean you can stay in the sun for 30 hours without burning yourself. Sunscreen should be applied liberally and often depending on how much you sweat and how wet you are. Make sure the sunscreen blocks UVB and UVA. Higher SPF provides better protection. Wear protective clothings, wide brimmed hat, sunglasses which block both ultraviolet rays.

The best protection against sun’s damaging rays is to stay away from the sun and take your vitamin D regularly. I guess that is too much to ask, especially when our summers are so short. So enjoy the sun but be sun smart.

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Have you checked your toenails lately?

Big Toe with Fungal Infection.

Now that summer is here, people from all walks of life have given up on shoes and socks. Sandals, flip flops or bare feet, yes people walking bare feet, is the norm. Now look at your feet then look at your toenails. Are they full of calluses, plantar warts, ingrown toenails and/or totally deformed nails due to fungal infection?

Wow, that sounds horrific. None the less not life threatening. So, you will live long enough to fiddle fuddle with your toenails, with nail clippers and all sorts of sharp instruments people use to fix the problem themselves until they end up getting infection. And if you are a diabetic then gangrene and amputation may be the end point.

Wow again! But don’t panic. If this is getting scary then get a glass of wine (will keep your heart and feet warm), relax and read. Just pay attention to your feet and toes and toenails and you won’t lose your foot.

Nails protect the tips of our fingers and toes. Two most common problems I see with toenails are ingrown toenails and fungal infection.

Ingrown toenail of the big toe usually occurs when sweaty feet are encased in tight shoes. The situation gets worse when the nail is trimmed short and the corners are curved down. The side of the nail curls inwards and grows to form outer spikes. This causes painful infection of the overhanging nail fold.

Ingrown toenails can be prevented by keeping feet nice and clean. Wear roomy shoes and clean cotton socks. Allow the outer corners of the nail to grow over the skin margins placing small piece of cotton soaked in an antiseptic just under the outer corners of the nail. Cut the nails straight. Antibiotics will help relieve acute infection but will not cure the primary problem. Eventually, surgical procedure done in the office under local anaesthetic becomes necessary.

Fungal infection of the nails is common as well. It affects toenails more than finger nails. The nail is thickened and discolored. It is usually yellowish. The nail may grow in a twisted manner. The infection is picked up in a public place where it is transmitted from person to person. Poor feet hygiene does not help.

Fungus infection is best treated with anti-fungal therapy orally and locally for three months. Cure rate is around 80 percent. Ongoing meticulous foot care is very important to prevent recurrence. If they are thick, stubborn, deformed, ugly and painful then surgery is required.

If you love your feet and toenails then keep your feet clean and shiny…yes you can do it.

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Non-melanoma Skin Cancer can Disfigure You

92 year old male with a two month history of left forearm lesion. The lesion was excised under local anesthetic. Pathology report: 2.5 cm diameter, well differentiated, invasive squamous cell carcinoma, completely excised. (Dr. Noorali Bharwani)
92 year old male with a two month history of left forearm lesion. The lesion was excised under local anesthetic. Pathology report: 2.5 cm diameter, well differentiated, invasive squamous cell carcinoma, completely excised. (Dr. Noorali Bharwani)

What is the most the most common cancer in Canada?

This is no brainer. It is skin cancer.

There are two types of skin cancers: melanoma (also known as malignant melanoma) and non-melanoma skin cancer. Non-melanoma skin cancers are basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). We discussed melanoma in the last column. Today, we will discuss BCC and SCC.

BCC and SCC are malignant tumours but typically are not life threatening and are usually successfully treated in doctors’ offices. If they are not treated then they grow slowly over a period of time and require bigger excision and this can be disfiguring. Especially, if they are on the face, head and neck – the most common sites of sun exposure.

Excessive sun exposure is responsible for 90 per cent of non-melanoma skin cancers and two thirds of melanomas.

What are the risk factors? People who have fair skin, have tendency to freckle, have high degree of sun exposure, make excessive use of sun beds, had previous radiotherapy or phototherapy and those who have genetic predisposition.

BCC arises from the lowest layer of the epidermis, called the basal cell layer. About 80 per cent of non-melanoma skin cancers are BCC.

BCC usually grow slowly. It is very rare for a basal cell cancer to spread to nearby lymph nodes or to distant parts of the body. But if a basal cell cancer is left untreated, it can grow into nearby areas and invade the bone or other tissues beneath the skin. They are locally invasive and disfiguring.

After treatment, BCC can come back in the same place on the skin. People who have had BCC are also more likely to get new ones elsewhere on the skin.

The first line treatment of BCC is often surgical excision. Many non-surgical alternatives are available but if it is not adequately treated then two thirds of recurrent tumors appear in the first three years of treatment and 18 percent appear between five and 10 years after treatment.

SCC – about 20 per cent of non-melanoma skin cancers are squamous cell carcinomas. They commonly appear on sun-exposed areas of the body such as the face, ears, neck, lips, and backs of the hands. They can also develop in scars or skin ulcers elsewhere.

SCC tends to be more aggressive than BCC. They are more likely to invade fatty tissues just beneath the skin, and are more likely to spread to lymph nodes and/or distant parts of the body, although this is still uncommon. Treatment is same as for BCC.

If you like to worship sun, then expect to burn and eventually get cancer.

Next week, what do you know about sunscreens?

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