Conditions Treated

Ankylosing spondylitis

+What is Ankylosing spondylitis?

Ankylosing spondylitis (AS) is a type of arthritis, which predominantly affects the spine, although other joints can be affected. It causes inflammation of the spinal joints (vertebrae) that can lead to severe, chronic pain and discomfort.(Figure 1) In the most advanced cases (but not in all cases), this inflammation can lead to new bone formation in the spine, causing the spine to fuse in a fixed, immobile position, sometimes creating a forward-stooped posture. (Figure 2)

+What causes it?

Although what causes Ankylosing spondylitis is not exactly known, we do know that genetics play a very important role. Most, not all, individuals who have AS also has a gene called HLAB27. Recent research has shown that genes other than B27 as well as bacterial infection are very important in the causation of AS. This disease more commonly affects males under the age of 35 years, although females can also be affected.

+What are the symptoms?

First symptoms of AS are frequent pain and stiffness in the lower back and buttocks, which comes on gradually over the course of a few weeks or months. The pain is usually dull and diffuse, rather than localized. This pain and stiffness have been usually worse in the mornings and during the night, but may be improved by a light exercise. The pain gradually spreads to involve the ribs and neck. Other joints like shoulder, hip, ankle, knee also can be involved. These patients may also complain of heel pain. It can also affect the eyes in the form invites which results in red, painful eye with blurred vision.

+How the diagnosis is made?

The diagnosis is made by a combination of suggestive clinical history and relevant investigations. The most important part in the history will be on set < 35 years and pain > 3 months. Mobility of the pack will be decreased even in early stages. The hallmark of Ankylosing spondylitis is the involvement of sacroiliac joints SI joints). Inflammation of SI joints is called Sacroiliitis. Secrets can be detected by X-rays, but the problem is that changes on x-ray take up to 10 years to appear. At the same time MRI can detect these changes during the first year itself and helps in early diagnosis.

+What is the importance of HLAB27?

HLAB27 is a gene which is a perfectly normal gene present in 8% of the population. But 5% of persons who have this gene develop AS. In suspected cases of AS especially in the early stages the test to detect HLAB27 is useful in making a correct diagnosis.

+What is the importance of early diagnosis?

It is very important to diagnose Ankylosing spondylitis in patients with chronic low back ache. This is important to start the management as early as possible and to prevent the spine from getting deformed.

+What are the management options for Ankylosing spondylitis ?

For patients who have Ankylosing spondylitis early diagnosis and correct management are the key so that normal lifestyle can be maintained. Exercise programs under supervision is one of the key factors in the management of these patients. Exercises help these patients not only to decrease pain, but also to prevent the bending posture which develops in these patients over time.
NSAIDS like Indomethacin helps to decrease inflammation in the spine and is very useful. Up to 75% of patients can be managed effectively by exercise and NSAIDS. Those patients who are not responding drugs like Sulfasalazine are very useful. Recent developments in the field of AS has made anti TNF agents like Infliximab a very good option in patients who are not responding to the first line drugs. These drugs are very effective in controlling the manifestations of AS and also improves quality of life in these patients.

+What is the prognosis?

The patients who have Ankylosing spondylitis if diagnosed early and treated well do have a normal life.


+What is Arthritis?

The term arthritis refers to pain, swelling and stiffness of joints. Pain is due to the irritation of nerve fibers in the inflamed joints. Swelling is due to either increased fluid in the joints or due to hypertrophy of the synovial membrane which is covering the joint (Figure1). Stiffness refer to the discomfort in moving joints following a period of inactivity. This is classically described as an increase in difficulty in moving joints or making a fist soon after getting up from the bed. This is relieved by activity and aggravated by rest. There are close to 230 movable joints in the body (figure 2). Arthritis can affect any of these parts resulting in pain in the corresponding area like knee pain, back pain or neck pain. (Figure 3)

+Arthritis a symptom NOT a disease

It is very important to remember that more than 150 disorders can present with pain in the joints. So joint pain is not a disease, but a symptom. We can explain this with a commoner example. If you go to a doctor with a fever, it can be due to mild viral infection to life threatening diseases like blood cancers or malaria. To determine what disease you have doctor examines you and does a series of tests. Similarly arthritis also can be due to very simple disease like viral infection to life threatening diseases like SLE. Joint pain is one of the ways body tells you that something is wrong somewhere and it is the duty of a physician to find out what disease the patient is suffering from and start him on the correct treatment.

