“Gone Away” and life’s transience and fragility

This weekend, I had the privilege of watching Five Finger Death Punch cover The Offspring’s “Gone Away” here in Phoenix. Three months ago, I watched Dexter Holland play the piano version of his own song from almost the same spot in the same venue.

Both singers paid tribute to friends they lost years ago. Before his version, Five Finger frontman Ivan Moody discussed his struggle with alcoholism and recent sobriety. He then asked the audience if they knew how much time they had left in life.

I turned to my friend and told him I did not want to think about that. The honest answer—for most of us, but especially me—is I don’t know.

As a writer and guitarist struggling with dermatomyositis, songs like “Gone Away” almost make me cry these days. They remind me, as Moody reminded us, of life’s transience and fragility.

Autoimmunity, methotrexate, and alcohol

Autoimmune patients taking methotrexate must avoid alcohol, according to most rheumatologists. So too say the makers of Otrexup (subcutaneous methotrexate). I messaged my doctor to double check: He agrees abstinence is best.

Not everyone agrees. Newer studies are changing some rheumatologists’ opinions. Many now say rheumatoid arthritis patients may consume alcohol in extreme moderation; in other words, a couple drinks a week is fine. Psoriasis patients, however, should avoid it.

So, where does that leave me? Since methotrexate is used off-label to treat dermatomyositis, all research on methotrexate and alcohol concerns psoriasis and rheumatoid arthritis patients. I can only trust my doctors and look at anecdotal evidence from other dermatomyositis patients.

Many myositis patients on online bulletin boards ignore doctors’ advice. “Live life!” they say. Others were told by their doctors a couple drinks a week is okay—just not on the same day as your injections.

One current complication for me is I am on prednisone and methotrexate. Both are hard on your liver. In fact, I can feel my liver throughout the day yelling at me. For me, until I get off the corticosteroids, alcohol is probably best avoided.

Writing and the injustices of rejection

Rejection sucks. Being rejected to your face hurts. Being rejected by judges and publishers you never met in favor of less talented authors frustrates and feels unjust.

Last May, I entered my novella, Goddess of the Night, into the industry-led American Book Fest American Fiction Awards. I didn’t expect to win. I wanted to win—even if it was ninth-place runner-up in the literary fiction category. I hoped some publisher would read my book and enjoy it. I prayed they would help me market it. At the very least, I expected an email notifying me I lost.

None of those things happened.

If I lost to Ernest Hemingway—or some other author I respected—I would graciously accept defeat. If I lost to someone more popular, someone more widely read, someone whose books sell, I would understand. But this year’s American Fiction Award for literary fiction went to Ted Morrissey’s Crowsong for the Stricken.

Apparently, Morrissey has a PhD and is a stalwart of the Midwestern Gothic genre (whatever that is). Editors compare him to horror authors Ray Bradbury (Fahrenheit 451) and Shirley Jackson (The Haunting of Hill House, from which Netflix’s acclaimed show is derived).

I read the first few pages of Crowsong for the Stricken. Morrissey’s prose is disorienting and verbose. Like some freshman creative writing major, he clogs his story with details that don’t advance the plot, with stale adjectives, and with cliched descriptions, such as: “It was a crisp October wind and orange embers bright in the starless night fell upon the Harper’s roof like God’s wrath become visible.”

Really? He couldn’t think of a better metaphor than hellfire? Or a less laundered adjective than “crisp”?

Creative writing PhDs can write. One of my favorite authors, TC Boyle, was an English professor at the University of Southern California. Perhaps even Morrissey can. But the prose in the Amazon preview of Crowsong was hardly award worthy.

A political thriller awarded by the American Book Fest is equally appalling. In his best impression of Victor Hugo’s worst Notre-Dame de Paris chapters, Alan Thompson drones on about the architectural history of Washington, DC, for the first several pages of his novel, Juvenal’s Lament. In fact, his history takes up the entire Amazon’s preview of his novel. All I can expect beyond page 6 is more failure.

