Vasculitis

Vasculitis

What is vasculitis?

Vasculitis means that the blood vessels are inflamed. When part of your body is inflamed, it swells and is usually uncomfortable or painful. Blood vessels are the tubes, which carry blood around your body. There are three types of blood vessels, which can be affected by vasculitis:

(1) Arteries, which take blood from the heart to various parts of the body.

(2) Veins, which take blood back to the heart.

(3) Capillaries, which are tiny vessels between the arteries and the veins where oxygen and other materials pass from the blood into the tissues

What are the causes of vasculitis?

There is no one cause, and in most cases the cause is unknown. We do know that vasculitis is not directly inherited. We know what causes some types of vasculitis – for example, drugs and a variety of infections, particularly those associated with hepatitis, can cause small vessel vasculitis.

What are the major manifestations of vasculitis?

Vasculitis can affect any system producing an almost infinite range of symptoms. Frequently, however, the initial presentation of a vasculitis will be as a skin lesion.

What should you expect from the doctor?

A full history should be taken and in view of the systemic nature of many vasculitic diseases, a complete physical examination should be carried out including central nervous system and ENT examination.

How is vasculitis diagnosed?

Depending on the degree of organ involvement, a variety of organ function tests can be abnormal. The diagnosis of vasculitis is definitively established after a biopsy of involved tissue demonstrates the pattern of blood vessel inflammation. An alternative to biopsy can be an x-ray test of the blood vessels called an angiogram, which can demonstrate characteristic patterns of inflammation in affected blood vessels.

What are the treatment options for vasculitis?

  • Glucocorticoids are an important part of therapy for most forms of vasculitis. Other immunosuppressive agents are used either because the disease is so severe that glucocorticoids alone are insufficient treatment, or because the long-term side effects of these other drugs are less severe than those of glucocorticoids.
  • Cyclophosphamide is the strongest of these immunosuppressive drugs and is used to treat severe diseases. Methotrexate, Azathioprine are used more widely in treating other rheumatic diseases are also used to treat non-life-threatening vasculitis and are useful as steroid-sparing agents.
  • Plasma exchange and intravenous immunoglobulin are sometimes used in severe cases of particular forms of vasculitis that are thought to be caused by circulating autoantibodies.

Systemic Sclerosis (Scleroderma)

Systemic Sclerosis (Scleroderma)

What is scleroderma?

Scleroderma is a chronic disease that causes skin thickening and tightening a build up of scar tissue, and damage to internal body organs.

What are the different types of systemic sclerosis?

Systemic sclerosis is classified into two main types:

(1) Limited cutaneous systemic sclerosis

  • 70% of systemic sclerosis cases
  • Affects only the face, forearms and lower legs up to the knee
  • CREST syndrome (Calcinosis, Raynaud’s disease, (Oesophageal dysmotility, Sclerodactyly, Telangiectasia) is an older term for limited scleroderma

(2) Diffuse cutaneous systemic sclerosis

  • 30% of systemic sclerosis cases
  • Involves the upper arms, thighs or trunk

What causes Scleroderma?

  • Studies of twins suggest it is not inherited.
  • Scientists suspect that scleroderma comes from several factors:
  • Abnormal immune or inflammatory activity
  • Genetic makeup: Although genes seem to put certain people at risk for scleroderma and play a role in its course, the disease is not passed from parent to child like some genetic diseases.
  • Environmental triggers: Research suggests that exposure to some environmental factors may trigger scleroderma-like disease in people who are genetically predisposed to it. Suspected triggers include viral infections, certain adhesive and coating materials, and organic solvents such as vinyl chloride or trichloroethylene.
  • Hormones: By the middle-to-late childbearing years (age 30 to 55), women develop scleroderma 7 to 12 times more often than men. Because of female predominance at these and all ages, scientists suspect that hormonal differences between women and men play a part in the disease. However, the role of estrogen or other female hormones has not been proven.

What are the main symptoms and signs of scleroderma?

  • Scleroderma is a variable, slow, and long-term disorder. It usually starts slowly, gradually gets worse over a few years, and then stabilizes.
  • An early symptom of scleroderma is an extreme sensitivity to cold, called Raynaud’s phenomenon. In Raynaud’s phenomenon, the blood vessels constrict or narrow. The narrowing of the blood vessels causes the blood supply to be greatly reduced; fingers and toes turn white and then blue. Often numbness and tingling are felt in the fingers and toes.
  • Another early symptom of scleroderma is swelling of the hands and feet, especially in the morning. The skin of the fingers and toes may look and feel swollen. It might get shiny and the usual skin creases may disappear. The facial skin may seem stiff.
  • Finger ulcers sometimes happen as a result of the narrowing of the small blood vessels. Some people will also develop small, white calcium deposits in various parts of the body.
  • Scleroderma can also cause inflammation of the joints. This may be accompanied by pain, stiffness, swelling, warmth and tenderness.
  • Muscle weakness is sometimes an early symptom of scleroderma.
  • The disease may also affect the connective tissue of the internal organs. For example, if the digestive system is involved the muscles in the esophagus may become weak. Swallowing is affected so that it is difficult to get food down into the stomach. Heartburn can be a frequent problem.
  • The lungs, heart, and kidney are occasionally involved in scleroderma.
  • Some develop severe lung disease, which comes in two forms: pulmonary fibrosis (hardening or scarring of lung tissue because of excess collagen) and pulmonary hypertension (high blood pressure in the artery that carries blood from the heart to the lungs).
  • Common among people with scleroderma, heart problems include scarring and weakening of the heart (cardiomyopathy), inflamed heart muscle (myocarditis), and abnormal heartbeat (arrhythmia).

How Is Scleroderma Treated?

Currently, there is no treatment that controls or stops the underlying problem in all forms of scleroderma. Thus, treatment and management focus on relieving symptoms and limiting damage.

Here is a listing of the potential problems that can occur in systemic scleroderma and the medical and nonmedical treatments for them:

(1) Raynaud’s phenomenon:

Don’t smoke!

  • Dress warmly, with special attention to hands and feet.
  • Dress in layers and try to stay indoors during cold weather.
  • For severe cases, speak to your doctor about prescribing drugs called calcium channel blockers, which can open up small blood vessels and improve circulation.

(2) Skin sores or ulcers:

  • Increasing your dose of calcium channel blockers
  • Applying nitroglycerine paste or antibiotic cream.
  • Severe ulcerations on the fingertips can be treated with the skin graft.

(3) Stiff and painful joints:

  • Stretching exercises under the direction of a physical or occupational therapist are extremely important to prevent loss of joint motion.
  • Exercise regularly.
  • Use acetaminophen or nonsteroidal anti-inflammatory drug.

(4) Skin disease:

  • Apply oil-based creams and lotions frequently, and always right after bathing.
  • Apply sunscreen before you venture outdoors to protect against further damage from the sun’s rays.
  • Use humidifiers to moisten the air in your home in colder winter climates.
  • Avoid very hot baths and showers, as hot water dries the skin.

(5) Dry mouth and dental problems:

  • Brush and floss your teeth regularly.
  • Have regular dental checkups.
  • Keep your mouth moist by drinking plenty of water, sucking ice chips, using sugarless gum and hard candy.
  • If dry mouth still bothers you, ask your doctor about a saliva substitute or prescription medications such as pilocarpine hydrochloride that can stimulate the flow of saliva.

(6) Gastrointestinal problems:

Eat small, frequent meals.

  • To keep stomach contents from backing up into the esophagus, stand or sit for at least an hour after eating.
  • Avoid late-night meals, spicy or fatty foods, and caffeine.
  • Oral antibiotics may stop bacterial overgrowth in the bowel, which can be a cause of diarrhea in some people with systemic sclerosis.

(7) Lung damage:

  • Pulmonary fibrosis may be treated with drugs that suppress the immune system, such as cyclophosphamide or azathioprine, along with low doses of corticosteroids.
  • Pulmonary hypertension may be treated with drugs that dilate the blood vessels, such as prostacyclin.

(8) Heart problems:

  • Treatment ranges from drugs to surgery and varies depending on the nature of the condition.

(9) Kidney problems:

  • Renal crisis occurs in about 10%t of all patients with scleroderma, primarily those with early diffuse scleroderma. The renal crisis results in severe uncontrolled high blood pressure, which can quickly lead to kidney failure. Check your blood pressure regularly. If you have kidney problems, take your prescribed medications faithfully.

Systemic Lupus Erythematosus (SLE)

Systemic Lupus Erythematosus (SLE)

What is SLE?

SLE is a chronic inflammatory disease that can affect the skin, joints, kidneys, lungs, nervous system, and other organs of the body. Usually, patients have skin rashes and arthritis, as well as fatigue and fever.

Who gets SLE?

SLE affects about 1 in 10,000 people in the world. It is ten times more common in women than men. It most typically develops in women aged between 20 and 40.

What causes SLE?

SLE is a complex disease, and its cause is unknown. In studies of identical twins, when one twin has SLE, the other twin has a 24% chance of developing it. This and other research suggests that genetics plays an important role, but it also shows that genes alone do not determine who gets SLE and that other factors play a role.

Some of the factors scientists are studying include sunlight, stress, hormones, cigarette smoke, certain drugs, and infectious agents such as viruses. Recent research has confirmed that one virus, Epstein-Barr virus, which causes mononucleosis, is a cause of lupus in genetically susceptible people.

In lupus, the body’s immune system does not work, as it should. A healthy immune system produces proteins called antibodies and specific cells called lymphocytes that help fight and destroy viruses, bacteria, and other foreign substances that invade the body. In lupus, the immune system produces antibodies against the body’s healthy cells and tissues. These antibodies, called autoantibodies, contribute to the inflammation of various parts of the body and can cause damage to organs and tissues. The most common type of autoantibody that develops in people with lupus is called an antinuclear antibody (ANA) because it reacts with parts of the cell’s nucleus.

What are the symptoms of SLE?

Patients with SLE can have one or more of the following symptoms:

  • Fever, fatigue, and weight loss
  • Arthritis lasting for several weeks in multiple joints
  • Butterfly-shaped rash over the cheeks or other rashes
  • Skin rash appearing in areas exposed to the sun
  • Seizures, strokes, and mental disorders
  • Blood clots
  • Miscarriages
  • Blood or protein in the urine
  • Low blood counts (anemia, low white blood cells, or low platelets)
  • Sores in the mouth or nose lasting for more than a month
  • Loss of hair

How is SLE diagnosed?

Giving the doctor a complete, accurate medical history is critical to the process of diagnosis. This information, along with a physical examination and the results of laboratory tests, helps the doctor consider other diseases that may mimic lupus, or determine if you truly have the disease. No single test can determine whether a person has lupus, but several laboratory tests may help the doctor to confirm a diagnosis of lupus or rule out other causes for a person’s symptoms. Most people with SLE have an antibody called antinuclear antibody in their blood. Another antibody called anti-doubled stranded DNA is often present in people with SLE.

How can a lupus patient help prevent disease activity?

Periodic increases in disease activity can usually be managed by varying medications. Since ultraviolet light can precipitate and worsen flares, people with systemic lupus should avoid sun exposure. Sunscreens and clothing covering the extremities can be helpful. Abruptly stopping medications, especially corticosteroids, can also cause flares and should be avoided. People with SLE are at increased risk of infections, especially if they are taking corticosteroids or immunosuppressive medications. Therefore, any unexpected fever should be reported and evaluated. 

How is SLE treated?

A conservative regimen of physical and emotional rest, protections from direct sunlight, a healthful diet, prompt treatment of infections, and avoidance of aggravating factors are the mainstays of lupus therapy. In addition, for female patients, pregnancy must be planned for times when the disease is under control, and the patient is on allowable medications.

Treatment options include the following:

  • Non-steroidal anti-inflammatory drugs (NSAIDs)

NSAID are commonly prescribed to ease joint or muscle pains. Examples of these are ibuprofen, naproxen and diclofenac.

  • Hydroxychloroquine

Hydroxychloroquine is often effective at improving skin problems, tiredness and joint pains that are not well controlled by non-steroidal anti-inflammatory drugs.

  • Steroids

Steroids reduce inflammation and the dose is usually given as low as possible in order to reduce any side effects from the steroids.

  • Immunosuppressant

Drugs such as azathioprine, cyclosporine, cyclophosphamide, methotrexate, and mycophenolate may be advised if you have severe SLE. These drugs are called immunosuppressive drugs because they work by suppressing the immune system.

What should I do if I have surgery to do?

Surgery may exacerbate the symptoms of SLE. Hospitalization may be required for otherwise minor procedures, and postoperative discharge may be delayed. If it is elective, the surgery should be postponed until lupus activity is under control.

What about immunization in patients with SLE?

Immunizations with killed vaccines have not been shown to exacerbate SLE. Influenza and pneumococcal vaccines are routinely recommended for SLE patients. A patient with lupus should consult her or his doctor before receiving any immunizations, even routine ones.

Spinal Stenosis

Spinal Stenosis

Spinal stenosis describes narrowing inside the spinal canal and mainly occurs from a combination of aging and degenerative changes in the spine. Wear and tear on the parts of the spine can cause discs to bulge, spine ligaments to thicken, and joints near the spinal canal to become enlarged. These can take up space inside the spinal canal and put pressure on the spinal nerves.

WHAT IS SPINAL STENOSIS?

Spinal stenosis is a narrowing of one or more areas of the spine. This narrowing, which occurs most often in lumbar region can put pressure on the spinal cord or nerves branching out from the compressed areas.

WHO GETS SPINAL STENOSIS?

This disorder is most common in men and women over 50 years of age. However, it may occur in younger people who are born with a narrowing of the spinal canal or who suffer an injury to the spine.

WHAT CAUSES SPINAL STENOSIS?

Spinal stenosis usually occurs in older people due to years of wear and tear of the spine. The changes that happen from this process include thickened ligaments, bone spurs, facet joint enlargement, and bulging discs.

WHAT ARE THE SYMPTOMS OF SPINAL STENOSIS?

When present, symptoms may include pain, or numbness or cramping in the legs, with or without back pain. Weakness in the legs may occur. Rarely, bowel and/or bladder problems can occur. Symptoms are often worse with prolonged standing or walking. Bending forward or sitting increases the room in the spinal canal and may lead to reduced pain or complete relief from pain.

HOW IS SPINAL STENOSIS DIAGNOSED?

Your physician will take a history and perform a physical examination. X-ray studies may be ordered that may reveal evidence of narrowed discs and/or thickened facet joints. A magnetic resonance imaging (MRI) study may be obtained for a more detailed evaluation of spinal structures.

HOW IS SPINAL STENOSIS TREATED?

The initial treatment for stenosis is to treat the symptoms rather than the condition itself. These treatments include:

  • Medication such as NSAID to relieve inflammation and pain
  • Rest
  • Physical therapy
  • Posture changes
  • Losing weight
  • Corticosteroid injections to reduce inflammation and relieve pain

If your condition is causing only mild symptoms and does not appear to be getting worse, your doctor may have you work with a physical therapist. A well-rounded rehabilitation program assists in calming pain and inflammation, improving your mobility and strength, and helping you do your daily activities with greater ease and ability.

Surgery is reserved for that small percentage of patients whose pain cannot be relieved by non-surgical treatment methods. Surgery will also be advised for those individuals who develop progressive leg weakness, or bowel and bladder problems.

Soft Tissue Diseases

Soft Tissue Diseases

What is tendonitis and BURSITIS?

Tendonitis is inflammation of the cord-like structure located where a muscle narrows down to join a bone. This structure called tendon, transmits the pull of the muscle to the bone to cause movement. Inflammation of the tendon is called tendinitis. In addition, Tenosynovitis means inflammation of the sheath that surrounds a tendon. Bursitis is inflammation of a bursa, a small sac that acts as a cushion or pad between moving structures (bones, muscles, tendons or skin). If a muscle or tendon is pulling around a corner, or over a bone, then a bursa serves to protect it from fraying and stress. Inflammation of this small sac is called bursitis.

These injuries typically occur when tendons are overused. For example, this may be after overuse in the course of your work. In other instances, infection can occur in a bursa or tendon sheath. Crystals, which are associated with gout, can sometimes be found in a bursa, and, like infection, may occur without any precipitating event. These problems are more common in middle-aged adults, and particularly in people who are quite sporty. They may be more common if your work involves repetitive movements such as writing, typing or use of a computer mouse.

What are the symptoms of tendonitis?

The main symptoms are pain, tenderness and sometimes swelling of the affected part of the tendon. The pain is typically when you move the affected area. The overlying skin in that area may also feel warm. You may have reduced movement or weakness of the part of the body that is pulled by the affected tendon.

Some types of tendonitis and tenosynovitis cause very characteristic symptoms, for example:

  • De Quervain’s tenosynovitis. This is a common condition that affects the tendons that are used to straighten your thumb. The typical symptom is pain over your wrist at the base of your thumb that is made worse by activity and eased by rest.
  • Tennis elbow (lateral epicondylitis). In this condition, you have pain on the outer side of your elbow. It is usually due to overuse of your forearm muscles.
  • Golfer’s elbow (medial epicondylitis). This is similar to tennis elbow but the pain is experienced on the inner side of your elbow.
  • Achilles tendonitis. This affects the large tendon just behind and above the heel.
  • Rotator cuff tendonitis. Your rotator cuff is a group of four muscles that help to lift and rotate your shoulder. The tendons from these muscles can sometimes become irritated due to overuse.
  • Trigger finger. This most commonly affects your ring finger. The condition prevents your finger from straightening fully.

How are tendonitis and bursitis diagnosed?

Diagnosis of tendonitis and bursitis requires a medical history and careful physical examination. X-rays do not show bursae or tendons, but may be useful in excluding other bone or joint problems. Blood tests are of little value in detecting these conditions and are not used.

What is the treatment of tendonitis and bursitis?

  • Stop doing the activity that caused the condition, such as sport or typing, or at least reduce it. This will help prevent any further inflammation or damage.
  • You can ease the pain and swelling by applying an ice pack or warm towel to the affected area.
  • Tenosynovitis may be treated with mild non-steroidal anti-inflammatory painkillers (NSAIDs). These should not be used for long periods of time and are not recommended for people with asthma or kidney or liver disease.
  • If there is swelling and evidence of inflammation, a steroid injection around the affected tendon or into the tendon sheath may be effective.
  • Physiotherapy, which involves manipulation and massage of the affected area, can be helpful.
  • If there are calcium deposits around the tendon, they can either be surgically removed or, if the condition is persistent, treated with a procedure called extracorporeal shock wave therapy (ESWT). ESWT involves passing shock waves through the skin to the affected areas to break up the calcium deposits.

What can I do to prevent this from happening again?

There are a few simple steps you can take to minimize your chances of developing this condition. First, always warm up and stretch before you begin any exercise. Second, always wear the correct footwear to suit the activity. And finally, if you have been away from exercise for an extended period of time you should ease back in – your tendons won’t be used to the stress!

Sjogren’s Syndrome

Sjogren’s Syndrome

What is Sjogren’s syndrome?

Sjogren’s syndrome is an autoimmune disease characterized by dryness of the mouth and eyes. Autoimmune diseases feature the abnormal production of extra antibodies in the blood that is directed against various tissues of the body. This particular autoimmune illness features inflammation in glands of the body that is responsible for producing tears and saliva.

Sjogren’s syndrome with gland inflammation that is not associated with another connective tissue disease is referred to as primary Sjogren’s syndrome. Sjogren’s syndrome that is also associated with a connective tissue disease, such as rheumatoid arthritis, systemic lupus erythematosus, or scleroderma, is referred to as secondary Sjogren’s syndrome.

What causes Sjogren’s syndrome?

The cause of Sjogren’s syndrome is not known, but it is considered an autoimmune disorder. The decreased production of tears and saliva seen in Sjogren’s syndrome occurs when the glands that produce these fluids are damaged by inflammation.

What are the symptoms of this disease?

  • The most common presenting features are dry eyes and dry mouth.
  • Dry eye/mouth may present with a number of related complaints:
  • Difficulty eating dry food, typically cracker biscuits
  • Habit of having a glass of water by the bed at night
  • Difficulty with dentures
  • Speaking for long periods of time causes hoarseness
  • Oral candidiasis (fungal infection)
  • Dry eyes tend to cause a gritty sensation. There is predisposition to blepharitis and the eyes may be sticky in the morning.
  • Dryness of the mucosa of the trachea and bronchi may present as a dry cough.
  • Dryness of the pharynx and oesophagus may cause difficulty in swallowing.
  • Disease of the pancreas can lead to malabsorption and even acute pancreatitis or chronic pancreatitis.
  • Fatigue is a common feature.
  • About 20% have Raynaud’s phenomenon.
  • Rare features include polyneuropathy or vasculitis can produce a mononeuritis multiplex.

What is the treatment for this condition?

  • There is no specific treatment for the disease but symptoms can be contained.
  • Artificial tears should be applied liberally. There are various types and some of the more viscous ones need less frequent application. Patients may try several and see which ones they prefer. If application at intervals of less than 4 hours is required then preservative-free preparations are preferred to reduce irritation.
  • Humidifiers may be helpful.
  • Severe dryness may require special glasses to improve the humidification of the eyes or temporary or permanent blockage of the puncta by electrocautery.
  • Patients should be encouraged to drink plenty to keep the mouth moist.
  • Artificial saliva is available and pilocarpine tablets have been used for this purpose. The dose is 5 mg tablets to be taken 4 times daily, before each meal and at night.
  • Topical fluoride and avoidance of sugars is recommended.
  • A possible role for immunosuppressant agents (e.g. cyclophosphamide) in the relief of ocular and oral symptoms has been identified.

What is the prognosis?

Some people may experience only the mild symptoms of dry eyes and mouth, while others go through cycles of good health followed by severe disease. Many patients are able to treat problems symptomatically. Others are forced to cope with blurred vision, constant eye discomfort, recurrent mouth infections, swollen parotid glands, hoarseness, and difficulty in swallowing and eating.

Rheumatoid Arthritis

Rheumatoid Arthritis

What is rheumatoid arthritis?

Rheumatoid Arthritis (RA) is a chronic, progressive and disabling autoimmune disease affecting 1% of the world adult population.
It affects approximately 3 times more women than men and onset is generally between 40 – 60 years of age.
Any joint may be affected but it is commonly the hands, feet, and wrists.

What is the cause of RA?

The cause of RA is unknown.

How does it present?