+What is the importance of early diagnosis?

As I have said earlier, arthritis may be a manifestation of an internal disease. Some of these diseases can affect internal organs like Lungs, kidney or heart. So it is absolutely essential that you get a proper check up and get the correct treatment.

+Who can treat arthritis?

The specialty of medicine which deals with arthritis and allied disorders is called Rheumatology. So it is advisable that you contact a qualified rheumatologist for evaluation of arthritis.


+What is Fibromyalgia?

Fibromyalgia syndrome is a common and chronic disorder characterized by widespread pain, diffuse tenderness, and a number of other symptoms. The word “fibromyalgia” comes from the Latin term for fibrous tissue (fibro) and the Greek ones for muscle (Myo) and pain (algia). Although fibromyalgia is often considered an arthritis-related condition, it is not truly a form of arthritis (a disease of the joints). Although like arthritis, fibromyalgia can cause significant pain and fatigue, and it can interfere with a person’s ability to carry on daily activities, it does not cause damage to the joints. In addition to pain and fatigue, people who have fibromyalgia may experience a variety of other symptoms including:

  • ⇒ cognitive problems

  • ⇒ sleep disturbances

  • ⇒ morning stiffness

  • ⇒ headaches

  • ⇒ irritable bowel syndrome

  • ⇒ numbness or tingling of the extremities

  • ⇒ pain in the calf muscles

  • ⇒ temperature sensitivity

  • ⇒ Sensitivity to loud noises or bright lights.

+Who gets Fibromyalgia?

It is estimated that at least 1 crore Indians are affected by Fibromyalgia. More than 80 % of patients affected with fibromyalgia are women. It can affect any age group.

+What Causes Fibromyalgia?

The basic problem in Fibromyalgia is increased sensitivity or reduced tolerance to pain. The causes of fibromyalgia are unknown, but there are probably a number of factors involved. Many people associate the development of fibromyalgia with a physically or emotionally stressful or traumatic event, such as an automobile accident. Some connect it to repetitive injuries. Others link it to an illness. For others, fibromyalgia seems to occur spontaneously.

+How Is Fibromyalgia Diagnosed?

Research shows that people with fibromyalgia typically see many doctors before receiving the diagnosis. One reason for this may be that pain and fatigue, the main symptoms of fibromyalgia, overlap with those of many other conditions. Therefore, doctors often have to rule out other potential causes of these symptoms before making a diagnosis of fibromyalgia. Another reason is that there are currently no diagnostic laboratory tests for fibromyalgia; standard laboratory tests fail to reveal a physiologic reason for pain.So diagnosis made basically by a detailed history and clinical examination by an expert based on American college of Rheumatology criteria.

+How Is Fibromyalgia Treated?

Fibromyalgia treatment often requires a team approach, a rheumatologist, a physical therapist, possibly other health professionals, and most importantly, yourself, all playing an active role. It can be hard to assemble this team, and you may struggle to find the right doctors to treat you. When you do, however, the combined expertise of these various professionals can help you improve your quality of life.
Exercise and yoga may help to relieve pain and improve the quality of life in these patients. There are different medicines which are used to treat this disease. Medicines such as Tramadol are used to decrease the pain. Medicines like duloxetine, milnacipran, and pregabalin modify the nerve signals and decrease pain in these patients. Understanding the disease by the patient and family as well as close cooperation is absolutely essential in the treatment of this condition.


+What is gout?

Gout is one of the most common and oldest forms of arthritis that can cause extreme pain in the areas affected. Gout is a condition in which uric acid gets deposited in the joint and causes severe, recurrent joint pain.

+Who gets the gout?

Uric acid is a breakdown product and is excreted by the kidney. In patients with gout, body either makes too much uric acid or it cannot excrete it from the body in large enough quantities. Persons who have high levels of uric acid in the blood are at high risk of developing gout. The higher the level of uric acid higher the risk of developing gout.
Risk factor for developing gout :

  • ⇒ Obesity

  • ⇒ Kidney disease

  • ⇒ Hypertension

  • ⇒ Alcoholism

+What are the symptoms of gout?