All rejection sucks. But when you are ignored for inferior writers whose stories and words are so flawed they wouldn’t pass high-school English, when you know you penned a better-written, more coherent tale that unveils more about human nature in 187 pages than these novelists squeeze into tomes three times as long, rejection is more than an act or a feeling—it’s personal, it’s unjust.

Time to add methotrexate

My rheumatologist and dermatologist agree with the Mayo Clinic dermatomyositis guru: After ten weeks on hydroxychloroquine, with few results, I need to add methotrexate and folic acid to my regimen of medications and supplements.

Otrexup: subcutaneous methotrexate
I’ll now be injecting myself with methotrexate in the thigh once a week with a cartridge that looks like a Soviet torture device. And I’ll be taking one milligram of folic acid every day—2.5 times the amount pregnant women take to stave off birth defects.

Methotrexate suppresses the body’s immune system. Developed in the 1940s as a chemotherapy agent to treat cancer, in low doses, studies and clinics have shown it effectively treats many autoimmune disorders. It’s a first-line treatment for rheumatoid arthritis and a second-line treatment for psoriasis. (Interestingly, it also used to induce abortions.) The drug is affordable, generally safe, and well tolerated by autoimmune patients.

Only time will tell whether or not the methotrexate relieves any of my rashes and itching. Medical journals show mixed evidence of its efficacy. In this dermatology study, only 1 of 4 patients with amyopathic dermatomyositis, in this one, only 2 of 3. However, this 1998 study showed it helped all 13 patients, whether they had muscle involvement or not. This 2011 study also found methotrexate reduced skin lesions in 8 of 11 patients.

Risks of Methotrexate

Liver toxicity is a risk of taking methotrexate. Though most of the above studies tout few adverse effects, one cancer-dermatomyositis patient had hair loss. These doctors observed psoriasis and dermatomyositis patients are at higher risk to liver damage than those with rheumatoid arthritis.

That said, methotrexate side effects are much more common in cancer patients. They take much higher doses of it than autoimmune patients. Brain damage is a real possibility for them.
 
I talked to all three of my doctors about side effects and risks. All three say the medication is generally safe and not to worry. Issues listed online and discussed in medical journals mostly affect autoimmune patients also battling obesity, drug or alcohol misuse or abuse, or cancer.
 
I will need regular blood tests to check for early signs of liver toxicity before the drug causes irreparable damage.

 

Gym Results: Evidence of Dermatomyositis

A few weeks ago, my gym results were the only way I knew dermatomyositis caused my muscles to progressively weaken. Between February and late June, I lost almost half my upper body strength.

Muscle Loss of Strength (Percent)
Triceps 40.9
Biceps 45.8
Deltoids 33.3
Trapezius 45.8
Pectorals 52

My Gym Results

I have never been the strongest guy in any room. Standing 6’5”, built more like a wide receiver than a linebacker, most of my strength is in my legs. Before tearing and repairing my meniscus, I could leg press over 700 pounds.

But with a high metabolism and a sprinter’s frame, upper body strength has never been natural for me. I worked my ass off in the gym four to five days a week during my twenties just to have a body that halfway looked and felt like a man’s.

My peak strength came in summer 2016, aged 31. Since then, between work, age, and inconsistency, my strength dropped a bit. Since February, it fell off a cliff. By June, one push-up seemed impossible.

February 1, 2018 June 28, 2018
Activity Reps / Weight (lbs.)
Reps / Weight (lbs.)
Bench Press 10 / 135 10 / 65
Bicep Curls 10 / 110 10 / 65
Lateral Deltoid Raises 12 / 30 (15 each arm) 8 / 20 (10 each arm)
One-Arm Dumbbell Row 12 / 60 10 / 45
Seated Cable Row 10 / 120 10 / 60
Push-ups 20 / 215 1 / 215

Getting Stronger Every Day

With numbers like these, I have to be careful not to give up, to compare myself to the gym rats and roid ragers. I can only be who I can be.

