Today’s case is an example of a very common complaint that patients come into the clinic for – “el gripe.” When translated, it literally means “flu,” but really I feel that it encompasses any or all of the symptoms of an upper respiratory illness (URI) or common cold. While URI’s and common cold symptoms are certainly very common in the U.S. as well, the treatment here in Peru is very different. Today’s case is actually based on Janie‘s symptoms and experience getting treated at the Belen Clinic, as she was recently “under the weather.”
HPI: 28 yo female presents to the clinic with a sore throat, nasal congestion, and headache. Overall, she felt very tired and “drained.” Symptoms had started about 3 days prior, and were not improving. She denied any cough, fever, nausea/vomiting/diarrhea. No recent sick contacts or sick persons within the household. She had tried some local over the counter cold medicine (psuedoephedrine/paracetemol combo) but still did not have much relief (on a side note, you do not need a prescription to buy antibiotics in Peru, so many patients will self-medicate, unfortunately for the wrong reasons or with an irregular dosing regimen).
PMHx, PSHx, FHx, SHx: History of mild seasonal allergies, no history of asthma; otherwise non-contributory
Gen: no apparent distress, voice sounds congested
HEENT: mucous drainage from nose, no sinus tenderness, no tonsillar exudates or erythema
Lungs: clear to auscultation bilaterally, no respiratory distress
Brief Differential Diagnosis:
– Viral Upper Respiratory Infection (Common Cold)
– Acute Sinusitis
Lab Tests: None Ordered
Treatment Plan: Based on the history and physical, we diagnosed our patient with a simple viral upper respiratory infection. Because there was no evidence of a bacterial origin, we chose not to give antibiotics (although Amoxicillin is commonly prescribed here for “common cold” symptoms, and furthermore many Peruvian patients expect to receive antibiotics). Because the infection is of viral origin, the best treatment we can offer is symptomatic, and allow body takes its course to impede the virus.
In the U.S., common treatments for “cold” symptoms are usually over the counter cough suppressants, nasal decongestants, throat analgesics, anti-pyretics/anti-inflammatories, etc. While some of these treatments are also commonly employed here in Peru as well, the mainstay treatment here for URI pain and symptoms is to give a shot of a combination of low dose dexamethasone and diclofenac. Dexamethasone is a steroid which works to suppress the body’s own immune system to decrease inflammation and release of prostaglandins, which cause pain. Diclofenac is an anti-inflammatory (NSAID) that also helps to relieve pain and inflammation.
Although it was foreign as a treatment for URI symptoms, Janie opted to go with the dexamethasone/diclofenac shot. The shot is given intragluteal (in the buttocks for the layperson) by one of the nurses in the clinic. According to Janie, she noticed improvement in her symptoms within a half-hour, and had a “100% improvement.” The problem with the shot is that the effects only last about a day, and so therefore her treatment plan was also supplemented with daily “AntiGripe,” a brand name drug for an oral anti-inflammatory and decongestant. Sometimes physicians will prescribe 2 days of dexamethasone/diclofenac shots to further relieve symptoms.
As I was surprised at how well the dexamethasone/diclofenac shot (or “the double – D” as I like to call it), worked in relieving symptoms, I wanted to search the literature to see if there was any further evidence of efficacy. As such, I found a systematic review titled “Steroids as Adjuvant Therapy for Acute Pharyngitis in Ambulatory Patients: A Systematic Review.” The review analyzed 5 randomized control trials that were testing steroids for symptomatic relief of URI symptoms. While the studies reviewed were not flawless, the results showed that steroids are effective for pain reduction in adult and pediatric patients complaining of sore throat. All RCTs found an earlier reduction in pain or complete pain relief after steroid administration compared withplacebo and concluded that steroids are effective. However, the authors also concluded that although no serious adverse effects were observed, the benefits must be weighed against possible rare adverse drug effects and further medicalization of a condition for which most people do not seek medical attention.
The question remains, if low-dose steroids are so effective at symptomatic relief of pain and inflammation, why don’t we see more of their use in outpatient clinics with the U.S.?
For further reading, please see: