A Cold Weather Syndrome.... Very Curious!

I AGREE TO USE MD STAT FOR EDUCATIONAL PURPOSES ONLY, THAT NO DOCTOR PATIENT RELATIONSHIP IS FORMED BY MY PARTICIPATION IN THIS EXCHANGE, AND I UNDERSTAND THAT MY QUESTION AND ANSWER(S) WILL BE POSTED ON THE WEBSITE AND WILL BE VIEWABLE BY VISITORS TO THE SITE.: Yes, I agree.

Hi Doctors,

I live in Canada and enjoy running outdoors for exercise. However, whenever I run in cooler temperatures (which for me is anywhere from about 10 to -10 degrees C), I get extreme pain in my ears soon after I start running (maybe 10 minutes into the run - sometimes less!). I always warm up and don't have issues in any other muscles or parts of my body, and I dress warmly, including a fitted headband that completely covers my ears.
 
The pain is debilitating and usually causes me to need to stop running and head home. It does not occur when I run indoors or in warm spring/summer weather. Sometimes it feels like intense pressure in my inner ear, and sometimes it feels like it is just behind my ear. Usually, my jaw also locks and tends to "pop" when I open my mouth. The symptoms take about 20 minutes to resolve. I should also mention that other than this pain, I feel fine while running - to my observation, it is not linked to fatigue.

I was wondering if there's anything I can do to stop this? I really love running but the pain is extreme.

Thanks!
Gender: Female
How old are you?: 21
How long has this been going on?: More than a year

Check all symptoms you are currently experiencing:
Ear/ Nose / Throat
Describe associated symptoms not listed above:

Pain/pressure in both ears on exposure to cold weather while running, even when well-dressed. The pain is debilitating and has at times been severe enough to cause nausea. Does not occur if I am outdoors in the same temperatures while not exercising. However, ears are sensitive to cold in general and I am most comfortable in a hat or headband from November to March. A locked jaw accompanies the pain in my ears. Both resolve in ~20 minutes after coming indoors.

What have you done so far to remedy this condition? Please include tests and relevant studies here.

Wear a headband or skullcap while running. I have been told that I should put cotton balls in my ears but I am confused about why this would help and am more interested in understanding the cause of this issue.



Please list any medications you are currently taking (and dosage if known) :: None
When was your last menstrual cycle?: 3 weeks ago
Are you currently using or do you have a history of tobacco use?: No
Are you currently using or do you have a history of illegal drug use?: No
Please describe your alcohol consumption :: Rarely
HOW QUICKLY DO YOU NEED THIS TO BE ANSWERED?: Within the next few days

So that we can serve you best, please try to tell us your top three things you wish to be addressed in our response. You will likely get more than you ask for, but we wish to understand your priorities.

1. What is this?
2. Why does it happen?
3. What steps can I take to reduce or eliminate the symptoms?
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Dear Canadian Runner,

I am struggling with this one. I did fine a link on WEB MD but I think the explanation, for what appears to be a fairly common syndrome, is less than satisfactory. My feeling is that your problem may be a combination of extreme sensitivity (because of your particular ear anatomy) of a Cranial Nerve, or, a cold-variant migraine, or, perhaps, some combination of these. Dr SWB is going to weigh in on this a little later today, and since this is right in his wheelhouse I think we will both learn something. Stand by, and thanks for your question.

MDSTAT DOC 1

Hypokalemia mystery

I AGREE TO USE MD STAT FOR EDUCATIONAL PURPOSES ONLY, THAT NO DOCTOR PATIENT RELATIONSHIP IS FORMED BY MY PARTICIPATION IN THIS EXCHANGE, AND I UNDERSTAND THAT MY QUESTION AND ANSWER(S) WILL BE POSTED ON THE WEBSITE AND WILL BE VIEWABLE BY VISITORS TO THE SITE.: Yes, I agree.

I’m a generally healthy 23 year old female who is having some problems with hypokalemia.

For the past 10 months I have been having trouble keeping my potassium at a normal level (above 3.5). Five times I have ended up in the ED or hospitalized for IV replacement after levels around 2.7

Other times I have caught it earlier around 3.1 and was able to get it back up after ED visits for some oral replacement.

After a the first few times this happened my doctor put me on a high potassium diet, and when it continued to happen I was put on 10meq of potassium daily and then when that didn’t work either it was increased to 20meq daily, however I am still having trouble keeping my potassium at normal level at times.

Most of the time my potassium is around 3.4-3.7, but randomly it will begin to drop and drop quickly to the 2.7. When it gets to around 3.0 I start to get really nauseated, shaky and generally feel like crap, when it gets down to the 2.7 I have usually started vomiting which only makes it drop lower (I do not vomit before it initially starts to plunge though so the low levels isn’t caused by vomiting).

I am normal weight, generally healthy, and my blood pressure always lower, 90/60 ( I know that there is one thing that can cause the low potassium levels but my doctors do not think I have it because it is associated with high blood pressure).

I really want to know why this is happening because when it happens I feel like crap, the IV potassium replacement is not any fun (many of my veins are shot from all the potassium infusions, once they had to use my foot) and I always feel horrible for days afterwards.