When I look at stronger men at the gym, I remind myself my immune system is attacking my muscles, theirs is not. Worse, most anti-autoimmune drugs also induce muscle weakness. While they do reduce muscle inflammation, their benefits are almost immediately canceled out.

But the people at my gym barely notice. Some are weaker than me. I doubt those stronger care. In fact, two have even helped spot me while I embarrass myself at the bench press. They even offered sympathy for my disease.

Since June, I’ve made progress. I workout four to five days a week. I eat a high-protein, creatine-supplemented diet. I’ve gained strength in several muscle groups. Compared to my numbers in the right column above, I can do more reps with more weight.

June 28, 2018 October 15, 2018
Activity Reps / Weight (lbs.) Reps / Weight (lbs.)
Bench Press 10 / 65 10 / 75
Bicep Curls 10 / 65 10 / 85
Lateral Deltoid Raises 8 / 20 (10 each arm) 12 / 20 (10 each arm)
One-Arm Dumbbell Row 10 / 45 12 / 55
Seated Cable Row 10 / 60 10 / 90
Push-ups 1 / 215 5 / 215

Those five push-ups are sloppy, to say the least, but for now, it’s progress.

My Rudolph Nose

My nose glows red with a dermatomyositis rash like the mythical reindeer of childhood Christmases past. The moral of that story—at least the CBS claymation version—is that what seems a flaw, what makes one different, what subjects one to ridicule, may be a blessing in disguise. But humans are not reindeer. No bearded, red-suited legend is going to ask me to guide his sleigh come some unforeseen foggy Christmas Eve.

We had a web conference with video at work today. It was all too obvious to me with my nose glowing on the screen, I am not who I was. I don’t feel attractive. I don’t feel positive. I don’t want my girlfriend to touch me. I barely feel human some days.

Doctors tell me in time my hydroxychloroquine will help. It has helped a little, but not enough, not fast enough.

Still, I wait for true relief, for what after six months seems like waiting for a miracle. Still, I taper down my steroids. Still, my nose gets redder. The skin on my jaw itches so much it wakes me in the night.

Am I supposed to find meaning in a red nose? Inspiration? Am I supposed to thank God or curse nature? Am I supposed to search for some metaphorical St. Nick for some purpose in this suffering?

As the philosopher Walter Kaufmann, paraphrasing the philosopher Frederich Nietzsche, observes, nature is too well designed to lack purpose but too ill designed to demonstrate intelligence.

Yet, as intelligent, conscious beings, we think; we feel. Aware of our own fragility in the face of near constant chaos, we agonize; we suffer. Aware of our own imperfections, we criticize; we despair. We seek symmetry, predictability, stability, security, order.

So what do we do with our imperfections? Can we fix them? Should we fix them? Or do we embrace them, stare nature in the face, and tell ourselves we are more than our faults?

I may not have a red nose forever. But right now, looking at myself in a photo or a mirror hurts. I tell myself these rashes are not who I am. But right now, I see only who I used to be. I tell nature I have had enough.

Dermatomyositis and muscle weakness

Nine out of ten times, dermatomyositis presents with heliotrope rashes and muscle weakness in the upper arms or thighs. Only weeks ago, I thought was the one in ten, the rarest of the rare in which my immune system attacks my skin, but not my muscles. Last week’s visit to the neurologist, however, shows I and my doctors were wrong: An electromyography (EMG) revealed inflammation in my biceps, triceps, and shoulder blades.

Though my immune system has caused some muscle weakness, the damage is minimal.

Truthfully, this changes little. I have long suspected something was going wrong with my muscles. In February, I easily could complete 30 consecutive push-ups. Then the rashes came. And by June, I couldn’t complete one.

Preliminary tests for muscle weakness involve the doctors checking clinical levels of strength. Can I stand up without exhausting myself? Can I push the doctors arms away with mine?

Both my rheumatologist and the dermatomyositis expert at Mayo Clinic checked these. But as the dermatomyositis expert explained, in rare cases, when this autoimmune disease affects strong young men, muscle loss is not obvious, especially in the clinic. For that reason, he ordered the EMG.