The major manifestations of RA are joint swelling, joint pain, morning joint stiffness of more than 30 minutes, fatigue, and feeling of having flu-like symptoms.

Can other systems be involved in RA?

Yes, other systems can be involved and this includes dry eyes, anemia, ischemic heart disease, skin nodules, and lung fibrosis.

How is rheumatoid arthritis managed?

There are a wide variety of non-pharmacologic therapies available. Education and counseling can help you to better understand the nature of RA and cope with the challenges of this condition. Programs on topics such as self-management skills, social support, and psychotherapy can be helpful. Regular exercise can help prevent and reverse pain and fatigue symptoms. Physical therapy can relieve pain, reduce inflammation, and help preserve joint structure and function.

Rheumatoid arthritis causes bone loss, which can lead to osteoporosis. Bone loss is more likely in people who are inactive. The use of glucocorticoids further increases the risk of bone loss. Consume an adequate amount of calcium (1000 to 1500 mg/day) and vitamin D (400 to 800 IU/day), either in the diet or by taking supplements will minimize the risk of osteoporosis.

Several classes of drugs are used to treat Ra: non-steroidal anti-inflammatory drugs, disease modifying anti-rheumatic drugs (DMARDs), and biologic response modifiers.

What are the goals of therapy?

  • To relieve symptoms including fatigue, pain, swelling and stiffness
  • To Prevent joint destruction, loss of joint function, deformity and disability
  • Achieve clinical remission

Reactive Arthritis

Reactive Arthritis

What is reactive arthritis?

Reactive arthritis is a type of arthritis in which the joints become painful and swollen after an infection. The infection might have been in the intestines, genitals, or the urinary tract.

Who gets reactive arthritis?

It most commonly affects men aged between 20 and 40. This is because they are most at risk of urethral infection from sexually transmitted diseases. However, it can occur at any age and in anyone. We are all at risk of getting a gut infection from food poisoning that may trigger a reactive arthritis. About 1 in 10 people in the world have a gene called HLA-B27. About three out of four people who have reactive arthritis have this gene. So, this gene seems to make you more likely to develop reactive arthritis if you have a ‘triggering’ infection.

What Causes Reactive Arthritis?

Reactive arthritis typically begins about 1 to 3 weeks after infection. The bacterium most often associated with reactive arthritis is Chlamydia trachomatis. It is usually acquired through sexual contact. Infections in the digestive tract that may trigger reactive arthritis include Salmonella, Shigella, Yersinia, and Campylobacter. People may become infected with these bacteria after eating or handling improperly prepared food, such as meats that are not stored at the proper temperature.

Approximately 80% of people with reactive arthritis test positive for HLA-B27. However, inheriting the HLA-B27 gene does not necessarily mean you will get reactive arthritis. Eight percent of healthy people have the HLA-B27 gene, and only about one-fifth of them will develop reactive arthritis if they contract the triggering infections.

What Are the Symptoms of Reactive Arthritis?

  • Reactive arthritis often affects the urogenital tract, including the prostate or urethra in men and the urethra, uterus, or vagina in women. Men may notice an increased need to urinate, a burning sensation when urinating, and a fluid discharge from the penis. Some men with reactive arthritis develop prostatitis. Symptoms of prostatitis can include fever and chills, as well as an increased need to urinate and a burning sensation when urinating.
  • Women with reactive arthritis may develop problems in the urogenital tract, such as cervicitis (inflammation of the cervix) or urethritis (inflammation of the urethra), which can cause a burning sensation during urination. In addition, some women also develop salpingitis (inflammation of the fallopian tubes) or vulvovaginitis (inflammation of the vulva and vagina). These conditions may or may not cause any arthritic symptoms.
  • The arthritis associated with reactive arthritis typically involves pain and swelling in the knees, ankles, and feet. Wrists, fingers, and other joints are affected less often. People with reactive arthritis commonly develop inflammation of the tendons or at places where tendons attach to the bone (ethesitis). In many people with reactive arthritis, this results in heel pain or irritation of the Achilles tendon at the back of the ankle.
  • Reactive arthritis also can cause spondylitis (inflammation of the vertebrae in the spinal column) or sacroiliitis (inflammation of the joints in the lower back that connect the spine to the pelvis).
  • Conjunctivitis, an inflammation of the mucous membrane that covers the eyeball and eyelid, develops in approximately half of people with reactive arthritis. Some people may develop uveitis, which is an inflammation of the inner eye. Conjunctivitis and uveitis can cause redness of the eyes, eye pain and irritation, and blurred vision.
  • Between 20-40% of men with reactive arthritis develop small, shallow, painless sores (ulcers) on the end of the penis. A small percentage of men and women develop rashes or small, hard nodules on the soles of the feet and, less often, on the palms of their hands or elsewhere.

How do we diagnose reactive arthritis?

The most reliable way to diagnose reactive arthritis is to identify the bacterial trigger in the stool or urine. Blood tests may be helpful but are not as specific as identifying the bacteria in the stool or urine.

What is the treatment for reactive arthritis?

  • If the trigger is an infection of the urethra, a short course of antibiotics will usually be advised.
  • Gut infections have often cleared on their own by the time the reactive arthritis develops. But, if a stool sample shows that a germ is still present then treatment may be advised to clear it.
  • Anti-inflammatory painkillers ease pain and stiffness.
  • An injection of steroid medicine directly into a joint is an option if it becomes badly inflamed.
  • Physiotherapy helps to keep the joints moving. It also helps to keep the muscles around affected joints strong if you are not using a joint very much.

If symptoms persist for more than a few months, or if other treatments have not worked, then you may be advised to take a ‘disease-modifying’ medicine. These aim to reduce the damaging effect on the joints.

Psoriatic Arthritis

Psoriatic Arthritis

What is psoriatic arthritis (PsA)?

  • PsA is a type of inflammatory arthritis and an autoimmune disease.
  • PsA is a chronic disease characterized by inflammation of the skin and joints.
  • The onset of psoriatic arthritis generally occurs in the fourth and fifth decades of life.
  • Males and females are affected equally.
  • No one knows what causes PsA but genetics plays a role.

What causes psoriatic arthritis?

  • If someone in your family has psoriasis or psoriatic arthritis there is a greater chance that you will develop it.
  • In patients with PsA who have arthritis of the spine, a gene marker named HLA-B27 is found in about 50% of cases.
  • Joint pain and stiffness is worse in the morning; typically lasting more than 30 minutes.

What are symptoms and signs of psoriatic arthritis?

  • The arthritis frequently involves the knees, ankles, and joints in the feet.
  • Usually, only a few joints are inflamed at a time.
  • The inflamed joints become painful, swollen, hot, and red.
  • Sometimes, joint inflammation in the fingers or toes can cause swelling of the entire digit, giving them the appearance of a “sausage like appearance”.
  • Inflammation in the colored portion of the eye (iris) causes iritis, a painful condition that can be aggravated by bright light as the iris opens and closes the opening of the pupil.
  • Inflammation in and around the lungs causes chest pain, especially with deep breathing, as well as shortness of breath.

What is the treatment for psoriatic arthritis?

  • Generally, the treatment of arthritis in psoriatic arthritis involves a combination of anti-inflammatory medications or/and Disease-Modifying Anti-Rheumatic Drugs (DMARDs).
  • Exercise programs at home or with a physical therapist can help patients with PsA.
  • Ice application after the routine can help minimize post-exercise soreness and inflammation.
  • The best-tolerated and most commonly prescribed DMARD for psoriatic arthritis is methotrexate. Other DMARDs includes Leflunomide, Cyclosporine, and Sulfasalazine.
  • Non-steroidal anti-inflammatory drugs are a group of medications that are helpful in reducing joint inflammation, pain, and stiffness.
  • Corticosteroids are potent anti-inflammatory agents. Corticosteroids can be given by mouth or injected directly into the joints to reduce inflammation.
  • Patients who experience progressive joint destruction in spite of NSAIDs are candidates for more aggressive DMARD medications.

Biologics agents like DMARDs are used to suppress inflammation and help prevent damage to the joint. In psoriatic arthritis, the biologics may also improve the psoriasis as well as the arthritis. Depending on the biologic prescribed; they are either given by injection at home or by an intravenous infusion at a clinic. Examples of biologic agents are Etanercept, Adalimumab, Infliximab and Golimumab.

Pseudogout

Pseudogout

What is Pseudogout?

Pseudogout also called Calcium pyrophosphate dihydrate deposition disease (CPPD disease). Pseudogout is a joint disease that can cause attacks of arthritis. Like gout, the condition involves the formation of crystals in the joints.

What is the cause of Pseudogout?

Pseudogout is caused by the collection of salt called calcium pyrophosphate dihydrate (CPPD). The buildup of this salt forms crystals in the joints. This leads to attacks of joint swelling and pain in the knees, wrists, ankles, and other joints.

Who get Pseudogout?

Pseudogout mainly affects the elderly. However, it can sometimes affect younger patients who have conditions such as thyroid disease, hemochromatosis, parathyroid diseases, and Wilson disease.

What are the symptoms of Pseudogout?

Pseudogout most commonly affects the knees. Other joints that may be involved include the ankles, hands, wrists, elbows and shoulders. You might experience:

Swelling of the affected joint or joints and joint pain.

What are the risk factors to developed Pseudogout?

Several factors are known to increase your risk of developing Pseudogout:

  • Older age.
  • Joint trauma.
  • Genetic disorder. Families can pass predisposition to CPPD crystals through their genes.
  • Excess iron stored in your body (hemochromatosis).

How is pseudogout treated?

When calcium crystals cause swelling and tissue damage you may be given a non-steroidal anti-inflammatory drug (NSAID). For severe pain and swelling, fluid from the affected joint is removed. Your doctor may also inject a corticosteroid, a powerful anti-inflammatory drug, into the affected joint.

Polymyalgia Rheumatica

Polymyalgia Rheumatica

What is polymyalgia rheumatica?

Polymyalgia rheumatica (PMR) is a condition that causes inflammation of large muscles. PMR mainly affects people over the age of 50.About 1 in 1,000 people over the age of 50 develop PMR each year. Women are three times more likely to be affected than men.

What causes PMR?

The cause of PMR is unknown. PMR does not arise from side effects of medications. PMR has a particular tendency to involve the shoulder and hip joints, and the bursa around these joints.

What are the symptoms of PMR?

If you have PMR you probably have severe and painful stiffness in the morning, especially in your shoulders and thighs. You may find that the stiffness in your arms is so bad that you cannot get out of bed without help, or you may have real difficulty dressing yourself or climbing stairs. It is also common to feel generally unwell or even to run a slight fever.

What tests are needed to diagnose PMR?

The diagnosis of PMR depends on your doctor taking a thorough history of your illness, followed by an examination and relevant tests. If PMR is suspected, your doctor will usually arrange for you to have a blood test called the erythrocyte sedimentation rate (ESR). Your doctor may also arrange for tests in order to rule out other diseases.

What is the treatment for polymyalgia rheumatica?

A steroid medicine such as prednisolone is the usual treatment. Steroids work by reducing inflammation. Treatment usually works quickly, within a few days. After starting treatment, the improvement in symptoms over 2-3 days is often quite dramatic. Treatment is usually started with 15 to 20 mg per day. This is then reduced gradually to a lower ‘maintenance’ dose. Treatment is often required for 2 years or longer, and some people with PMR need to remain on small doses of steroid tablets for many years.