When the uric acid level in the blood is high, it deposits in the joint and causes inflammation in the joint resulting in excruciating pain. Gout most commonly affects the foot, although any joint in the body can get affected. Pain starts as a dull aching pain but soon develops into very severe throbbing pain which may be one of the most severe pain one has ever experienced.Pain of gout usually subsides in 2-3 days and the patient can resume normal life. If uric acid levels are not controlled other joints get affected.

+What are other problems in gout patients?

Gout if not treated properly can result in kidney stones and result in kidney failure. Moreover, these patients are at higher risk of heart attacks. Uric acid can get deposited beneath the skin resulting in formation of a chalky substance called “Tophi”

+How is gout diagnosed?

Since diagnosing gout doctor has to aspirate fluid from the affected joint. This fluid will show needle shaped crystals under the microscope. God cannot be diagnosed based only on elevated uric acid levels in the blood.

+How is gout treated?

First priority in a patient who has a severe attack of gout is to relieve his pain. For this the best available method is to give intraraticular injections. Other drugs available are NSAIDs, Cochicine etc. The primary aim of long term management of gout is to decrease the uric acid levels to normal. Weight reduction helps in reducing the uric acid levels in the blood.
Foods like seafood, soft drinks like Coca cola/Pepsi, alcohol, etc. increases the uric acid level in the blood and has to be avoided. Taking lot of milk decreases uric acid level in the blood. Drinking lots of water also can help gout patients by increasing the uric acid excretion. To decrease the uric acid levels like Allopurinol or newer drugs like Febuxostat has to be used in the majority of patients with gout. The aim is to keep the level of uric acid below 6.

Low Back Pain (LBA)

+What Is Back Pain?

Back pain is a very common problem that can range from a dull, constant ache to a sudden, sharp pain that leaves you incapacitated. It can come on suddenly from a fall, or lifting something heavy or it can develop slowly. Every one of us gets back pain during some part of our life.

+How Common Is Back Pain?

In a 3-month period, about 25 % adults experience at least 1 day of back pain. It is one of our society’s most common medical problems. It is the problem which causes maximum loss of work days.

+What are the risk factors for getting back pain?

Although anyone can have back pain, a number of factors increase your risk. They include:
Age: The first attack of low back pain typically occurs between the ages of 30 and 40. Back pain becomes more common with age.
Fitness level: Back pain is more common among people who are not physically fit. Weak back and abdominal muscles may not properly support the spine.
Diet: A diet high in calories and fat, combined with an inactive lifestyle, can lead to obesity, which can put stress on the back.
Heredity: Some causes of back pain, such as Ankylosing spondylitis, a form of arthritis that affects the spine, have a genetic component.
Presence of other diseases: Many diseases can cause or contribute to back pain. These include various forms of arthritis, such as osteoarthritis and Ankylosing spondylitis, and cancers elsewhere in the body that may spread to the spine.
Occupational risk factors:Having a job that requires heavy lifting, pushing, or pulling, particularly when this involves twisting or vibrating the spine, can lead to injury and back pain. More common during this era of computerization, long hours of working on computers in poor posture can lead on to low backache.

+What Are the Causes of Back Pain?

Like any other pain, back pain tells you that something is wrong somewhere and is not a diagnosis by itself. It is for the physician to find out what is the exact problem causing back pain. Medical problems that can cause back pain include the following:
Mechanical problems: A mechanical problem is a problem with the way your spine moves. Perhaps the most common mechanical cause of back pain is a condition called intervertebral disc degeneration, which simply means that the discs located between the vertebrae of the spine are breaking down with age. As they deteriorate, they lose their cushioning ability. This problem can lead to pain if the back is stressed. Other mechanical causes of back pain include spasms, muscle tension etc.
Injuries: Spine injuries such as sprains and fractures can cause either short-lived or chronic pain. Sprains are tears in the ligaments that support the spine, and they can occur from twisting or lifting improperly. Fractured vertebrae are often the result of osteoporosis.
Acquired conditions and diseases: Many medical problems can cause or contribute to back pain. They include scoliosis, a curvature of the spine that does not usually cause pain until middle age; various forms of arthritis, including osteoarthritis, and ankylosing spondylitis. Although osteoporosis itself is not painful, it can lead to painful fractures of the vertebrae.
Infections and tumours: Although they are not common causes of back pain, infections like cause destruction of the vertebrae and cause back pain. Tumors also are relatively rare causes of back pain. Occasionally, tumors begin in the back, but more often they appear in the back as a result of cancer that has spread from elsewhere in the body.