Since being on the high potassium diet and 20meq of potassium daily I have had less of these episodes, but they are still happening.

Gender: Female
How old are you?: 23
How long has this been going on?: More than a month
Check all symptoms you are currently experiencing: None
Describe associated symptoms not listed above: During these episodes I first feel weak, leg cramps, nauseated then I get shaky, and begin to have muscle contractions in my hands and finally begin to vomit.


What have you done so far to remedy this condition? Please include tests and relevant studies here.

Potassium is generally normal (3.4-3.7) with these occasional drops to 2.7-3.1

Magnesium is always normal.

Thyroid is normal.

Abdominal/Pelvic CT is normal.

Only thing that works once it gets really low (2.7) is a few days in the hospital getting IV potassium infusions.

Please list any chronic medical problems and also list any prior surgery (lacerations don't count!): Hemicrania Continua: treated with an occipital nerve stimulator implant

Neurocardiogenic Syncope: Loop recorder implant and explant surgeries.

Inappropriate Sinus Tachycardia

3 EP studies

Check all conditions present in your immediate family... :

Asthma / Lung Problems
Cardiac Disease
Diabetes
Hypertension
Stroke
 
Please list any medications you are currently taking (and dosage if known) :: Bisoprolol 10mg 1x a day (for inappropriate sinus tachycardia)

Zoloft 100mg 1z a day (for neurocardiogenic syncope)

Multi-vitamin 1x a day

Potassium 20 meq 1x a day

Vitamin D 50,000IU 2x a week (vitamin D level one month ago was 13)

Ambien CR 12.5mg 1x day

When was your last menstrual cycle?: 1 week ago
Are you currently using or do you have a history of tobacco use?: No
Are you currently using or do you have a history of illegal drug use?: No
Please describe your alcohol consumption :: Occasionally

HOW QUICKLY DO YOU NEED THIS TO BE ANSWERED?: Within the next few days
So that we can serve you best, please try to tell us your top three things you wish to be addressed in our response. You will likely get more than you ask for, but we wish to understand your priorities.

Why does my potassium level drop like this?

My doctors seem to have given up on finding a cause for this and are just treating as it happens, should I be pressing for answers or should I just accept that this is what my body does?

Any additional tests I should ask my doctor for?

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Well, as an Emergency Doctor I see disorders of potassium all the time. But it is rare indeed for me to see someone like yourself.... someone in pretty good health, with persistent, unexplained hypokalemia. And make no mistake.... this is serious business. Hypokalemia in the extreme is terribly dangerous, and you say the only way for you to get repleted and feel well is to have IV runs of potassium. This is going to my contribution here and I'm going to let my good Internal Medicine docs go a little more in depth... It is, after all, what they do. ER docs are shallow, Internal Medicine docs are deep. I am making a bit of a joke but an ER doc knows a little about a lot, and the Internist knows a lot about a little (if you consider all of adult medicine a little.... but I digress). 

Disorders of potassium can be disorders of absorption, excretion, or intake. The strange fact about your case is that you do not seem to properly absorb the oral potassium. So I wonder if you have an absorption problem. In the ER if someone is low on potassium then the quickest way to get them back to where they need to be is to give the potassium orally, usually mixed in a liquid. 

And by the way, click on this sentence to learn about potassium homeostasis and how physicians try to track down the causes of irregular levels. 

The other likely cause would be a problem in the kidney itself, something called 'renal tubular acidosis', and a problem with the kidney's ability to hold onto potassium would also make sense in your case.

So with hope my Internal Medicine colleagues ride to my rescue here, I am concerned about your intestinal absorption of potassium since the oral supplementation does not seem to work AND also concerned this may be a kidney problem. If you have not been referred to a nephrologist then that would be a good next step.

None of the medicines you are on are potassium-wasters but just so you know, people who take certain diuretic pills off label... often to lose weight, can stay very low on potassium. People who self induce vomiting or take laxatives can have this problem too. And, finally, if you live on black licorice then that may honestly be the culprit. 

Please feel free to ask questions in the comment section and I will stand by for more insightful commentary from my fellow docs. 

MD STAT ER DOC 1

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High Blood Pressure, Chest Pain, and All that Jazz.....

I AGREE TO USE MD STAT FOR EDUCATIONAL PURPOSES ONLY, THAT NO DOCTOR PATIENT RELATIONSHIP IS FORMED BY MY PARTICIPATION IN THIS EXCHANGE, AND I UNDERSTAND THAT MY QUESTION AND ANSWER(S) WILL BE POSTED ON THE WEBSITE AND WILL BE VIEWABLE BY VISITORS TO THE SITE.: Yes, I agree.

My question has to do with high blood pressure.  I have been taking my blood pressure with a home wrist machine.  It ranges anywhere between 145/90 and has been as high as 175/110 a few times.  Most of the time it ranges in the 150/100 ish.  This has been going on for about 2 years now.  More recently, I have been experiencing a racing heart when I'm at rest.  It's like my heart goes out of control before it corrects itself back to a normal heartbeat.  Within the last couple of months, I have been experiencing heart burn.  I don't know if it is severe or not because I don't have anything to compare it to as I have never experienced heart burn before.  Lastly, and also within the last couple of months, I have experienced pain under my ribcage in the front and up through my right shoulder-blade.  I don't know if this is all related or a coincidence that these have all happened about the same time.


