In clinical practice, when one condition mimics another, it makes it difficult to obtain an accurate and timely diagnosis. The impersonating condition is a red herring, defined as "something intended to divert attention from the real problem or matter at hand; a misleading clue."
In chiropractic care, red herrings often exist in the form of pathological conditions that mimic pain of biomechanical origin.1 Many of these conditions are also referred to as red flags. Some of these red herring / flag conditions are well-known; some are not.
The purpose here is to bring two of the lesser-known red herring / flag conditions forward: alcoholism and general infections of joints and bones. These are important conditions to identify, as their presence warrants referral to appropriate medical specialists.
Red Herring #1: Alcoholism
Many of the signs and symptoms of alcoholism overlap with signs and symptoms of other spinal conditions:
Mood swings can be seen in alcoholism and in patients suffering from significant pain. Acute and chronic pain both can cause patients to have mood swings. Loss of interest in social activities and neglect of physical appearance are also common for both alcoholism and significant pain.
Patients in pain commonly do not feel well enough to maintain their normal level of grooming. It is not unusual for a patient with biomechanical spine pain to enter the office as unkempt as a severe alcoholic.
Abdominal pain can be a symptom of several conditions that refer pain to the spine. The importance here is abdominal pain that lasts longer than the typical bout of stomach flu, food poisoning or some other temporary GI irritation. A key observation is the timing of abdominal pain occurring in conjunction with spine pain. The abdominal pain from a temporary GI irritation will subside, while the spine pain will continue. In alcoholism, both pains may persist.
Weakness and numbness in the limbs are common signs and symptoms in musculoskeletal conditions. These findings can be neurological or myofascial in origin. Signs and symptoms in a single limb point to a radicular condition. Signs and symptoms in multiple limbs point to central nervous system pathology or a systemic disease such as alcoholism.
An exception here is unilateral pain in the hip region. Osteonecrosis of the femur head is a common secondary condition in alcoholism. It is thought to be the result of emboli from a fatty liver.3
Fever and weight loss are probably the two most concerning signs and symptoms. Fever could indicate viral pharyngitis, gastroenteritis or acute sinusitis, common in alcoholism or other conditions including infection of the spine. Weight loss is a common sign of cancer, especially unexplained weight loss not associated with diet and exercise. Recording vital signs identifies these findings, a procedure missing from many chiropractic patient examinations.
There are no direct tests for alcoholism. The best tests are directed at liver function and detecting cirrhosis. Information from friends and family regarding the personal habits of the patient can be eminently helpful.
Alcoholics do not tend to be completely honest about their health histories. Gathering this information is much harder than it used to be due to enhanced HIPAA laws. It is difficult to obtain permission from an alcoholic to talk to their family and friends. A discussion of the ill consequences with a suspected alcoholic is warranted as part of a thorough history and examination.
As described above, fever with alcoholism is associated with secondary infections. Since the infection could be in the spine, our focus now shifts to infections related to the spine and their red herring characteristics.
Red Herring #2: Infections
Skeletal infection or osteomyelitis was common prior to the advent of modern chemotherapy (antibiotics). Its occurrence decreased after the development of chemotherapy. Recently, there has been a resurgence of the condition in immunosuppressed patients.2 Osteomyelitis is common in immunosuppressed patients and intravenous drug users.
Staphylococcus aureus is responsible for 90 percent of osteomyelitis infections of joints and bones. It enters these areas through four major pathways; the bloodstream, spread through a contiguous source, direct implantation or postoperative infection. Yochum and Rowe relate that 50 percent of patients with osteomyelitis have pre-existing infections of the skin, genitourinary tract or respiratory tract.2 Infections comprise 10 percent of all skeletal lesions, with 90 percent of these involving the appendicular skeleton.
Bone and joint infections have different presentations between infants / children and adults.2 Signs and symptoms like pain, swelling, edema and loss of use in a limb a can all create red-herring findings that can mimic biomechanical problems and injury:
| Osteomyelitis: Signs and Symptoms in Infants /Children vs. Adults* | |
| Infant / Child | Adult |
| Pain | Pain |
| Swelling | Fever |
| Fever | Edema |
| Chills | Erythema |
| Loss of limb use (affected limb) | Malaise |
| *Most signs and symptoms occur over the affected area. | |
Radiographic examination of the infected patient may be negative early; with time, lytic bone destruction will be seen. The time between these two states is dependent upon the degree of aggressiveness of the organism causing the infection.
A key radiographic finding is joint destruction. This occurs if the infection begins in the joint or spreads to the joint. Infections will cross a joint space from one bone to the next, a feature not seen with most tumors.
Laboratory testing for osteomyelitis includes erythrocyte sedimentation rate (ESR) and determination of white cell counts. Both could be elevated by the infection. A Schilling test could also be used in conjunction with the white cell count.
Since fever is a common thread between alcoholism and skeletal infections, it should again be stressed that recording the patient's temperature is an important aspect of a musculoskeletal examination. It should also be noted that fever and infection are both associated with substance abuse. A thorough social history should be conducted to help rule substance abuse in or out for patients.
Alcoholism and its secondary conditions and various infections are only two of the conditions that can produce red-herring findings / red flags. Their identification can help provide an accurate and timely diagnosis in order to provide appropriate patient care.
References
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