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Nurse Susan
Nurse Susan, Nurse (RN)
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I am a 41 year old female who had onset of R arm and R foot

Customer Question

I am a 41 year old female who had onset of R arm and R foot pain. I literally went to sleep on Friday and woke up on Saturday morning with the pain the next morning. The pain/soreness felt as though I had a tough workout. The pain got worse in my arms by Monday and it was hard to grip and pinch anything for 2-3 days. The leg soreness ended up in both my legs by Monday, but, I remembered doing 20 squats, which may have caused the leg pain. Tuesday morning I also had a sore throat. I went to see the PA on Tuesday morning and they did some tests. He started me on Doxcycline, in case it was Lyme Disease (I live in CT). He also ran some other tests, one was a CPK test in which he said my number was high, 198. He referred me to a rheumatologist who I will see this Thursday. I feel better on the antibiotic, however, my arms still are not 100%. I am tired, not as tired as I had been but, I am always tired, I do not sleep well in general and I have a 2 year old. I did not work on Tuesday, Wed and and 5 hours on Thur, Fri and Saturday. It was hard to work, I still had pain and my muscles were tired. I worked about 50 hours that week and about 43 the week before and 45 the week before that. I have been under enormous stress, especially the day before the symptoms occured. I am a bit nervous about the CPK level and everything that is going on. Any advice would be appreciated. LAB TESTS: CBC- Auto = Auto Diff- all WNL Comprehensive Metabolic Panel=WNL CPK= 198 Ehrilichia Chaffeensis ABS Panel: normal ESR: WNL Lyme Titer w.Reflex- Western Blot- normal Rheumatoid Factor + CCP- WNL Strep, GP A Direct DNA: neg TSH, ULTRASENSITIVE: WNL West Nile ABS IGG/IGM, blood: negative/no reaction Awaiting Lyme C6 Peptide results

Submitted: 2 years ago.
Category: Health
Expert:  Nurse Susan replied 2 years ago.
Hello JACustomer,

I am so sorry to read of your discomfort, and I hope I can help you here. Please understand though that online no one can state anything with 100% certainty, all I can do is make my best educated guess based upon what you wrote.

I think it was a wise choice to begin Lyme's disease treatment given the joint pain, fatigue, and you are in a high Lyme's area. Many with Lyme's disease never noticed the classic bulls eye rash, so if you never had one, that does not mean you don't have Lyme's disease.

The CPK is a non specific measure of inflammation. It tells me that somewhere, something in your body is having some type of inflammatory response to something. But it doesn't tell me what and it does not tell me where it is. The RF factor was a good test to run, and I am happy it is negative. It tests for the abnormal protein most often found in rheumatoid arthritis (RA), an autoimmune disease in which the body mistakenly attacks its own systems in the errant "belief" they are invaders. In RA, whats attacked are the joints. Having a negative RF does not rule out autoimmune disorders though.

There is another test called the ANA (antinuclear antibodies) which screens for abnormal proteins found in autoimmune disease. Given your high CPK, if your joint pain continues and you are negative for Lyme's disease, I think it may be wise to talk to your doctor about running this test. If it is positive, further studies called phosphorescence, where the pattern of the proteins are decoded, can tell what autoimmune disease this could be, if it is one.

I liked that your white blood cell counts were normal. (WNL stands for "within normal limits and means nothing abnormal was found or present for that test). These are the cells that help the body fight off infection, and abnormal levels of specific types of WBC can help tell us what the problem might be as each type of WBC is geared to different functions. Your levels were normal, so whatever is happening, it is not affecting your white blood cell count at this time.

Another possible comes to mind. Your sore throat and fatigue makes me wonder if you might possibly have mononucleosis. This is a viral illness caused by the Epstein Barr virus and its hallmarks are the sore throats and usually extreme exhaustion that ensues. Other symptoms can be headache, fevers, skin rashes, nigh sweats. There is a blood test for mono, but there is no treatment for it because it is a virus and not a bacteria. It has to run its course, and typically lasts about four to six weeks. Mono can cause inflammation and enlargement of both the liver and the spleen, which may explain a high CPK. If this is the case, please avoid contact sports or other strenuous acts until your organs are their normal size (can be checked with sonogram/ ultrasound).

More information about mononucleosis is here: http://www.mayoclinic.com/health/mononucleosis/DS00352

I also see you did a heavy work out, (20 squats) and wonder how much of your pain can be attributed to that; but unless you were doing something with your arms at the time, it would not explain the arm pain.

I hope I was able to help, and that you feel better soon,
Sincerely,
Susan
Customer: replied 2 years ago.


Hi Susan,


Do you think this episode could have just been the result of too much work. I work in an outpatient setting, using my hands all day.


I feel about 75 % better but, I have not worked since Saturday.


I am afraid that when I work tomorrow I will be fatigued and in some pain/discomfort in my arms. I dread it!


 


I am looking into the anti-inflammatory diet. Maybe something like this will help? I have a ton of environmental allergies and a touch of autoimmune disorder to my thyroid..that is under control and levels are normal. But, maybe with all the stress I am causing some type of autoimmune reaction/inflammatory reaction within my body. Can this happen?