Pain In The Tail Bone (Coccydynia)

Pain In The Tail Bone (Coccydynia)

What does the coccyx do?

The coccyx is sometimes referred to as the ‘tail bone’ because it is the last remaining part of the full tail that belonged to our ape-like ancestors. The coccyx is located just above the cleft in the buttocks, and it curves forwards so that it points towards the front of the body.

What is coccydynia?

Pain in the area of the coccyx is called coccydynia. Coccydynia can be anything from discomfort to acute pain, varying between people and varying with time in any individual.

What are the symptoms of coccydynia?

The classic symptom is pain when pressure is applied to the tailbone, such as when sitting on a hard chair. Symptoms usually improve with relief of pressure when standing or walking. Some patient may experience pain during bowel movements, or pain during sex.

What cause coccydynia?

Coccydynia can follow after falls, childbirth, repetitive strain or surgery. In some cases the cause is unknown. It is five times more common in women than men, probably because the female pelvis leaves the coccyx more exposed.

How we diagnose coccydynia?

One of the first aims of investigation is to rule out any diseases such as cancer or fracture as the cause of the pain. This is very unlikely, but it needs to be checked. X-rays, CAT scans, and MRI scans may be used for this purpose.

What treatment options for coccydynia?

  • Pain-relieving medications including anti-inflammatory drugs may be prescribed.
  • A stool softener may help prevent constipation and reduce painful bowel movements.
  • Symptoms may be relieved by sitting on one buttock or sitting on a donut-shaped foam or inflated pillow.
  • A physical therapist may be able to help with coccygeal massage, positional release, and stretching of the levator ani muscle.
  • The therapist can teach you how to relax the pelvic floor muscles.
  • In chronic cases, local nerve blocks may be beneficial. Injection of a local anesthetic and corticosteroid is given directly into the painful segment.
  • Removing the coccyx called a may be considered only when conservative care fails to relieve painful symptoms or if symptoms recur.

What can I do to help relieving the pain?

  • If you have coccydynia, it may not be possible to reduce the pain of sitting down altogether. However, it may help to lean forward in your seat and rest your arms in front of you on a flat surface, such as a table.
  • Wear loose fitting clothes that will not squeeze the tissues around your coccyx.
  • Wear flat, comfortable shoes.
  • Try sleeping with a pillow or cushion between your knees.
  • Applying either a warm or cold pack to the base of your spine may help to ease your pain.

Paget’s Disease of Bone

Paget’s Disease of Bone

What Is Paget’s Disease of Bone?

Paget’s disease is a chronic disorder that can result in enlarged and misshapen bones. The excessive breakdown and formation of bone tissue cause affected bone to weaken—resulting in bone pain, misshapen bones, fractures, and arthritis in the joints near the affected bones.

What causes Paget’s disease?

The cause of Paget’s disease is unknown. It does appear to be, at least partially, due to heredity, perhaps when activated by exposure to a virus.

What are the main symptoms and signs of Paget’s?

  • Pain may develop directly from a bone affected by the Paget disease, or more often, from complications related to the presence of abnormal bone. Examples of complications include arthritis (when bones near a joint are affected) and numbness or weakness (due to pressure from a bone on a nerve).
  • Abnormal bone growth may cause visible deformities, particularly in the arms, legs, skull, and clavicle. If the leg is affected, there can be bowing of the leg, which can cause a limp or back or joint pain.
  • The abnormal bone of Paget disease is more likely to fracture when exposed to weight-bearing stresses.
  • The risk of developing tumors of the bone is increased in people with Paget disease.

How do we treat Paget’s disease?

The goal of treatment is to relieve bone pain and prevent progression of the disease. Several bisphosphonates are currently available to treat Paget’s disease. Calcitonin is a naturally occurring hormone made by the thyroid gland. The medication may be appropriate for certain patients but is less effective than bisphosphonates and seldom used.

Medical therapy before surgery helps decrease bleeding and other complications. Patients who are having surgery should discuss pretreatment with their doctor. Surgery may be advised for three major complications of Paget’s disease:

  • Surgery may allow fractures to heal in better position.
  • Severe degenerative arthritis. Hip or knee replacement may be considered if disability is severe and medication and physical therapy are no longer helpful.
  • Bone deformity. Cutting and realigning pagetic bone may reduce the pain in weight-bearing joints, especially the knees.
  • Women age 50 and older and men age 70 and older should get 1,200 mg of calcium and at least 600 IU of vitamin D every day to maintain a healthy skeleton.
  • Exercise is important because it helps preserve skeletal health, prevent weight gain, and maintain joint mobility.

Osteoporosis

Osteoporosis

What is osteoporosis?

Osteoporosis (OP) is a disease in which the density and quality of bone are reduced. As the bones become more porous and fragile, the risk of fracture is greatly increased. The loss of bone occurs “silently” and progressively.

What are the Symptoms and Risks factors for (OP)?

Because bone loss is gradual and painless, there are usually no symptoms to indicate that a person is developing osteoporosis. This is one reason why osteoporosis is often referred to as the “silent epidemic”.

People with the following risk factors are at increased risk for OP:

  • Thin, small-boned frame.
  • Broken bones, stooped posture in older family members.
  • Early estrogen deficiency in women who experience menopause before age 45.
  • Advanced age in both men and women.
  • Diet low in calcium and vitamin D.
  • Cigarette smoking.
  • Excessive use of alcohol.
  • Prolonged use of glucocorticosteroids.
  • Excessive thyroid hormone.
  • Prolong use of some anti-seizure medications such as phenytoin, carbamazepine, primidone, phenobarbital, and valproate).

Why it’s important to make an early diagnosis?

As osteoporosis has no obvious symptoms other than a fracture when the bone is already significantly weakened, it is important to go to your doctor if any of the risk factors apply to you. By making positive lifestyle changes and following appropriate treatment strategies in consultation with a doctor this will prevent OP.

How you can prevent OP?

  • Fortunately, preventive treatments are available that can help to maintain or increase bone density. The most important treatments for preventing osteoporosis include diet, exercise, and stopping smoking.
  • The nutritional and lifestyle criteria to prevent excessive bone loss would include adequate calcium and vitamin D intake, and regular, weight-bearing exercise.
  • Experts recommend that premenopausal women and men consume at least 1000 mg of calcium per day; this includes calcium in foods and drinks plus any calcium supplements. In addition, experts recommend that most people consume 800-1000 International Units (IU) of vitamin D each day.
  • Exercise helps rebuild bone and strengthens muscles. Walking, low-impact aerobics and stationary cycling are all good forms of exercise.Your doctor or physical therapist will help you find the exercise that meets your needs best.
  • Taking measures to prevent falls can decrease the risk of fractures. Such measures may include the following: remove loose rugs and electrical cords or any other loose items in your home that could lead to tripping, slipping, and falling. In addition, avoid walking on wet or polished floors will reduce your risk of falls.

What are the treatment options for OP?

There are a number of medications are available to help slow bone loss and maintain bone mass, including:

  • Bisphosphonates

This group of drugs can inhibit bone breakdown, preserve bone mass, and even increase bone density in your spine and hip. Examples of these medications include alendronate (Fosamax), ibandronate (Boniva), risedronate (Actonel) and zoledronic acid (Reclast).

A hormone produced by your thyroid gland, calcitonin reduces bone resorption and may slow bone loss. It may also prevent spine fractures, and may even provide some pain relief from compression fractures. It’s usually administered as a nasal spray and may cause nasal irritation in some people who use it, but it’s also available as an injection.

  • Raloxifene (Evista)

This medication mimics estrogen’s beneficial effects on bone density in postmenopausal women, without some of the risks associated with estrogen, such as increased risk of uterine cancer and, possibly, breast cancer.

  • Teriparatide (Forteo)

This drug, an analog of a parathyroid hormone, treats osteoporosis in postmenopausal women and men who are at high risk of fractures. It works by stimulating new bone growth. Teriparatide is given once a day by injection under the skin on the thigh or abdomen.

  • Hormone therapy

Estrogen can help maintain bone density. However, the use of hormone therapy can increase your risk of blood clots, endometrial cancer, breast cancer and possibly heart disease. Because of concerns about its safety and because other treatments are available, hormone therapy is generally not a first-choice treatment anymore.

Osteoarthritis

Osteoarthritis

What is osteoarthritis (OA)?
OA is a type of arthritis in which there is a gradual loss of cartilage from the joints.

What causes osteoarthritis?

  • OA is more common in elderly population.
  • Women are more likely to developed OA than men.
  • Previous joint injury increase risk of OA.
  • OA may be inherited in some patients.
  • Knee OA is more common in obese patients.

Who gets osteoarthritis?

  • Primary OA develops in previously healthy joints.
  • Secondary OA develops in joints previously abnormal for a variety of reasons. For example, it may develop in injured joints.

Which joints are affected?

The most common joints affected by OA are hips, knees, finger joints, thumb joints and lower spine.

What are the symptoms of osteoarthritis?

  • Joint pain that is worse with activity and relieved by rest.
  • Joints affected by OA may be tender to the touch.
  • Morning stiffness is a common symptom of osteoarthritis.
  • May cause joint swelling.
  • Crackling sensation called crepitus.

What are the aims of treatment for osteoarthritis?

  • To reduce any pain and stiffness.
  • To maintain or improve the mobility of your affected joint or joints.
  • To minimize any disability that may result from your OA.

What is the treatment of OA?

  • If arthritis flares and causes significant pain and inflammation, your healthcare provider may recommend rest for 12 to 24 hours.
  • Weight loss may reduce joint pain from weight-bearing joints, such as the hips and knees.
  • Physical therapy and exercise improve flexibility and strengthen the muscles surrounding the joints.
  • Some people have found that transcutaneous electrical nerve stimulator (TENS) machines help to ease pain from OA.
  • Acupuncture may also help to ease symptoms in some cases.
  • Applying heat and cold to arthritic joints can help to control arthritis symptoms such as pain and stiffness.
  • Glucosamine and chondroitin are dietary supplements that may have potential benefit in reducing pain and slowing the progression of arthritis.
  • Paracetamol or Acetaminophen is the common medicine used to treat OA.
  • An injection with steroid directly into a joint may be an option if a joint becomes badly inflamed.
  • Synthetic hyaluronates (gel injection) may be injected into the knee to treat arthritis.
  • Surgery is usually reserved for severe arthritis that significantly limits patient activities and does not respond to arthritis treatments.

Neck Pain

Neck Pain

What are the structures of the neck?
The neck contains the top end of the spinal column or spine, which supports the head and also protects the spinal cord. The spinal cord is the main nerve, which runs from the brain, through the neck and down the back, and connects with nerves to the rest of the body. The spine is made up of 33 bones called vertebrae stacked one on top of another to form a column.

The 7 bones in the neck are known as cervical vertebrae. Between the bones are discs of cartilage known as intervertebral discs. Facet joints link the sides of the bones. Many ligaments and muscles are attached to the spine and fan out from the neck to the shoulder blades and back. The muscles control movements of your head. The spine protects the spinal cord from outside damage while still allowing you to move your head in any direction.

