Episode #359: Fever, Rapid Heart Rate, and Difficulty Swallowing in 22-Year-Old Bodybuilder (Medical Mystery)

Summary

In this episode of the Barbell Medicine Podcast, hosts Dr. Jordan Feigenbaum and Dr. Austin Baraki engage in a medical mystery case, exploring the complexities of leptin resistance, the role of wellness influencers, and the misconceptions surrounding back pain. They analyze a quack watch article on back pain advice, discuss the importance of movement, and delve into a patient’s presentation of extreme pain when swallowing in a young bodybuilder.

🎧 Listen on Apple Podcasts: https://podcasts.apple.com/us/podcast/episode-359-fever-rapid-heart-rate-and-difficulty/id1199780143?i=1000720587301

Key Takeaways

Episode Timestamps

01:47: Leptin Resistance

09:03 Quack Watch

26:00 Case

Clinical Pearls

References

• Quack Watch: https://www.nytimes.com/2025/03/28/well/bad-habits-back-spine-surgeons.html 
• Case:  https://link.springer.com/article/10.1007/s11606-023-08432-9  
• https://pmc.ncbi.nlm.nih.gov/articles/PMC11395561 
• https://pmc.ncbi.nlm.nih.gov/articles/PMC11179451/ 
• https://pubmed.ncbi.nlm.nih.gov/36764046/ 

Transcript

Quack Watch

• https://www.nytimes.com/2025/03/28/well/bad-habits-back-spine-surgeons.html 
• “As I write this, I’m wearing a large heating pad on my back like a cape. Why? Because when I parked my car at the grocery store, I made the mistake of twisting around to grab shopping bags from the back seat.”
• “So I thought it might be helpful to focus on how to prevent back pain in the first place. I’ve asked orthopedic doctors for their best tips.”
• Dr. Arthur L. Jenkins III, a neurosurgeon in New York City who specializes in spinal surgery, says to avoid bending, lifting, and twisting (The BLT)
  • maximizes the stress on the disc, making it more likely to rupture,” Dr. Jenkins said. “As a spine surgeon, I would never do it.”
• “When lifting an object, make sure both feet are planted and your weight is evenly distributed. Then lift from your legs instead of your arms and back.” said a spine surgeon at the Hospital for Special Surgery in Manhattan.
  • “I’m in my mid 40s, and I no longer help family members move furniture,” he said.
• Dr. Alpesh Patel, a spine surgeon at Northwestern Medicine, often sees patients “running into trouble” with activities such as pickleball, paddle tennis and golf.
  • “flexibility is key,” Dr. Patel said. So build in a warm-up and stretching routine before and during these sports, recommended Dr. Patel. “For example, with golf, add a low back and chest stretch every three holes
• Don’t overload your carry-on bag.
  • “That’s not a motion most people do every day,” Dr. Sokunbi said. So be mindful not to overload your luggage, he advised.
  • Dr. Jacob Joseph, a neurosurgeon at University of Michigan Health specializing in spinal injuries, “I personally never take a carry-on bag on planes anymore,” he said.
• Steer clear of situps.
  • they may put a lot of stress on the discs in your spine. Core-strengthening exercises such as planks, Pilates, swimming, yoga and the elliptical machine “are a lot healthier for your back in general,” he said.
• Nothing about RT, staying calm if you have an injury, lots of focus on the disc vs more common non specific LBP, nocebo?
• Pain ed, BPS,  exercise counseling should be in med school….

Paper: https://link.springer.com/article/10.1007/s11606-023-08432-9 

Presentation

Here’s the sign out you get from the ED:

• 22 year old male with 4-day history of fevers, difficulty swallowing, and throat pain that’s associated with SOB
• You go see the patient, I’ll be playing the role of the patient
  • Torque Lewith, but my friends call me T
  • Are you Austin BarbellMedicine?
  • Sx for 4 days
    • Started 4 days ago
    • Post workout meal (normal), workout was SBD, all normal
    • That night, got Fever to 101 at home
    • Difficulty swallowing, mostly from pain so its hard to eat or drink
    • No food getting stuck
    • No nausea, vomiting, throwing up blood, or in stool, no weight loss
    • No meds, no medical hx, no drug use, no tobacco 
    • Supplements- multivitamin, pre workout- it’s 3rd party tested bc I listen to BBM