+Can Back Pain Be Prevented?

One of the best things you can do to prevent back pain is to exercise regularly and keep your back muscles strong.
Diet: Eating a healthy diet also is important. For one thing, eating to maintain a healthy weight—or to lose weight, if you are overweight—helps you avoid putting unnecessary stress and strain on your back. To keep your spine strong, as with all bones, you need to get enough calcium and vitamin D every day.
Postures: Practicing good posture, supporting your back properly, and avoiding heavy lifting when you can may all help you prevent injury. If you do lift something heavy, keep your back straight. Don’t bend over the item; instead, lift it by putting the stress on your legs and hips.
Although the causes of back pain are usually physical, emotional stress can play a role in how severe pain is and how long it lasts. Stress can affect the body in many ways, including causing back muscles to become tense and painful.

+How is cause for back pain diagnosed?

Diagnosing the cause of back pain requires a medical history and a physical exam. If necessary, your doctor may also order medical tests, which may include x rays or sometimes MRI.

+How Is Back Pain Treated?

Treatment for back pain generally depends on what kind of pain you experience: acute or chronic.
Acute Back Pain: Acute back pain usually gets better on its own and without treatment, although you may want to try acetaminophen, aspirin, or ibuprofen to help ease the pain. Perhaps the best advice is to go about your usual activities as much as you can with the assurance that the problem will clear up. Getting up and moving around can help ease stiffness, relieve pain, and have you back doing your regular activities sooner. Exercises or surgery are not usually advisable for acute back pain.
Chronic Back Pain: Treatment for chronic back pain falls into two basic categories: the kind that requires an operation and the kind that does not. In the vast majority of cases, back pain does not require surgery. Doctors will nearly always try nonsurgical treatments before recommending surgery. In a very small percentage of cases—when back pain is caused by a tumour, an infection, or a nerve root problem called cauda equina syndrome, for example—prompt surgery is necessary to ease the pain and prevent further problems.
Nonsurgical Treatments
Hot or cold: Hot or cold packs—or sometimes a combination of the two—can be soothing to chronically sore, stiff backs. Applying heat or cold may relieve pain, but it does not cure the cause of chronic back pain.
Exercise: Although exercise is usually not advisable for acute back pain, proper exercise can help ease chronic pain and perhaps reduce the risk of it returning.
Medications: Medications like paracetamol, NSAIDS may be helpful in acute pain to relieve the inflammation of the spine.
Traction: Traction involves using pulleys and weights to stretch the back. The rationale behind traction is to pull the vertebrae apart to allow a bulging disk to slip back into place. Some people experience pain relief while in traction, but that relief is usually temporary. Once traction is released, the stretch is not sustained and back pain is likely to return. There is no scientific evidence that traction provides any long-term benefits for people with back pain.
Corsets and braces: Corsets and braces include a number of devices, such as elastic bands and stiff supports with metal stays, that are designed to limit the motion of the lumbar spine, provide abdominal support, and correct posture. Although these may be appropriate after certain kinds of surgery, they should not be used in the management of chronic low back ache. In fact, by making the back muscles weaker the corsets harm you rather than helping you in the long term.
Injections: When medications and other nonsurgical treatments fail to relieve chronic back pain, doctors may recommend injections for pain relief.
Surgical Treatments
Surgery is indicated only in a minor group of patients. In general, two groups of people may require surgery to treat their spinal problems. People in the first group have chronic low back pain and sciatica, and they are often diagnosed with a herniated disk, spinal stenosis, spondylolisthesis, or vertebral fractures with nerve involvement.

Neck Pain

+What is Neck pain?

