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Cold IntoleranceCold intolerance is a non-specific symptom of either focal neuromuscular injury or systemic disease. History and physical exam are crucial in determining the etiology. The onset, frequency, duration, location of the cold intolerance, alleviating and aggravating factors, and any other associated symptoms need to be clarified. Cold intolerance can be
divided into acute or chronic onset, and focal or systemic symptoms, with
much overlap in between.
Although rare, “cold
intolerance” could be the initial complaint of an emergency condition. If the symptoms are of acute onset and localized to one area, e.g. the hand, vascular damage or injury
remains the first priority. Ask
about any recent trauma, family history of clotting disorders, and
associated symptoms of numbness, paresthesias, weakness, and color
changes. These should also be sought on physical exam, along with
two-point discrimination, capillary-refill, and vibratory sensation. Positive findings would
constitute a medical emergency and would need urgent evaluation.
If the symptoms are localized
but have been there chronically, this usually is the result of prior
damage or injury to that neuromuscular distribution. Ask about prior trauma or surgery to that area, possible frostbite
exposure, and occupational jobs. Posttraumatic
cold intolerance can last for 2-3 years after a significant injury. Workers with vibration-induced injury may also have associated
sensory impairment and difficulty with manual tools and handwriting. These are not emergencies and require surveillance, symptomatic
control, and minimal exposure to cold environments.
Cold intolerance of acute
onset, with associated orthostatic symptoms, nausea, vomiting, fatigue,
and overall sick-appearance could be the presentation of adrenal
insufficiency or sepsis, both of which are medical emergencies. Patients with prior steroid exposure (e.g. for asthma), with low
sodium, and high potasium on initial labs should be suspected for adrenal
insufficiency.
Evaluation of systemic cold intolerance that has been present for several weeks depends heavily on the history and physical examination. If associated with weight gain, constipation, fatigue, thinning of the hair, amenorrhea and menorrhagia, and a goiter, you should suspect hypothyroidism. If the patient delivered a baby within the last 6 months, you should suspect postpartum thyroiditis. Mild hypothyroidism can be caused by medications, including amiodarone, lithium, and interferon alpha, or by a prior history of external beam radiation to the head and neck. If the patient is a young,
extremely thin female, you should suspect an eating disorder, such as
anorexia nervosa. Other
diseases associated with malnutrition, such as inflammatory bowel disease
and celiac sprue, should be considered if the initial evaluation is
negative.
Initial labwork should include
a chem 7 (to check for electrolyte abnormalities), a TSH with Free T4, a cbc with sed rate (to screen for anemia and other
inflammatory conditions). If
bradycardic, obtain an ECG. If
normal, then regular follow up is scheduled. If the TSH is high and Free T4 is low, and repeat labs confirm these findings, one can start
treatment with thyroid replacement, with an initial dose of 1.6 mU//kg/day
of thyroid
hormone as replacement. Adjustments
are then made with small doses every 6-8 weeks. If the TSH is high with a normal Free T4, this suggests
sublinical hypothyroidism, for which treatment is controversial. Indications for treatment include reversible symptoms, high
cholesterol, or a high risk of progression (i.e., TSH>
10 mU/l, elderly).
If an eating disorder is
suspected, communication in a relaxed atmosphere and developing a rapport
with the patient is crucial. Initial therapy should focus on the symptoms, since many do
not associate their symptoms with their disease. These patients require an interdisciplinary approach with
dieticians, mental health professionals, and primary care providers. Reasons for admitting, or medevacing an anorexic would include
hypothermia and bradycardia, frequent syncopal episodes, or severe
electrolyte imbalance.
References
This section provided by LT Daniel Seidensticker, MC, USN
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*This web version is provided by The Brookside Associates, LLC. It contains original contents from the official US Navy NAVMED P-5139, but has been reformatted for web access and includes advertising and links that were not present in the original version. The medical information presented was reviewed and felt to be accurate in 2001. Medical knowledge and practice methods may have changed since that time. Some links may no longer be active. This web version has not been approved by the Department of the Navy or the Department of Defense. The presence of any advertising on these pages does not constitute an endorsement of that product or service by either the US Department of Defense or the Brookside Associates. The Brookside Associates is a private organization, not affiliated with the United States Department of Defense.
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