Thots/play along at home

Exam/Workup

• VS significant for HR 110bpm and fever 101*F, otherwise normal BP, o2 sats
• Physical exam
  • Appears nontoxic, well nourished, and alert and oriented
  • Head and next exam- no lymph node swelling, no thrush, no focal deficits
  • Cardiopulmonary exam normal
  • Maew
• Labs
  • Normal chemistry save for creatinine 1.5
  • D dimer 595 ng/mL FEU
    • Austin, what’s a D-Dimer
  • Negative for HIV, CMV, HSV
• Imaging
  • EKG sinus tachycardia
  • CT chest shows no PE, but some circumferential distal esophageal thickening 
• Thots?

Further Workup

• Talk to the patient?
• Esophageal gastroduodenoscopy
  • Severe punctate ulcerations, linear ulcers, and scattered linear gastric erosions
  • Biopsy shows severe chronic inflammation of squamous mucosa with basal cell hyperplasia and lots of eosinophils 
• Thots/diagnosis?

Diagnosis/Course

• Patient received supportive care via IV hydration
• Fevers, tachycardia, and elevated creatinine resolved 
• Started on PPI, Diet was advanced and patient was able to tolerate normal diet before discharge
  • 4 weeks later, endoscopic improvement nearly normal, PPI stopped at 8 weeks
• Esophageal ulcer from dry scooping 

Pearls

• Esophageal Ulcers
  • Def: “Discrete breaks in the tissue lining the esophagus” 
  • Causes
    • GERD
      •  most common (LES weakening/inappropriate relaxation) > erodes tissue and can cause ulcer formation, about 60-80% of cases 
      • Prolonged exposure to a caustic agent…like the acidic gastric juice in the stomach leads to injury 
      • LES weakening/inappropriate relaxation
    • Drugs- 2nd most common, NSAIDs, antibiotics (doxycycline) are common (a quarter)
      • Lots of different drugs tho
      • Supplements- l-arginine, caffeine….
        • Alkaline (basic) and acidic stuff can cause injury
          • Common ingredients in pre workout
            • Malic acid- acid induced injury pH 2-3
            • Citric acid (pure is 1.5)
            • Tartaric acid (1.6)
        • study conducted with the purpose of analyzing the pH of energy drinks and pre-workout beverage found that
          • Pre workouts mixed with water, which is neutral (ph 7)
          • pH ranged from 3-4
            • https://pmc.ncbi.nlm.nih.gov/articles/PMC11395561 
            • Likely lower when dry scooped
      • Direct caustic exposure > damage to tissue 
    • Infections (HSV, CMV, HIV), 
    • Other stuff like radiation, various autoimmune diseases, cancers, and genetic conditions
  • Symptoms
    • Heart burn, chest pain (not from heart),
      • Case report of STEMI in healthy 25 yo man 
      • https://pmc.ncbi.nlm.nih.gov/articles/PMC11179451/ 
    • Difficulty swallowing-dysphagia
    • Pain with squallowing- odynophagia 
    • Nausea, vomiting, lack of appetite 
    • Bleeding > hemetemesis if thrown up, melena (dark blood) in stool or if brisk, hematochezia (bright red blood) in stool
  • Evaluation
    • Upper GI endoscopy for both diagnosis and treatment 
    • Can also use esophagram or barium swallow 
  • Tx
    • Stop bleeding (if bleeding) 
    • GERD -PPI
    • Infection- tx with appropriate antiviral or antibiotic
    • Caustic-remove caustic agent, secure airway, NPO due to risk of perforation> advance as tolerated 
  • Complications
    • Bleeding, perforation, stricture (narrowing of esophagus > stenting or surgery)
  • Dry Scooping
    • Recent study analyzed nearly 3000 young Canadians who worked out and used a pre workout
      • 17% reported dryscooping in the past year
      • https://pubmed.ncbi.nlm.nih.gov/36764046/ 
    • Don’t dry scoop