What are the types and causes of neck pain?
About 2 in 3 people develop a bout of neck pain at some time in their life.
Types and causes of neck pain include:

  • Non-specific neck pain is the most common type. Often the exact cause or origin of the pain is not known. It may include minor strains and sprains to muscles or ligaments in the neck.
  • A ‘whiplash’ jolt to the neck, most commonly due to a car crash, can cause neck pain.
  • Acute torticollis. A torticollis is when the head becomes twisted to one side and it is very painful to move the head back straight. The cause of acute primary torticollis is often not known. However, it may be due to a minor strain or sprain to a muscle or ligament in the neck. Some cases may be due to certain muscles of the neck being exposed to cold. It is common for people to go to bed feeling fine and to wake up the next morning with an acute torticollis.
  • Degeneration (‘wear and tear’) of the spinal bones and the ‘discs’ between the vertebrae is a common cause or recurring or persistent neck pain in older people. This is sometimes called cervical spondylosis. However, most people over the age of 50 have some degree of degeneration without getting neck pain.
  • Cervical radiculopathy is when the root of a nerve is pressed on or damaged as it comes out from the spinal cord in the neck region. As well as neck pain, there are symptoms such as loss of feeling, pins and needles, pain and weakness in parts of an arm supplied by the nerve.
  • More serious and rare causes include: rheumatoid arthritis, bone disorders, infections, cancers, and serious injuries that damage the vertebrae, spinal cord or nerves in the neck.

What are the symptoms that are associated with neck pain?
You may feel pain in the middle of your neck or on one side or the other. The pain may travel to the shoulder and shoulder blade or to the upper chest. In tension headaches the pain often travels to the back of the head and sometimes to the side of the head and behind the eye or even into the ear. If a nerve root is pinched, then as well as the pain you may have numbness or tingling that can be felt down the arm right to the fingers.

You may find it painful to move and your muscles feel tight. Stiffness is often worse after long periods of rest or after sitting in one position for a long time. You may also have muscle spasm or, in cervical spondylosis, you may lose movement because of the changes to the bones and discs.

You may hear or feel clicking as you move your head. This is caused by roughened bony surfaces moving against each other or by ligaments rubbing against bone. The noises are often loudest at the top of the neck. This is a common symptom and can be upsetting.

Dizziness can sometimes happen when bony changes in cervical spondylosis cause pinching of the vertebral artery. You may feel dizzy when looking up, or you may occasionally have blackouts.

Do I need any tests?
Your doctor will usually be able to diagnose non-specific neck pain from the description of the pain, and by examining you. Therefore, in most cases, no tests are needed.
What are the symptoms of more serious causes?
The following are the sort of symptoms that may indicate a more serious problem:

  • If neck pain develops when you are ill with other problems such as rheumatoid arthritis, AIDS, or cancer.
  • If the pain becomes progressively worse.
  • If some function of an arm is affected. For example, weakness or clumsiness of a hand or arm, or persistent loss of feeling.
  • If you develop any problems with walking or with passing urine.

What are the treatments for non-specific neck pain?

  • Aim to keep your neck moving as normally as possible. At first the pain may be quite bad, and you may need to rest for a day or so. However, gently exercise the neck as soon as you are able.
  • You should not let it ‘stiffen up’. Gradually try to increase the range of the neck movements. Every few hours gently move the neck in each direction.
  • Paracetamol NSAID can be used alone or combined with Paracetamol. Examples of NSAID are diclofenac or naproxen needs a prescription.
  • A stronger painkiller such as codeine is an option if anti-inflammatory do not suit or do not work well. Codeine is often taken in addition to Paracetamol. Constipation is a common side effect from codeine. To prevent constipation, have lots to drink and eat foods with plenty of fiber.
  • A muscle relaxant such as tryptazol or diazepam is occasionally prescribed for a few days if your neck muscles become very tense and make the pain worse.
  • A firm-supporting pillow seems to help some people when sleeping.
  • A physiotherapist may advise various treatments. These include traction, heat, cold, manipulation, etc.

Muscle Diseases

Muscle Diseases

WHAT ARE MYOPATHIES?

Myopathy is the medical term for muscle disease. A general term meaning inflammation of the muscles, myositis includes the following diseases: dermatomyositis (DM), polymyositis (PM), inclusion body myositis, and juvenile myositis.

WHO GETS MYOPATHIES?

Inflammatory myopathies are rare diseases. Polymyositis and dermatomyositis occur in approximately one person in 100,000. All age groups are affected, with peak incidence between the ages of 5 and 10 in children and between the ages of 40 and 50 in adults. Women are affected about twice as often as men. All ethnic groups are affected.

WHAT CAUSES MYOPATHIES?

We do not know what causes myositis. But because myositis has many forms, it probably has many causes. Some scientists think that myositis results when a person with a certain genetic background is exposed to particular chemicals, viruses, or other infectious agents.

WHAT ARE THE SYMPTOMS OF MYOPATHIES?

Symptoms of myositis may include:

  • Difficulty climbing stairs or lifting arms
  • Trouble swallowing or breathing
  • Muscle pain and soreness that does not resolve after a few weeks
  • Known elevations in muscle enzymes by blood tests (CPK)
  • Trouble rising from a chair
  • Tired feeling after standing or walking

HOW ARE MYOPATHIES DIAGNOSED?

Criteria for diagnosing PM and DM include:

  • History of and findings on physical examination of muscle weakness of hip and/or shoulder region
  • Elevation of muscle enzymes on laboratory testing
  • Evidence for abnormal muscle activity on electromyography testing
  • Findings of inflammation on muscle biopsy
  • Typical rash of DM

WHAT IS THE RELATION BETWEEN DM AND CANCERS?

Because of the association of DM with cancer, all adult patients diagnosed with this form of myositis should be evaluated for cancer.  Most authorities in the field simply recommend that types of cancer most common for the patient age group and gender be screened.

HOW ARE MYOPATHIES TREATED?

Corticosteroids are the treatment of choice for the majority of patients with myositis.  The most commonly used medication in this class is oral prednisone, but intravenous forms of corticosteroids can be given to rapidly control the disease during an acute flare.

Immunosuppressive drugs such as methotrexate, azathioprine, cyclosporine, cyclophosphamide, or Chlorambucil have been reported to demonstrate efficacy in patients with myositis resistant to prednisone alone or in those unable to taper off prednisone without experiencing a relapse.

In patients with myositis resistant to these standard therapies, intravenous immunoglobulin G has been shown in well-designed studies to have a beneficial effect on treating the muscle disease.  IV IgG consists of antibodies taken from normal donors at the blood bank and appears to work by blocking abnormal antibodies produced by myositis patients.

Leg Cramping

Leg Cramping

What is muscle cramp?
A muscle cramp is a sudden, uncontrolled contraction of a muscle. This type of pain is most commonly experienced in the legs, and therefore often called a leg cramp. Leg cramps occur when the muscle suddenly and forcefully contracts.

What causes a leg cramp?
The exact cause of a leg cramp is not well understood. Skeletal muscle cramps can be categorized into four major types. These include “true” cramps, tetany, contractures, and dystonic cramps.

(1) True cramps
True cramps involve part or all of a single muscle or a group of muscles that generally act together. We believe that true cramps are caused by hyper excitability of the nerves that stimulate the muscles.

  • Injury: Persistent muscle spasm may occur as a protective mechanism following an injury, such as a broken bone.
  • Vigorous activity: True cramps are commonly associated with the vigorous use of muscles and muscle fatigue.
  • Rest cramps: Cramps at rest are very common, especially in older adults. Rest cramps often occur during the night. The actual cause of night cramps is unknown.
  • Dehydration: Vigorous activities can cause excessive fluid loss from perspiration. This kind of dehydration increases the likelihood of true cramps.
  • Low blood calcium, magnesium: Low blood levels of either calcium or magnesium directly increase the excitability of both the nerve endings and the muscles they stimulate. This may be a predisposing factor for the spontaneous true cramps experienced by many older adults.

(2) Tetany
In tetany, all of the nerve cells in the body are activated, which then stimulate the muscles. This reaction causes spasms or cramps throughout the body. Low calcium and low magnesium, which increase the activity of nerve tissue non-specifically, can produce tetanic cramps.

(3) Contractures
Contractures result when the muscles are unable to relax for an even more extended period than a common muscle cramp.

(4) Dystonic cramps
In this type of cramping muscles that are not needed for the intended movement are stimulated to contract. Muscles that are affected by this type of cramping include those that ordinarily work in the opposite direction of the intended movement, and/or others that exaggerate the movement.

What are the symptoms of muscle cramps?
Characteristically, a cramp is painful, often severely so. Usually, the sufferer must stop whatever activity is under way and seek relief from the cramp; the person is unable to use the affected muscle while it is cramping.

Severe cramps may be associated with soreness and swelling, which can occasionally persist up to several days after the cramp has subsided. At the time of cramping, the knotted muscle will bulge, feel very firm, and may be tender.

How can muscle cramps be prevented?

  • Stretching before and after exercise or sports, along with an adequate warm-up and cool down, to prevent cramps that are caused by vigorous physical activity.
  • Good hydration before, during, and after the activity is important, especially if the duration exceeds one hour, and replacement of lost electrolytes can also be helpful.

What is the treatment for a leg cramp?
Stretching and massaging the affected muscle can usually relieve an attack of cramp. Most cramps soon ease off. Painkillers are not usually helpful, as they do not act quickly enough. However, a painkiller such as Paracetamol may help to ease muscle discomfort and tenderness that sometimes persists for up to 24 hours after a cramp has gone.

What can I do to help me heal faster?

  • Drinking plenty of fluids to avoid dehydration
  • Wearing shoes that have proper support
  • Stretching your leg muscles for a few minutes before you go to bed
  • Flexing your foot up toward your head
  • Massaging the cramped muscle with your hands or with ice

Infectious Arthritis

Infectious Arthritis

What is infectious arthritis?

Infectious arthritis is an infection in a joint. Infection with a bacterium called Staphylococcus aureus is the most common cause.

Who is at risk for infectious arthritis?

  • Patients with rheumatoid arthritis.
  • Patients with certain infections, including HIV infection.
  • Patients with certain types of cancer.
  • IV drug abusers and alcoholics.
  • Patients with artificial joints.
  • Patients with diabetes, sickle cell anemia, or systemic lupus erythematous.
  • Patients with recent joint injuries or surgery, or patients receiving medications injected directly into a joint.

How do you get infectious arthritis?

If some bacteria settle on a small section of a joint, they can multiply and cause infection. Bacteria can get to a joint:

  • Via the bloodstream. Bacteria may get into the blood from an infection in another part of the body and travel to a bone.
  • From an injury. Bacteria can get into a joint if you have a wound that cuts into a joint.
  • During surgery. Infection is an uncommon complication if you have joint surgery or joint investigations (such as arthroscopy).

How do we diagnose Infectious Arthritis?

The diagnosis of infectious arthritis depends on a combination of laboratory testing with careful history taking and physical examination of the affected joint. It is important to keep in mind that infectious arthritis can coexist with other forms of arthritis, gout, rheumatic fever, Lyme disease, or other disorders that can cause a combination of joint pain and fever.

What is the treatment of Infectious Arthritis

(A) Medications for Infectious Arthritis

After the disease organism has been identified, the doctor may give the patient a drug that targets the specific bacterium or virus. Non-steroidal anti-inflammatory drugs are usually given for viral infections.

Intravenous antibiotics are given for about six weeks, or until the inflammation has disappeared. The patient may then be given a two- to four-week course of oral antibiotics.