I have no shortness of breath and can exercise without tiring.   My weight is proportionate to my height (5"3, 125 lbs) so my high blood pressure is not a result of being too heavy.

Gender: Female
How old are you?: 52
How long has this been going on?: More than a year
Check all symptoms you are currently experiencing:
Chest Pain
Palpitations

What have you done so far to remedy this condition? Please include tests and relevant studies here.
: Eat healthy and exercise.  I typically stay away from junk food except for once in a while.  My diet consists of fish and whole foods, not processed.  Fruits, vegetables, brown rice and fish make up most of my diet.  Vegetables are fresh, not canned.

Please list any chronic medical problems and also list any prior surgery (lacerations don't count!): None.

Check all that apply to you or your immediate family (parents, siblings, grandparents):
Cardiac Disease
Hypertension

Please list any medication allergies that you have : : None.

Please list any medications you are currently taking (and dosage if known) :: Also, please tell us if there is medicine you are supposed to be taking but are not. Thanks! NONE

When was your last menstrual cycle?: I no longer have a menstrual cycle

Are you currently using or do you have a history of tobacco use?: No

Are you currently using or do you have a history of illegal drug use?: No

Please describe your alcohol consumption :: Occasionally

So that we can serve you best, please try to tell us your top three things you wish to be addressed in our response.

My high blood pressure is untreated because I am uninsured.  Until I am covered under insurance again, I would like to know what I can do to help prevent a heart attack.  I realize that I will need to be seen but at the moment, that is not possible.  Other than baby aspirin and my diet/exercise, is there anything else I can do to tide me over until I can be seen?  I'm just looking for some advice that can help tip the odds in my favor until I can be seen by a physician.

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Ma'am,

My board certification is in Emergency Medicine. From our perspective and training EVERYONE has a life threatening condition until we prove they don't. Therefore it is from this perspective of 'worst case scenario' that I am going to provide an initial answer. My colleagues will follow, I'm sure, shortly.

Three things.....

1. You are at risk of heart attack and are having some symptoms that might be angina. Your blood pressure is all over the place, and the device you use may be part of the problem. You can get a three day blood pressure check at the health department or even at the fire station down the street using a manual cuff and a set of real human ears. This average measurement will be much more telling of your real blood pressure. Also, you would feel pretty silly if you showed up in heaven and St. Peter said, "Oh! You are here early!" And you found out that the blood pressure medicine you are now missing costs four dollars for a month's supply, and that a visit with a primary care physician who could give you the once-over and get you back on some inexpensive and efficacious medicines would be about $125. Not trying to scare you, just saying that you have some cardiac risk factors and you are taking a gamble waiting for your insurance.

2. A baby aspirin a day and good diet and exercise is great. Keep doing it.

3. You may have a gall bladder problem causing many of your symptoms. If the sharp pain you get is pain that comes particularly after eating then I am even more suspicious of this. Click on this sentence to learn about the symptoms of gall bladder disease and see if you agree. Now here you are really going to run into a money problem and there's nothing you can do, if you have gallstones, to reverse the process apart from having your gall bladder out. Be aware though, that if I am correct about your gall bladder, that you run the risk of developing Cholecystitis

I am going to make room for my colleagues here. Do not put of a primary care visit for the sake of 'waiting on your insurance'. The cost is less than you think for a one time 'howdy do' and some medication prescriptions. The doc could also get an idea about your gall bladder and could form a plan of action with you were it to become worse suddenly.

Thanks so much for your question!

MD STAT ER DOC 1
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1) YOUR BLOOD PRESSURES : The range you describe is not good. (should be around 130/80). The wrist blood press. cuffs are often inaccurate. You can google mayo clinic wrist blood pressure monitors to see if you are doing measurements correctly. Very likely the family history of hi b.p. is partly responsible for your pressures.

2) RAPID HEART RATE (tachycardia) can be related to hi thyroid levels in the blood &/or some changes in the conduction system of the heart.

3) RIGHT SIDED PAIN UNDER RIBS GOING TO RT. SHOULDER BLADE. Could be gall bladder or liver problems.

4) "HEARTBURN". ( Unrelated to the heart). Stomach and esophageal reflux of acid. Tums or over the counter Omeprazole can help.

5) DIET. Low fat intake and avoiding acidic foods might help gall bladder and heartburn

6) SUMMARY:(a) Bl.Press. needs to controlled!! probably with medication since your weight,exercise and eating habits seem good.
(b) Need heart evaluation! (ekg etc} to check out heart rate & rhythm
(c) Need gall bladder evaluation (ultra sound etc.)
(d) One of our docs has a lot of emergency room experience and maybe he can help out on where to get things done that won't cost you an arm and a leg. I would be quite hesitant to continue on without getting these things checked out.

Good Luck---don't wait too long!!

Space Doc

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