Neck pain is a common complaint. Most causes of neck pain aren't serious. The neck muscles can be strained from poor posture — whether it's leaning into your computer at work or hunching over your workbench doing hobbies at home. Wear-and-tear arthritis also is a common cause of neck pain. But sometimes neck pain can signify something more serious. Seek immediate medical care if you experience:

  • ⇒ Shooting pain into your shoulder or down your arm

  • ⇒ Numbness or loss of strength in your arms or hands

  • ⇒ Change in bladder or bowel habits

  • ⇒ Inability to touch your chin to your chest

+What are the causes of neck pain ?

Neck pain can result from a variety of causes, ranging from overuse injuries to diseases such as rheumatoid arthritis and meningitis.
Muscle strains: Overuse, such as too many hours hunched over a steering wheel, often triggers muscle strains. Neck muscles, particularly those in the back of your neck, become fatigued and eventually strained. When you overuse your neck muscles repeatedly, chronic pain can develop. Even such minor things as reading in bed or gritting your teeth can strain neck muscles.
Wear and tear: Just like all the other joints in your body, your neck joints tend to experience wear and tear with age, which can cause osteoarthritis in your neck.
Nerve compression: A variety of problems in your neck vertebrae can reduce the amount of space available for the nerves to branch out from the spinal cord. The best example of this is a herniated disc.
Injuries: Injuries to the neck can result in short as well as long lasting neck pain.
Rheumatoid arthritis: Rheumatoid arthritis if properly not treated properly developes neck involvement.
Cancer: Rarely, neck pain can be caused by cancerous tumors in the spine. The cancer may have travelled to the spine from other parts of your body.

+What are the tests required to diagnose the cause of neck pain ?

Your doctor often will be able to diagnose the cause of your neck pain and recommend treatment just by asking questions about the type, location and onset of your pain. In some instances, however, imaging tests, nerve tests or lab tests may be warranted.
Imaging tests
X-rays: X-rays can reveal areas in your neck where your nerves or spinal cord may be pinched by bone spurs or a bulging disk. But many people, especially those over 60, have these findings and don't experience any neck pain.
Computerized tomography (CT): CT scans help to visualize the bony structures as well as alignment of the bones.
Magnetic resonance imaging (MRI): MRI reveals the alignment of the vertebrae to the nerves of the spinal cord and is a very useful imaging modality.

+What is the treatment for neck pain?

Cervical spondylosis requires a multidisciplinary care. The first and most important thing is to make a correct diagnosis. The most important feature which helps your doctor determine which type of treatment you should receive depends on whether the nerves are being compressed.
Exercises: Exercises which increase the strength of the neck muscles is one of the key steps in the management. Drugs: Drugs have a major role in treating neck pain due to rheumatoid arthritis. Other causes of neck pain drug therapy is more or less limited to decreasing the pain and inflammation.
Rest: In cases of neck pain occurring following injury a short period of rest is absolutely essential in the management. But the wearing of collar for a long time will result in weakening of the muscles of the neck and can result in further aggravation of pain.
Surgery: Surgery may be required in patients who do not respond to conservative treatment.


+What Is Osteoarthritis?

Osteoarthritis is the most common type of arthritis and is seen especially among older people. Sometimes it is called degenerative joint disease or osteoarthritis

+Why does osteoarthritis occur?

Osteoarthritis mostly affects cartilage, the hard but slippery tissue that covers the ends of bones where they meet to form a joint. Healthy cartilage allows bones to glide over one another. It also absorbs energy from the shock of physical movement. In osteoarthritis, the surface layer of cartilage breaks and wears away. This allows bones under the cartilage to rub together, causing pain, swelling, and loss of motion of the joint. Over time, the joint may lose its normal shape. Also, small deposits of bone—called osteophytes or bone spurs—may grow on the edges of the joint. Bits of bone or cartilage can break off and float inside the joint space. This causes more pain and damage.
Causes of Osteoarthritis:
The cause of OA is not yet known, but certain factors increase the risk of developing OA

  • ⇒ Heredity

  • ⇒ Overweight

  • ⇒ Joint injury

  • ⇒ Repeated overuse of certain joints

  • ⇒ Lack of physical activity

  • ⇒ Nerve injury

  • ⇒ Aging

+Who develops Osteoarthritis?