(B) Surgery for Infectious Arthritis

In some cases, surgery is necessary to drain fluid from the infected joint. Patients who need surgical drainage include those who have not responded to antibiotic treatment, those with infections of the hip or other joints that are difficult to reach with arthrocentesis, and those with joint infections related to a gunshot or other penetrating wounds.

What is the prognosis?

If the infection is treated promptly, then there is a good chance of complete cure with no long-term problems. If there is a delay in treatment, the infection can quickly destroy parts of the joint.

 

Hepatitis and Arthritis

Hepatitis and Arthritis

How does liver damage occur in hepatitis C infection?
The presence of HCV in the liver triggers the human immune system, which leads to inflammation. Over time, prolonged inflammation may cause scarring. Extensive scarring in the liver is called cirrhosis. When the liver becomes cirrhotic, the liver fails to perform its normal functions and this leads to serious complications and even death.

How is hepatitis C virus spread?
HCV is spread most efficiently through inadvertent exposure to infected blood. The most common route of transmission is a needle shared among users of illicit drugs. 
Accidental needle-sticks in healthcare workers also have transmitted the virus. HCV also can be passed from mother to unborn child. A small number of cases are transmitted through sexual intercourse. Finally, there have been some outbreaks of HCV when instruments or sharp tool have been re-used without appropriate cleaning between patients.

Who get hepatitis rheumatic diseases?
Hepatitis associated rheumatic disorders affect individuals of all ages, ethnicities, and genders who have the HCV virus. Hepatitis C virus infection and rheumatic disorders are both common in the Middle East and share many clinical and immunological manifestations, raising diagnostic problems.

What are the symptoms of hepatitis rheumatic diseases?
Multiple joint pain or swelling (polyarthritis)was the most common rheumatic manifestation (35%) in the cases, followed by skin lesions/rash (cutaneous vasculitis) (15%). Kidney diseases (Glomerulonephritis) were uncommon.
Two subsets of the disease have been identified:

  1. Multiple joints affected involving small joints that resemble rheumatoid arthritis, but is usually milder.
  2. Single or little joint involvement that shows an intermittent course and is frequently associated with the presence of cryoglobulins in serum.

Do I need to do blood tests?
Immunological abnormalities included serum rheumatoid factor, cryoglobulins, and one or more autoimmune antibodies are useful for diagnosis. Hepatitis C virus RNA is used to determine virus activity.

What are the treatment options for these conditions?
Hydroxychloroquine, low doses of corticosteroids and NSAIDs are frequently administered to patients with hepatitis associated arthritis diseases.

Use of antiviral drugs (Interferon plus ribavirin) shows good results, but interferon can induce or worsen autoimmune disorders. For this reason, in our opinion, this approach should be prescribed only when required by the coexistent liver disease.

On the basis of the poor available data, the administration of biological (anti-TNF-α) agents seems safe in HCV patients, but the usually non-aggressive course of hepatitis associated diseases does not justify their use as a current therapy.

Gout

Gout

What is gout?

Gout is a metabolic disorder that causes acute, intermittent and painful attacks of arthritis in the joints of the foot, knee, ankle, hand and wrist. Gout occurs most frequently in men between the ages of 40 and 60.

Gout can be associated with diets that are high in animal protein and alcohol. Gout usually only affects one joint at a time (sometimes two) most often the feet and ankles. The joint at the base of the big toe is the most common site.

What causes gout?

Gout occurs as a result of excess uric acid in the blood and tissues.

There are many cause of high uric acid and include:

  • Some people just have higher levels, which is hereditary.
  • High alcohol intake.
  • High intake of food that contain purines.
  • Some of the drugs used to treat high blood pressure can precipitate a gouty attack.
  • Those with kidney disease may also develop high levels of uric acid.
  • Drugs – including diuretics and antibiotics which can interfere with the normal excretion of uric acid.
  • Surgical operations
  • Unusual physical exercise

Who is at risk?

Gout is a common joint disease affecting over five times more men than women.

How is gout treated?

When an acute attack of gout occurs, anti-inflammatory drugs are usually very effective to help gain control of the gout symptoms in the first 12-24 hours. Rest and elevation of the foot is important.

Once the attack has passed, the next step is to help prevent recurrences by addressing trigger factors. In most patients who have repeated attacks, long-term treatment to lower the level of uric acid in the blood below the level at which crystals forms in the tissues is required.

What food should be avoided?

There are several things sufferers can do to help prevent a recurrence of gout. Once of these measures is to modified their diets. The following foods have higher levels of purines should be restricted or avoided:

  • Foods like liver, kidneys, sweetbreads and tongue.
  • Large amounts of red meat and Shellfish.
  • Lentils and beans.
  • Alcohol intake should be reduced.

What should I do for self-management of gout?

  • Take your medication as instructed by your doctor
  • Reduce your weight
  • Take dietary advice to lower your intake of proteins.

Giant Cell Arteritis

Giant Cell Arteritis

What is giant cell arteritis (GCA)?

GCA is an inflammation of the lining of your arteries. Most often, it affects the arteries in your head, especially those in your temples. For this reason, giant cell arteritis is sometimes called temporal arteritis or cranial arteritis.

What is the manifestation of GCA?

  • Persistent, severe head pain and tenderness, usually in your temple area
  • Decreased visual acuity or double vision
  • Scalp tenderness (it may hurt to comb your hair)
  • Jaw pain when you chew
  • Fever
  • Unintended weight loss
  • Pain and stiffness in the neck, arms or hips are common symptoms of a related disorder, polymyalgia rheumatica (PMR).

 

What tests are needed to diagnose GCA?

  • Elevation of ESR usually in excess of 50 mm/hour.
  • CRP can sometimes be elevated in the presence of a normal ESR.
  • Anemia and thrombocytosis are common.
  • Auto-antibody and complement levels are normal.
  • Alkaline phosphatase (liver test) may be elevated.
  • Temporal artery biopsy:
    • Is the gold standard
    • Biopsy should be taken on the symptomatic side.
  • Aortic aneurysms may develop many years after the patient no longer requires steroid therapy, follow-up chest X-rays and thoracic or abdominal ultrasound may be needed over time.

 

What is the major complication of GCA?

  • Aortic aneurysm.

 

What is the treatment of GCA?

Treatment for GCA consists of high doses of a corticosteroid drug. You should start feeling better within just a few days, but you may need to continue taking medication for one to two years or longer. After the first month, your doctor may gradually begin to lower the dosage until you reach the lowest dose of corticosteroids needed to control inflammation as measured by ESR and CRP tests.

Fibromyalgia

Fibromyalgia

What is fibromyalgia?

Fibromyalgia is generalized as pain in the area of the muscles, ligaments, and tendons.

How common is fibromyalgia?

Women are much more likely than men to develop fibromyalgia. It is estimated that fibromyalgia affects 0.7-4.5% of the population across the globe.

What causes fibromyalgia?

The cause of fibromyalgia is unknown. Possible triggers are accidents, work injuries, surgery, infections, emotional trauma, and stress.

What are the symptoms of fibromyalgia?

The symptoms can come and go over time, although it is unlikely they will ever disappear altogether. Your symptoms may sometimes get better or worse, depending on factors such as changes in the weather, your stress levels and how physically active you are.

The main symptoms of fibromyalgia are:

  • One of your main symptoms is likely to be a widespread pain. This may be felt throughout your body but could be worse in particular areas, such as your back or neck.
  • Fibromyalgia can cause you to become extremely sensitive to pain all over your body, and you may find that even the slightest touch is very painful.
  • Fibromyalgia can make you feel stiff.
  • Fatigue as a result of fibromyalgia can range from a mild, tired feeling to the exhaustion often experienced during a flu-like illness.
  • You may find you often wake up tired even when you have had plenty of sleep. This is because fibromyalgia can sometimes prevent you from sleeping deeply enough to refresh you properly.
  • If you have pain and stiffness in your neck and shoulders from fibromyalgia, you may also have frequent headaches.
  • Other symptoms of fibromyalgia can include:

Restless legs syndrome, tingling, numbness, prickling, or burning sensations in your hands and feet.

How do you know if you have fibromyalgia?

  • Having pain throughout your body for more than three months and tenderness in 11 of 18 specific tender point sites may mean you have fibromyalgia.
  • Tender points are positive when your doctor using his/her thumb applies pressure to them and there is pain.
  • Blood tests, x-rays and other tests may be used to exclude or rule out another diagnosis.

 

How is fibromyalgia treated?

Exercise

  • It is very important to start exercising gradually.
  • Exercises to consider include walking, low impact aerobics, water exercise programs, and use of exercise equipment like bikes or treadmills.

Medication

  • The most effective medications are muscle relaxant and anti-depression medications. They may increase the amount of time you spend in deep sleep as well as relieve pain.

Lifestyle Management

  • Your physician can help you develop strategies so that you will not feel so tired or stressed.
  • Relaxation can include deep breathing exercises, listening to music, prayer, and meditation or listening to relaxation tapes.

Fibromyalgia Quick Facts

  • Affects 2-5% of the general population
  • Occurs in people of all ages, even children
  • Men develop fibromyalgia too, although more women are diagnosed with it
  • Symptoms are chronic but may fluctuate throughout the day
  • Roughly one-quarter of people with fibromyalgia are work-disabled

Costochondritis

Costochondritis

What is costochondritis?

Costochondritis is a common form of inflammation of the cartilage where ribs attach to the breastbone, the sternum. The inflammation can involve multiple cartilage areas on both sides of the sternum but usually is on one side only.

The cause(s) of costochondritis is not known and may involve several factors. Possible causes include heredity (genetic predisposition), viruses, and trauma (injury).

Costochondritis can be an independent condition by itself or sometimes be a feature of a more widespread disorder. Examples of illnesses that can feature costochondritis include fibromyalgia, psoriatic arthritis, ankylosing spondylitis reactive arthritis, and inflammatory bowel diseases.

What is the Tietze syndrome?

Costochondritis should be distinguished from Tietze syndrome, a condition involving the same area of the front of the chest. Costochondritis is not associated with swelling, as opposed to Tietze syndrome where swelling is characteristic. Tietze syndrome is an inflammation of the costochondral cartilages of the upper front of the chest.

What are the symptoms of both conditions?

One of the main symptoms of costochondritis and Tietze’s syndrome is a sharp pain where your ribs join your breastbone. The pain may come on slowly, or suddenly, and it is usually also felt in your second and third ribs on one side of your body. If you have Tietze’s syndrome, your ribs may feel tender to the touch, and you may also have swelling around the affected area. Sudden movements of your ribs, such as when you cough or sneeze, may make the pain worse.

The syndrome usually affects the upper ribs, especially the second or third ribs. The pain is aggravated by physical activity, movement, coughing or sneezing. Although the pain usually disappears spontaneously, the swelling may persist long after the tenderness has disappeared in cases of Tietze’s.

What cause this disease?

The cause of costochondritis or Tietze’s syndrome is not fully understood, although it may be linked to upper respiratory tract infections, such as sinusitis and laryngitis.

Who can get this condition?

Anyone can develop costochondritis/Tietze’s syndrome, although it is most common among people who are between 20-40 years of age. The condition affects twice as many men as women.

What is the treatment for costochondritis?