Minimal muscle weakness, maximum treatments

I am glad he did. Without the EMG, I would have had no evidence of muscle loss beyond push-ups and dumbbells.

Again, this changes little. The damage to my muscles is minimal. The neurologist explained muscle involvement in dermatomyositis as not an either/or, but as a spectrum and said I am still 90 percent amyopathic. That is, the inflammation in my arm muscles is minimal.

I am not letting this disease stop me from being and feeling like a man.

Plus, I have been living as though I my muscles are under attack. I take as much creatine as an Olympic bodybuilder. I changed to a protein-heavy diet. I go to the gym at least four days a week. I spend an additional day or two strengthening my core. I am not letting this disease stop me from being and feeling like a man. I can now do five push-ups in a row.

Itching and burning and the rashes from hell

The severe itching has returned. My arms are inflamed and covered in rashes that resemble first degree burns just before they turn into blistering, second degree ones, that vivid ruby rose color that looks like I feel asleep in the Arizona sun. I feel like a shell of the creature who was once called a man.

Today marks week five since I started taking hydroxychloroquine. It is not yet working. I try to stay optimistic, to remind myself many patients only notice effects after six weeks, most notice nothing until months later. But until then, am I supposed to live in hell?

Meanwhile, my primary rheumatologist has been tapering me off steroids, slowly reducing the dosage to keep my immune system from overreacting. Taking corticosteroids for more than a few months could cause damage to my immune and endocrine systems.

Must I choose between damaging my body years from now and living in this itching, burning hell? Is the price of a quality life today a shorter tomorrow?

Some evenings, I curse my doctors’ treatment plan. Other evenings I curse myself. Others still, I curse whatever natural or supernatural entity decided I must suffer yet again, as though Scheuermann’s disease wasn’t enough, as though ADHD and depression haven’t been enough, as though life isn’t already hard enough. What kind of being would cripple his creation with a rash that makes you wish you were dead?

In reply to some twisted medical corollary to French mathematician and philosopher Blaise Pascal’s famous wager, I told my girlfriend I would gladly trade a long life in hell for a short one in paradise.

Must I make this choice?

To quote Djimon Hounsou’s character in Gladiator, Juba, “Not yet, not yet.”

One more week. Can I make it? Yes, but will six weeks be enough?

Finding beauty and inspiration in feeling overwhelmed

Today was tough. I felt overwhelmed. I’m trying to manage an autoimmune disease and four proposals at once. I itched more than usual this week. My hair has started to quickly thin. My rashes flared up. To top it off, dumbass drivers clogged Phoenix roads with accidents, turning a 20-minute drive into a 45-minute commute.

Caspar David Friedrich - Wanderer Above the Sea of Fog
Caspar David Friedrich’s “Wanderer Above the Sea of Fog” depicts man above the choppy seas, as though to say, “I can and will conquer whatever chaos may come.”

For the first time since being diagnosed, I wanted to give up. I didn’t want my life to be going from doctor to doctor, lab to lab, spending every penny I have on increasing insurance copays only for doctors to basically say the same thing week after week until the medications show results.

I’m collecting specialists like preteens collect Pokemon. At first, I thought this could be fun. Like a grueling sports practice, fun has turned into work.

In the past three weeks, I saw a dermatologist, two rheumatologists, and a psychologist. A radiologist reviewed my CT scan. Pathologists analyzed my blood. Thursday, I see my psychiatrist for my ADHD medications. I made an appointment with an ophthalmologist to monitor my retinas because of known side effects from hydroxychloroquine (Plaquenil). Next week, I have an electromyograph (EMG) with a neurologist at Mayo Clinic.

I’m collecting medical specialists like preteens collect Pokemon. At first, I thought this could be fun. Like a grueling sports practice, fun has turned into work.

Turning despair into inspiration

I want more from life. I want friends and strangers to see me not as some guy who battles an incurable illness, but as me—a writer, a thinker, a proposal specialist, an amateur saucier, a wine connoisseur.

