Operational Medicine 2001
Cold Intolerance

Cold 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

• Eating Disorders.  Primary care Medicine, Goroll, 3^rd ED.  Lipincott-Raven Publishers, NY;1995: 1074.

• Becker H. Medical Limitations to Wilderness Travel, Emergency Medicine Clinics of North America Feb 1997;  15 (1):17-28.

• Ayala AR.  When to treat mild hypothyroidism.  Medical Clinics of North America Jun 2000; 29 (2): 199-209.

• Campbell RA  What is Cold intolerance?   Journal of Hand Surgery 23(1); Feb 98:3-5.

• Kreipe RE.  Eating Disorders in adolescents and young adults.  Medical Clinics of North America  Jul 2000; 84 (4):1027-1049.

This section provided by LT Daniel Seidensticker, MC, USN

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Operational Medicine 2001
Health Care in Military Settings

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