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CASE 25

Agnes is a 63-year-old post-menopausal woman with lichen planopilaris. She was diagnosed at age 56 and has been treated in the past with steroid injections, clobetasol, doxycycline and topical tacrolimus. Her current treatment plan includes hydroxychloroquine (Plaquenil) at 400 mg once daily, topical betamethasone lotion “as needed”, oral cetirizine 10 mg once daily,  and Clobex shampoo (clobetasol propionate 0.05%) shampoo once weekly.  

Agnes reports that she has ongoing itching, but it’s better with the current plan than it was in the past.  She feels she is still losing hair and hair shedding has increased in the past 6 months to the point where she is now noticing more hair on her clothing and in her food from time to time.

Hydroxychloroquine was started 18 months ago. Eye examinations have been fine, and blood tests for complete blood counts and liver enzymes have been okay up until recently. Now, the liver enzymes are rising on tests done last week.

Agnes has come to the office to see you today. Hydroxychloroquine has been causing all sorts of gastrointestinal issues. Agnes says she gets periods of nausea, bloating and diarrhea. She says it seems to depend on what she eats but she is not sure of exactly what foods are safe and which cause problems.  She has episodes of abdominal pain. She has lost about 4 kg since starting hydroxychloroquine and says she is not always sure what food to eat. Sometimes, she does not feel like eating a lot as she tends to feel full quickly. She notes there has been an increase in “burping” with hydroxychloroquine, which is quite embarrassing.

Agnes says that she had a colonoscopy a few years ago, and everything seemed fine. She was diagnosed with heartburn in the past, but this was successfully treated with antacids, and Agnes stays away from spicy foods. She was also diagnosed with irritable bowel syndrome (IBS) but felt she had come to learn how to deal with it. She feels that the hydroxychloroquine is really making things worse.  Her normal bowel pattern is diarrhea or loose stool every so often but it had been under control.  Now, things are really not under control.

Agnes has back pain and attributes it to her gardening and the fact she is lifting her new grandson all the time.   Her grandson is 18 months old and Agnes looks after him on Tuesdays and Saturdays.

Agnes is 5 ft 7 and 188 pounds.

 Agnes has the following questions for you. How would you answer them?

1.        Do you feel the dose of hydroxychloroquine is appropriate for me?

2.        What can you do to help me next?

3.        Is the hydroxychloroquine damaging my liver? I see my liver enzyme counts are going up.

4.        Is acetaminophen okay for me to use with my back pain? I understand that both acetaminophen and hydroxychloroquine are hard on my liver.

5.        Should I see a specialist about my IBS? What type of IBS do you think I have ?  

6.        Do I have hemochromatosis? I have high ferritin!

7. I am quite fatigued lately. Do I need a red blood cell transfusion? What about getting iron infusions? My iron is low!!!!!

CASE 26

Alvin is a 55-year-old male with folliculitis decalvans. He was diagnosed with it 8 months ago and is using doxycycline at 100 mg once daily. Alvin says that doxycycline is working really well for controlling the disease. Alvin notes that the redness has reduced, there are fewer pimples and scalp burning has subsided.

Unfortunately, doxycycline has been causing Alvin to have gas and bloating. Alvin says his waist size has increased quite a lot, and he has to use a new belt buckle setting because he feels so gassy. In addition to the gas, Alvin feels that doxycycline is also making him feel like he’s gaining weight. For the last three days, Alvin has had diarrhea. He wonders if he has clostridium difficile diarrhea and needs to go to the emergency room immediately. He has read online just how serious this can be.

Alvin mentioned to you that he has been diagnosed with irritable bowel syndrome (IBS) in the past. He gets abdominal cramps and periods of constipation.  He has tried eating more fiber and sticking to a low FODMAP diet where possible.

Alvin has the following questions for you. How would you answer them?

1.        Should I stop my doxycycline, or is it safe to continue? If I need to stop, what treatment should be used next?

2.        Will my waistline return back to normal once I stop doxycycline ? I feel like I need new pants!

3.        Should I go to the emergency room to get my diarrhea checked out?

4.        I’ve heard about the ROME criteria for IBS. What type do you think I have?