  • Costochondritis can be aggravated by any activity that involves stressing the structures of the front of the chest cage. It is generally best to minimize these activities until the inflammation of the rib and cartilage areas has subsided.
  • Reassurance once the diagnosis is confirmed.
  • Non-steroidal anti-inflammatory drugs.
  • Local injection of long-acting corticosteroids may help.

An intercostal nerve block may also help but is rarely required.

Chronic Fatigue Syndrome

Chronic Fatigue Syndrome

What is chronic fatigue syndrome (CFS)?
Chronic fatigue syndrome is a condition of prolonged and severe tiredness or weariness that is not relieved by rest and is not directly caused by other conditions.

What cause CFS?
The cause or causes of CFS remain unknown, despite a vigorous search. While a single cause for CFS may yet be identified, another possibility is that CFS represents a common endpoint of disease resulting from multiple causes. Conditions that have been proposed to trigger the development of CFS include virus infection or other traumatic conditions, stress, and toxins.

What are the symptoms of CFS?
Persistent fatigue is the hallmark of chronic fatigue syndrome. Typically, the fatigue develops suddenly, often following an infection such as upper respiratory infection or mononucleosis. After the initial illness gets better, you are left with overwhelming fatigue and a number of additional symptoms. Physical activity makes the symptoms worse.

Many, if not most, people with CFS have physical symptoms for which no cause can be found with an examination and/or testing. In addition to the fatigue, you may have one or more of the following:

  • Memory and concentration problems
  • Generalized pain
  • Headaches
  • Difficulty sleeping

How we diagnose CFS?
Diagnosing CFS can be complicated by a number of factors:

  • There’s no diagnostic laboratory test or biomarker for CFS.
  • Fatigue and other symptoms of CFS are common to many illnesses.
  • CFS is an invisible illness and many patients don’t look sick.
  • The illness has a pattern of remission and relapse.
  • Symptoms vary from person to person in type, number and severity.

Who is at risk to develop CFS?
CFS is diagnosed more often in young and middle-aged adults than in children or older adults. CFS is diagnosed about twice as often in women as in men, and is also more likely to be diagnosed in white people compared with other ethnic groups.

Is there any treatment for CFS?
There is currently no cure for CFS. Instead, the symptoms are treated. Many people with CFS experience depression and other psychological problems that may improve with treatment.

The best strategy for treatment includes:

  • A healthy diet.
  • Antidepressant drugs in some cases.
  • Cognitive-behavioral therapy and graded exercise.
  • Sleep management techniques.
  • Activity management.
  • Relaxation techniques.

Activity management should involve:

  • Avoiding doing too much on days when you feel tired.
  • Balancing your time between activity, rest, and sleep.
  • Spreading out more challenging tasks throughout the week.
  • Relaxation and stress-reduction techniques can be helpful in managing chronic pain and fatigue.

Relaxation techniques may include:

  • Deep breathing exercises
  • Hypnosis
  • Massage therapy
  • Meditation
  • Muscle relaxation techniques

Carpal Tunnel Syndrome

Carpal Tunnel Syndrome

WHAT IS CARPAL TUNNEL SYNDROME?
Carpal tunnel syndrome (CTS) is a common problem affecting the hand and wrist. Symptoms begin when the median nerve gets squeezed inside the carpal tunnel of the wrist, a medical condition known as nerve entrapment. Any condition that decreases the size of the carpal tunnel or enlarges the tissues inside the tunnel can produce the symptoms of CTS.

WHAT CAUSES CARPAL TUNNEL SYNDROME?
Anything that increases the volume of the structures passing through the carpal tunnel will cause pressure against the median nerve. Many causes have been linked to the development of CTS, such as tasks that require rapid repetitive use of the hands, the use of vibrating tools, or prolonged power grip. Bone dislocations, fractures and arthritis can also cause narrowing of the tunnel, but they are usually not as common. Other conditions such as hypothyroidism, rheumatoid arthritis and diabetes can increase the likelihood of developing carpal tunnel syndrome. Fluid retention during pregnancy can sometimes cause swelling in the tunnel and produce symptoms of carpal tunnel syndrome, which are usually reversible after the pregnancy is over.

WHAT ARE THE SYMPTOMS OF CTS?
One of the first symptoms of CTS is gradual tingling and numbness in the areas supplied by the median nerve. This is typically followed by dull, vague pain where the nerve gives sensation in the hand. The hand may begin to feel like it’s asleep, especially in the early morning hours after a night’s rest.

HOW IS CARPAL TUNNEL SYNDROME DIAGNOSED?
An accurate medical history and detailed clinical examination will establish the diagnosis in most cases. A nerve test, called a nerve conduction study and electromyography is often obtained to confirm the diagnosis.

HOW IS CARPAL TUNNEL SYNDROME TREATED?

Conservative:
Changing activities to reduce repetitive or strenuous use of the hand or keeping the wrist in a straight position may help reduce the swelling within the tunnel, allowing more room for the nerve.
Wearing wrist splints at night may relieve the symptoms that interfere with sleep.
A local injection of steroids into the carpal tunnel may provide help by reducing the swelling within the carpal tunnel.

Surgical:
If conservative treatment is not successful in treating the carpal tunnel syndrome, then surgical treatment would be the treatment of choice.
The main purpose of the surgery is to divide the transverse carpal ligament and therefore open the carpal canal and increase the volume of the carpal tunnel, and therefore relieve the pressure from the median nerve.
Surgery is performed under a block anesthesia, which is essentially a local anesthesia on same-day surgery basis.

Avascular Necrosis

Avascular Necrosis

What is avascular necrosis (AVN)?

Osteonecrosis occurs when your bones lose their blood supply. The bones die and eventually collapse, leading to pain and arthritis. You can have osteonecrosis in one or several bones. It is most common in the upper leg. Other common sites are your upper arm and your knees, shoulders, and ankles. The disease can affect men and women of any age, but it usually strikes in your thirties, forties or fifties.

Why people developed AVN?

There are many causes of AVN. Anything that damages the blood supply to the hip can cause AVN.

  • Injury to the hip itself can damage the blood vessels. Fractures of the femoral neck bone can damage the blood vessels.
  • A dislocation of the hip out of the socket can tear the blood vessels.
  • Corticosteroids such as prednisone or methylprednisolone are the most common drugs known to lead to AVN.
  • Smoking causes blood vessels to constrict or narrow thereby limiting the amount of blood flow to an area such as the hip with its already limited backup supply.
  • Excessive alcohol intake somehow damages the blood vessels and leads to AVN.
  • Deep-sea divers and miners who work under great atmospheric pressures also are at risk for damage to the blood vessels.
  • Then there is a long list of other diseases that are associated with increased incidence of femoral head osteonecrosis. Examples of these diseases are leukemia, sickle cell diseases, and HIV infection.

What joints can be affected by AVN?

The most common joints affected by AVN include:

  • Hip.
  • Knee.
  • Shoulder.
  • Other joints that are less commonly affected by AVN include: Ankles, Feet, Hands, Jaw, Spine and Wrists.

How is AVN diagnosed?

Once there is a suspicion of osteonecrosis, your physician will likely obtain one or more of the following tests: X-ray, Magnetic Resonance Imaging (MRI), Bone Scan, Computed Tomography (CT), or rarely Biopsy.

What are the treatment options for AVN?

(A) Non-Surgical Treatment

  • Protected weight bearing: Canes, crutches or a walker are useful in alleviating the pain associated with AVN.

(B) Pharmaceutical Treatment

  • There are no established drugs for the prevention or treatment of osteonecrosis.

 (C) Surgical Treatment

  • Core Decompression: This is a surgical procedure that involves taking a plug of bone out of the involved area. It is applicable for mild to moderate degree of involvement that has not yet progressed to collapse.
  • Bone Grafting: When a section of the bone has died, it does not spontaneously heal. One approach to this problem is to surgically remove the dead bone and fill the empty space with bone graft that is either taken from the patient or from the bone bank.
  • Osteotomy (Cutting the Bone): Usually the location of the AVN is in the area of the bone that bears weight. In some cases, the bone can be cut below the area of involvement and rotated or turned so that another portion of the bone can become the new weight-bearing area.
  • Femoral Head Resurfacing: This involves implanting a metal hemisphere over the femoral head, which exactly matches the size of the original femoral head.
  • Femoral Head Replacement: This is basically half a total hip replacement.

How I can prevent AVN?

  • To minimize the risk of AVN caused by corticosteroids, doctors use these drugs only when essential, prescribe them in as low a dose as needed, and prescribe them for as short duration as possible.
  • To prevent osteonecrosis caused by decompression sickness, people should follow accepted rules for decompression during diving and when working in pressurized environments.
  • Excessive alcohol use and smoking should be avoided.

Antiphospholipid Syndrome

Antiphospholipid Syndrome

WHAT IS antiphospholipid syndrome (APS)?

Antiphospholipid syndrome (APS) is an autoimmune disease associated with frequent clotting in arteries and veins and/or miscarriages. The clotting results from the presence of proteins in the blood called anti-phospholipid autoantibodies formed against the person’s own tissues. In circulation, these autoantibodies are able to interfere with some mechanisms of coagulation leading to clot formation or thrombosis.

IS APS COMMON?

All age groups can be affected, from infants to the elderly. However, the majority of people with APS are aged between 20 and 50 years. It seems to affect the health of women more than men because of its effect on pregnancy.

WHAT ARE THE DIFFERENT MANIFESTATIONS OF APS?

Virtually any system can be affected including:

  • Peripheral artery thrombosis, deep venous thrombosis.
  • Cerebrovascular disease (stroke).
  • Thrombocytopenia.
  • Pregnancy loss:
    1. There may be a history of recurrent fetal loss at any gestation.
    2. Late loss of a morphologically normal fetus is usually due to placental infarction and should also lead to tests for APS.
  • Pulmonary embolism, pulmonary hypertension.
  • Livedo reticularis (persistent red or blue pattern of the skin of trunk, arms or legs; it does not disappear on warming and may consist of regular broken or unbroken circles).
  • Myocardial infarction.
  • Retinal thrombosis.
  • Avascular necrosis of bone.

HOW IS APS DIAGNOSED?

There are two main blood tests that are used for diagnosis:

  • The anticardiolipin test
  • The lupus anticoagulant test.

There are a small number of people with APS (about 20%) in whom one or other test will be negative. In other words, one test alone could miss the diagnosis, so it is important to have both.

The level of antibodies is very important. Higher levels tend to give a much greater risk of blood clots and other APS symptoms. One positive test for Antiphospholipid antibodies does not mean that a person has APS. The test should be repeated after 6–8 weeks. A positive test on two occasions is much more important for doctors making the diagnosis than a test that is only positive once. Tests that are only just positive and that are present on only one occasion are probably not significant.

HOW IS APS TREATED?

Due to the increased tendency to clot, the main aim of treatment is to ‘thin’ the blood, so that this tendency is reduced. This is usually achieved for most patients, by providing anticoagulant therapy based on the extent of the clotting.

Patients with APS are often treated with an injectable anticoagulant called heparin or low molecular weight heparin. In some cases, the heparin is given into a vein while the patient is in the hospital. In other cases, heparin is injected under the skin.

Aspirin is another medication sometimes recommended for people with APS. Aspirin inhibits the clumping of platelets; platelets are tiny cell fragments in the blood that have a role in blood clotting. Under normal circumstances, platelets clump together and help form blood clots to stop bleeding when needed.