 


Thank you,


Lynette


 


 

Expert:  Nurse Susan replied 2 years ago.
Hi JACustomer / Lynette,

Thanks for that additional detail. If you do a lot of work with your hands I suppose it is possible you stressed your arm or shoulder in some way and that is the cause of the arm pain you had. But it doesn't explain the sore throat or the high CPK. I wonder if some of that high CPK is a result of the autoimmune disorder of your thyroid. I am guessing it is Hashimoto's syndrome? Many women have that hypothyroid disorder; it should not raise your CPK that high though. Autoimmune thyroid disorder may cause a elevated ANA test, but I still think the test is worthwhile if you still have this pain; having one autoimmune disease does not mean you can not get another.

You can certainly try the anti-inflammatory diet and see if that helps any, but I would keep an eye on that CPK level. It is saying something is going on in your body.

See what happens with work tomorrow. If the pain comes back, it is stronger evidence that it could be from overuse or some sort of muscle stress....but I would still wonder why your arms would be so easily provoked to pain. Yes, stress can make autoimmune disorders worse, if this is one.

My advice, see what happens...and follow up with your doctor if this pain continues or worsens and certainly the rheumatologist regarding the Lyme's disease result. You may also be feeling better because the doxycycline is working. Repeat the CPK and get an ANA if your doctors agree that it is worthwhile.

I hope I was able to help, and that you had a happy Labor Day celebration.
Sincerely,
Susan
Customer: replied 2 years ago.

Hello again,


Both Lyme tests were both negative. The doc told me to continue taking the antibiotic until I see the rheumatologist. I will ask the rheum. to take the CPK level again and ask about the ANA test. My arms are a bit sore from working (I am still here..a long day unfortunately).


My thyroid levels were normal on Friday so, I don't think it could be that.


Hmmmm... I guess I will just wait and see after I talk to the rheum.


 


Also, you don't think that just overworking could cause an increase in CPK. I know it can happen with strenous exercise...I guess overworking could be a form of strenuous exercise. But, I guess it should have gone down after working?


 


 


thanks for your help!


 

Expert:  Nurse Susan replied 2 years ago.

HI Lynette,

You are most welcome! I am pleased I can be of help. I am so happy your Lyme's test was negative. Second stage Lyme's with its joint pains was not a thing you needed.

Strenuous exercise can cause inflammatory changes that can raise those markers that measure inflammation like CPK because the work out is itself a source of inflammation. I do not know what you do but I think you are in health care in some way given that you wrote you work in an "out patient setting". I cant see any health care profession's tasks being so constantly strenuous to the extent that they raises ones CPK.

Since Lyme's is out of the question, maybe this is something a bit more unusual. An outside thought that occurred to me was wondering if for some reason...maybe due to the exercise, maybe due to something else, you had a condition where the muscle fibers themselves break down. This is called rhabdomyolysis, and while some cases can be mild some can be rather severe. Symptoms are joint pain, fevers, fatigue, muscle aches. People with this can also report abnormal colored urine because of the breakdown of muscle. The confounder here is that rhabdomyolysis will raise some liver enzymes, and you write that all your tests in the Comprehensive Metabolic Panel (They'd be SGOT/ SGGT or written as ALT and AST) were normal. There are quite a few different causes of rhabdomyolysis, strenuous exercise is one. Here is more information on it, and you will see that many of its most common causes seem to have nothing to do with you at all.

http://www.nlm.nih.gov/medlineplus/ency/article/000473.htm and http://www.medicinenet.com/rhabdomyolysis/article.htm (this article has a more comprehensive list of causes)

It really is a shot in the dark, but it is worth asking the rheumatologist about, and his or her response may well be that the online nurse is nuts.

I hope that helped, and please keep me informed about what the rheumatologist had to say.

Sincerely,
Susan

Nurse Susan, Nurse (RN)
Category: Health
Satisfied Customers: 1086
Experience: RN, BSN, MSN-ED, Nurse Educator whose passion is helping people understand their health and wellness
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Customer: replied 2 years ago.

 


Hi Susan,


I did read about the rhabdomyolosis and bizarrely enough, I did have some darker urine. I remember asking myself if I took any extra supplements! I know that is probably not what it is.


I did some light and deeper massage and a lot of joint work/stretching for people (I am an occupational therapist) that week. I usually don't sleep well anyway and like I said, I was under an enormous amount of stress.


But, I will see tomorrow. My arms are not 100% but they are a lot better than one week ago.


I will see the MD tomorrow so, I will let you know. Maybe he will just repeat the CPK and do the ANA test.


Thank you!

Expert:  Nurse Susan replied 2 years ago.

Hi Lynette,

Thank you so much for the Accept and the lovely bonus. And Occupational Therapists do work quite hard....but I cant see that as enough to raise the CPK like that. Please do let me know what the MD has to say...and good luck at the appointment! I hope you continue to feel better.

Sincerely,
Susan

Customer: replied 2 years ago.


Thanks, Susan!

Expert:  Nurse Susan replied 2 years ago.
Lynette you are quite welcome.
Sincerely, Susan
Customer: replied 2 years ago.


HI Susan,


Just following up with you. The rheumatologist thinks that I had a virus. He said that my CPK level was not really significant. Usually a value of 500 is significant. He wants me to check my value again and follow-up with him in 8 weeks if I do not feel 100%. Thankfully I am feeling normal again.


Thank you again for your assistance!

Expert:  Nurse Susan replied 2 years ago.
Hi Lynette,

I was not notified that I had a lovely message from you! Thank you so much for the follow up there. I am happy it was due to a virus and not anything horrible.

I hope you continue to keep healthy,
Sincerely,
Susan

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