Osteoarthritis is by far the most common type of arthritis, and the percentage of people who grows it higher with age.
Age: Although osteoarthritis become more common with age, younger people can develop it, usually as the result of a joint injury, a joint malformation, or a genetic defect in joint cartilage. Both men and women have the disease.
Sex: Before age 45, more men than women have osteoarthritis; after age 45, it is more common in women.
Overweight: Because in an overweight individual joints have to bear extra weight, knee joints get damaged and leads on to the development of osteoarthritis.
Jobs: Jobs which put lots of strain on the knees may lead on to the development of osteoarthritis.

+What Areas Does Osteoarthritis Affect?

The most common areas affected by osteoarthritis are knee joints and hip joints. Other joints like cervical spine (Cervical spondylosis), lumbar spine (lumbar spondylosis) and fingers also can get affected. It usually does not affect the wrist and elbow.

+What are the symptoms of osteoarthritis?

People with osteoarthritis usually experience pain in the joints. Usually, osteoarthritis comes on slowly. Early in the disease, joints may ache after physical work or exercise. Later on, joint pain may become more persistent. The joint pain which affects these joints increases with activity. For eg: pain in the knee increases with squatting or climbing stairs etc.The pain gradually becomes severe but only very rarely causes wrist pain. Patients may also experience joint stiffness, particularly when they first wake up in the morning or have been in one position for a long time. These patients also can develop deformity like bending of the knee. Swelling of the joints is usually not seen in osteoarthritis and may indicate some other pathology. Unlike rheumatoid arthritis, osteoarthritis do not affect internal organs.

+How is osteoarthritis diagnosed?

Osteoarthritis are diagnosed based on clinical examination as well as by taking x-rays. X-ray usually reveals loss of joint space in these patients. Recent developments have helped to detect changes in MRI, which can predict future development of osteoarthritis.

+What are the treatment options for osteoarthritis?

The main goal of osteoarthritis treatment is to improve the functionality of the patient by relieving the pain. Along with these physicians try to prevent the progression of osteoarthritis. Treatment plans often include a combination of drugs, rest, physical activity, joint protection, use of heat or cold to reduce pain, and physical or occupational therapy.
Weight loss: For every one pound of weight lost, there is a four pound reduction in the load exerted on the knee for each step taken during daily activities. It has also been shown that if a osteoarthritis patient loses 5kg of weight the pain decreases by 50%.
Exercise: Exercise plays a very important role in the management of osteoarthritis. It has been shown consistently that quadriceps strengthening exercise is an integral step in the management of osteoarthritis (figure 7). Pain relievers: During acute exacerbation pain relievers like acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) to help reduce joint pain, stiffness and swelling.
Drugs : Only supplement which has been proven to be effective in the management of osteoarthritis is Glucosamine. Most of other neutraceuticals have been disappointing in well conducted clinical trials, although manufactures claims are very high.
Surgery: Surgery in the form of joint replacement has seen major advances during last 2 decades. This is an important consideration in people with advanced Osteoarthritis associated with joint damage and/or marked limitations in joint function.

Rheumatoid Arthritis

+What is Rheumatoid Arthritis?

Rheumatoid Arthritis (RA) is a chronic, painful and disabling autoimmune disease affecting 1% of the Indian population. It can affect any joint in the body. It causes swelling and damage to the cartilage and bone around the joint. It is a systemic disease which means that it can affect the whole body and internal organs (although this is not the case for everyone with RA) such as the lungs, heart and eyes. This disease affects people of any age, including children and is three times more common in female than males.

+What causes it ?

“Why me?” is a common question by someone who develops rheumatoid arthritis. The exact answer for this question is not known. Smoking, both active and passive, is undoubtedly a very important cause. In the last decade, research has shown that lot of genes are associated with rheumatoid arthritis and RA may run in families.

+What are the symptoms?

The diagnosis of early RA is a very difficult. If you have these symptoms you should contact your rheumatologist immediately. Swelling of many joints along with stiffness in the joints, particularly in the morning hours is a very troublesome for these patients.

  • ⇒ Joint swelling

  • ⇒ Pain

  • ⇒ Morning joint stiffness

  • ⇒ Poor sleep

  • ⇒ Fatigue

+What happens to joints in rheumatoid arthritis?