WHAT SHOULD I DO IF I GET PREGNANT WITH APS?

In women with Antiphospholipid antibody antibodies and recurrent miscarriage with no history of thrombosis, consensus guidelines recommend low-dose aspirin in combination with prophylactic or intermediate-dose unfractionated heparin or prophylactic dose low molecular weight heparin, administered before pregnancy.

If you have lupus without APS, are you at risk for developing it later on? If you have APS without lupus, what are your chances for developing lupus?

In general, if both diseases appear, they do so at about the same time, so the answers to the questions are “no” and “very low,” respectively.

What are some symptoms a person with APS should worry about?

Visual changes, speech defect, sudden change of anything, persistently blue digit, unusual bruising or red spots on the skin. 

How you can help yourself?

In theory, increasing the amount of essential fatty acids in your diet, particularly omega-3 found in oily fish, should help reduce the risk of thrombosis, but there are no clinical trials to suggest this is the case.

Ankylosing Spondylitis

Ankylosing Spondylitis

What is ankylosing spondylitis?

Ankylosing Spondylitis (AS) is a type of chronic inflammatory arthritis that affects spine and the sacroiliac joints. Chronic inflammation in these areas causes pain and stiffness in and around the spine. AS affects men three times more often than women. The first symptoms of AS typically start in late adolescence. AS can cause inflammation or injury to other joints away from the spine, as well as to other organs, such as the eyes, heart, and lungs. AS can cause inflammation of the tendons surrounding the joints (enthesitis). Some of the common spots for enthesitis are the back of the heels (Achilles tendonitis), and underneath the bottoms of the feet (plantar fasciitis).

What causes ankylosing spondylitis?
The majority of people (90%) with AS have a gene called HLA-B27. The HLA-B27 gene appears only to increase the tendency of developing AS, while some factor(s), perhaps environmental, are necessary for the disease to become expressed. Not everyone with AS carries this gene; therefore, if your doctor tests you and you don’t have it you may still have AS.

What are ankylosing spondylitis symptoms?
Fatigue is a common symptom associated with active inflammation. Inflammation of the spine causes pain and stiffness in the low back, and upper buttock area. The onset of pain and stiffness is usually gradual and progressively worsens over months. The symptoms of pain and stiffness are often worse in the morning or after prolonged periods of inactivity. Movement, heat, and a warm shower often ease the pain in the morning.

Chronic spondylitis and ankylosis cause forward curvature of the upper torso. Spondylitis can affect the areas where ribs attach to the upper spine, further limiting lung capacity. AS can cause inflammation and scarring of the lungs, causing shortness of breath, especially with exercise and infections.

How is ankylosing spondylitis diagnosed?
There is no specific test to diagnose AS. The diagnosis of ankylosing spondylitis is based on evaluating the patient’s symptoms, a physical examination, X-ray findings, and blood tests. Symptoms include pain and morning stiffness of the spine and sacral areas with or without accompanying inflammation in other joints, tendons, and organs.

These blood tests are called ESR (erythrocyte sedimentation rate) and CRP (C-Reactive Protein). Test for the HLA-B27 gene can be helpful. Finally, X-rays may be taken to determine if there are changes in the joints at the bottom of the spine (sacroiliac joints).

What are treatment options for ankylosing spondylitis?
The goal is to keep the spine flexible and the joints moving with the hope to prevent or delay permanent damage. Medications decrease inflammation in the spine and other joints and organs. Physical therapy and exercise help improve posture, spine mobility, and lung capacity.

Disease-Modifying Anti-Rheumatic Drugs such as methotrexate and sulfasalazine can be used in combination with Non-steroidal anti-inflammatory drugs (NSAIDs) although they generally don’t work as well for inflammation in the spine. NSAIDs are commonly used to decrease pain and stiffness of the spine and other joints. Commonly used NSAIDs include indomethacin, naproxen and diclofenac.

In AS, steroids are usually used for short durations to quickly relieve a flare of symptoms. They are usually injected into a joint or taken orally (prednisone).

Newer, effective medications for spine disease attack a messenger protein of inflammation called tumor necrosis factor (TNF). These TNF-blocking medications have been shown to be extremely effective for treating ankylosing spondylitis by stopping disease activity and improving spinal mobility. Examples of these TNF-blockers include etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), and golimumab (Simponi).

Acute Or Chronic Back Pain

Acute Or Chronic Back Pain

What is back pain?

Acute or short-term low back pain generally lasts from a few days to a few weeks. Most acute back pain is the result of trauma to the lower back or a disorder such as arthritis. Symptoms may range from muscle ache to shooting or stabbing pain, limited flexibility and range of motion, or an inability to stand straight. Chronic back pain is pain that persists for more than 3 months.

What causes back pain?

  • Below are some common spinal conditions:
  • Back strain
  • Degenerative Disc disease
  • Herniated disc
  • Spondylolisthesis
  • Spinal stenosis
  • Spinal fractures

How is back pain diagnosed?

  • The first thing is to rule out any other obvious conditions which also cause back pain.
  • There are a number of warning signs, which are factors which lead the doctor to arrange for more rapid investigation and treatment than would otherwise be necessary.
  • Most times an X-Ray is unhelpful, and in fact, it gives you a high dose of radiation, so do not be surprised if your doctor does not arrange one.
  • Sometimes your doctor will arrange blood tests to rule out the rarer causes of back pain.
  • When the pain has continued for more than 6weeks your doctor may arrange a CT or MRI scan.
  • MRI and CT generally are not useful during acute LBP or acute sciatica unless surgery, cancer, or infection is considerations.

WHAT ARE THE MAJOR INDICATIONS TO DO AN MRI?

MRI Indications:

  • Major or progressive neurological dysfunction such as foot drop or functionally limiting weakness such as hip flexion or knee extension.
  • Cauda Equina syndrome (disease of the nerve roots near the tail bone) (loss of bowel or bladder control or saddle [area around the tail bone] numbness).
  • Progressively severe pain and limitations despite conservative therapy.
  • Severe or incapacitating back or leg pain, such as requiring hospitalization, limiting the ability to walk or significantly limiting the activities of daily living.
  • Clinical or radiological (x-ray images) suspicion of neoplasm (cancerous growth), history of cancer, unexplained weight loss, or systemic (related to the entire body) diseases.
  • Clinical or radiological suspicions of infection, such as endplate (area at the end of bones) destruction, history of drug or alcohol abuse, or systemic diseases. 

How is back pain treated?

(1) Acute back pain

Most cases of acute back pain can be treated using self-help techniques

* Painkillers

Paracetamol is usually recommended to treat acute lower back pain. If Paracetamol proves ineffective, a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen may be used instead.

* Stronger painkillers

If your back pain symptoms are severe, your GP may prescribe a mild opiate-based painkiller, such as codeine, which can be taken in combination with Paracetamol or a NSAID.

* Muscle relaxants

If your back pain symptoms are very severe, your GP may prescribe a muscle relaxant such as diazepam.

* Exercise

It’s important to remain as physically active as possible. While bed rest may provide some temporary relief from your symptoms, prolonged bed rest will make your symptoms worse.

* Cold and heat therapies

(2) Chronic back pain

When back pain does not respond to more conventional approaches, patients may consider the following options:

* Acupuncture involves the insertion of needles the width of a human hair along precise points throughout the body.

* Interventional therapy can ease chronic pain by blocking nerve conduction between specific areas of the body and the brain. Approaches range from injections of local anesthetics, steroids, or narcotics into affected soft tissues, joints, or nerve roots to more complex nerve blocks and spinal cord stimulation.

* Traction involves the use of weights to apply constant or intermittent force to gradually “pull” the skeletal structure into better alignment. Traction is not recommended for treating acute low back symptoms.

* Ultrasound is a noninvasive therapy used to warm the body’s internal tissues, which causes muscles to relax.

* Minimally invasive outpatient treatments to seal fractures of the vertebrae caused by osteoporosis include vertebroplasty and kyphoplasty.

* In the most serious cases, when the condition does not respond to other therapies, surgery may relieve pain caused by back problems or serious musculoskeletal injuries.

  1. Discectomy is one of the more common ways to remove pressure on a nerve root from a bulging disc or bone spur. During the procedure, the surgeon takes out a small piece of the lamina to remove the obstruction below.
  2. Foraminotomy is an operation that “cleans out” or enlarges the bony hole where a nerve root exits the spinal canal. Bulging discs or joints thickened with age can cause narrowing of the space through which the spinal nerve exits and can press on the nerve, resulting in pain, numbness, and weakness in an arm or leg.
  3. Spinal fusion is used to strengthen the spine and prevent painful movements. The spinal disc(s) between two or more vertebrae is removed and the adjacent vertebrae are “fused” by bone grafts and/or metal devices secured by screws. Spinal fusion may result in some loss of flexibility in the spine and requires a long recovery period to allow the bone grafts to grow and fuse the vertebrae together.


WHAT IS THE PROGNOSIS?

Most patients with back pain recover without residual functional loss, but individuals should contact a doctor if there is not a noticeable reduction in pain and inflammation after 72 hours of self-care. Engaging in exercises that don’t jolt or strain the back, maintaining correct posture and lifting objects properly can help prevent injuries. Applying ergonomic principles (designing furniture and tools to protect the body from injury) at home and in the workplace can greatly reduce the risk of back injury and help maintain a healthy back.

WHEN DO YOU NEED TO CONTACT YOUR DOCTOR IMMEDIATELY?

Call your doctor right away if you have:

  • Trouble controlling your bladder or bowels
  • Numbness or weakness in the feet legs, groin or rectal area
  • The pain gets worse or extends into your leg and below the knees
  • Pain limits your normal activities for more than 4 weeks
  • Shooting pain down the leg 

Can back pain be prevented?

Recurring back pain resulting from improper body mechanics or other non-traumatic causes is often preventable. A combination of exercises that don’t jolt or strain the back, maintaining correct posture, and lifting objects properly can help prevent injuries. 

WHAT KIND OF EXERCISE I CAN DO AT HOME?

  • Lying supine hamstring stretch: Lie on your back with a small rolled towel under your waist. Place your left leg down with knee straight. Bend your right hip so your knee is pointing to the ceiling. Hold your right thigh by locking your fingers. Keep your elbows straight while holding and straighten your right knee and move the foot toward the ceiling. You should feel a stretch on the backside of your thigh. Hold for 30 seconds and repeat 2 times. Repeat the same stretch on your other leg.
  • Camel Stretch: In a hands and knee position, place your hands under the shoulders and the knees under your hips. Raise your head up while at the same time raise your hips up and allow your stomach to fall to the floor. Hold the position for 5 seconds and repeat 10 times.
  • Pelvic tilt: Lie on your back with your knees bent and your feet flat on the floor. Tighten your abdominal muscles and push your lower back into the floor. Hold this position for 5 seconds, and then relax. Do 2 sets of 10.
  • Partial curl: Lie on your back with your knees bent and your feet flat on the floor. Tighten your stomach muscles and flatten your back against the floor. Tuck your chin to your chest. With your hands stretched out in front of you, curl your upper body forward until your shoulders clear the floor. Breathe out as you come up. Hold this position for 3 seconds. Relax. Repeat 10 times. Build to 3 sets of 10. To challenge yourself, clasp your hands behind your head and keep your elbows out to the side.