I try not to focus on the difficult parts of my life. I try to borrow strength from overcoming my past.

This evening, I channeled my negativity and hammered out almost a thousand words in my new novel, even if they were about my character’s obsessions with Russian vodka and marijuana politics, about him being stood up by a strip-club cocktail waitress.

Writers and artists teach us how to make things beautiful, attractive, and desirable even when they are not.

Writing is what I do. For over fifteen years, it’s what I’ve done when the future seems grim, especially when I feel down. Besides, inspiration has to come from somewhere.

As the philosopher Frederich Nietzsche comments in The Gay Science, art and artists, including writing and writers, teach us “how to make things beautiful, attractive, and desirable for ourselves [even] when they are not.”

Visiting the dermatomyositis expert at Mayo Clinic

Mayo Clinic Scottsdale looks like a corss between a Cold War military complex and a lost Frank Lloyd Wright building.

Mayo Clinic Arizona is nestled on the northeastern edge of Scottsdale in the desert foothills of the McDowell Mountains. Its main structure looks like a cross between an unmapped military complex and a lost Frank Lloyd Wright building. In a nod to Wright’s organic architecture, the campus blends in with the Sonoran landscape; southern Arizona staples like saguaro, pipe organ cactus, mesquite, and palo verde surround it.

My girlfriend and I drive past the sparse vegetation, then park and enter underground, reinforcing my comparisons to a Cold War military site. We take two different sets of elevators to the second floor.

Hospitals rarely, if ever inspire positivity or happiness. Those waiting next to us either have serious health problems or are accompanying someone who does. Many are in wheelchairs. Several are bald. Others, like myself, have mottled skin.

Mayo Clinic in Rochester, Minnesota is, by most measures, the world’s best hospital. U.S. News and World Report rank its sister campus, Mayo Clinic Phoenix-Scottsdale, eleventh in the United States. I remind myself as I look around, wondering how many of these people are here as a last resort.

Mayo Clinic Uber-Rheumatologist, Part I

Just like any other visit to a specialist, after being called back, a nurse measures my height and weight, and I put on a gown. I wait.

The physician’s assistant enters with a stack of paperwork—written testament to the amount of time I’ve spent over the past six months in doctor’s offices, labs, and imaging centers. Unlike many physician’s assistants, this woman’s thoroughness and knowledge of internal medicine is immediately apparent.

After reviewing my medical history, she spends another half-hour examining my muscles, rashes, and lungs. She finds no additional evidence of muscles weakness or lung involvement.

Mayo Clinic Uber-Rheumatologist, Part II

The doctor enters. In my mind, I’ve talked up his reputation and specialty as though he holds all the answers, but as I told my girlfriend that morning, he is not a miracle worker. But he does know more about dermatomyositis than all but a handful of other highly trained men and women.

The rheumatologist re-checks my muscle strength. He remarks my muscle strength is excellent, but unlike my regular rheumatologist, he notes when a dermatomyositis patient works out as much as me, it’s possible people do not notice the muscle regression.

I certainly did. I went from being able to do thirty push-ups to being able to squeeze out three. Of course, that weakness could be from all the corticosteroids I’ve needed to manage my condition.

He surveys my rashes, then says these are classic dermatomyositis rashes. It’s a relief for someone to immediately recognize what I have.

All that said, he agrees with my rheumatologist that I most likely have amyopathic dermatomyositis. He thinks my prognosis is actually quite good and likes my current treatment plan. He nonetheless orders an electromyography (EMG) test to confirm my muscles are in good health and additional imaging to make certain I do not have cancer (10 percent of dermatomyositis patients have cancer).

My girlfriend asks him if my muscles could get worse over time, if my immune system could further attack itself, if this is only the beginning of the end. She wants answers, to know I’ll be around to love her as long as she is to love me.

He cannot promise that. Neither can I. But for now, apart from the itchy, painful rashes covering my chest and arms, I still have my health.