The diagnosis of early RA is a very difficult. If you have these symptoms you should contact your rheumatologist immediately. Swelling of many joints along with stiffness in the joints, particularly in the morning hours is a very troublesome for these patients.
Normally the synovium (green) which lines a joint is very thin. In rheumatoid arthritis this lining becomes thick and starts destroying the cartilage, which lines the ends of bones. The defects in cartilage caused by these cells are called erosions If this process is not controlled early it results in destruction of the joint.
Organs other than joints can be affected in rheumatoid
Other parts of the body can get affected: (not affected in everyone with RA)

  • ⇒ Eyes - dryness, redness

  • ⇒ Lungs - fluid, breathlessness (rare)

  • ⇒ Skin - nodules, ulcers

  • ⇒ Heart - heart attack

  • ⇒ Blood - anaemia

+How is Rheumatoid arthritis diagnosed?

There is no single diagnostic test that you can take which can give you an immediate definite diagnosis. It is a ‘clinical’ diagnosis, which means that apart from taking a detailed history and examining your doctor has to do a few blood tests and X-rays before making a diagnosis. Most important of these are:

  • ⇒History of symptoms

  • ⇒Signs of swollen joints

  • ⇒Pain on squeezing knuckles

  • ⇒Raised inflammatory markers in a blood test (CRP + ESR)

  • ⇒Presence of Rheumatoid Factor (though about 30% of people with RA do not have Rheumatoid Factor)
+What is the importance of seeing a specialist?

Arthritis can be manifestation of more than 150 different diseases. The list of conditions varies from mild viral infection to joint destroying rheumatoid and got to dangerous, potentially lethal diseases like SLE and Vasculitis. Each of this disease has different treatment based on the seriousness of the condition. Some of these have exactly opposite treatments. The bottom line is that “All the arthritis are not rheumatoid”.A specialist can make a correct diagnosis and give you the right treatment. Failure to make a right diagnosis may cost you your joint or even life.

+Importance of early diagnosis and treatment?

In rheumatoid arthritis, cartilage is being destroyed. Delay in initiating appropriate treatment can result in the destruction of cartilage. It has been shown in latest research that more than 80% of patient develops erosions (defects in cartilage) by the end of one year. Once the cartilage is destroyed it cannot be regenerated fully. So in rheumatoid “time is cartilage”. So, it is essential not only to make a right diagnosis, but also to start treatment as early as possible.
Importance of treating even if it is late
Even after many years of disease the rheumatoid patients have ongoing pain, swelling and destruction in their joints. Moreover, in late stages of the disease, there is more chance that other organs in your body may get affected. So it is essential that you get the right treatment even if it is late. The bottom line is “It is better to be late than never.”

+What is the treatment of rheumatoid arthritis?

The understanding of rheumatoid arthritis has improved vastly in last 10 years, and there are now many effective treatments available. Most of it is cheap and is affordable to most of the Indians. With these drugs majority of patients get better relief and joint damage can be prevented. The initial treatment options are DMARDS (Disease Modifying Anti-Rheumatic Drugs). The most important of these drugs is Methotrexate. Once these drugs fail, which happens only in a few patients, newer agents like Biologicals (Eg: Infliximab, RItuximab) are used.

+Are steroids mainstay in modern medicine?

It is a misconception that management of RA is with steroids. Till 1980s steroids where the first line treatment in rheumatoid arthritis. Thanks to modern day management strategies the use of steroids in RA has decreased tremendously. If we use the right drug in correct doses the use of steroid can be easily avoided.

+Can a rheumatoid arthritis patient have a normal life?

If the disease is diagnosed early and well controlled with drugs, these patients can have a normal life as any other individual.

+What are biological medicines for rheumatoid arthritis?

Biologics are a new class of drugs that have been used for more than one decade. As already told rheumatoid arthritis is an autoimmune disease which means the immune system attacks the person. Some time back we used to suppress the whole of the immune system to protect the joint as we did not have methods to block harmful molecules alone. The problem with this approach was that the as we have suppressed the whole of the immune system, there is a higher risk of infection. By the advent biological it has become possible to block the specific molecules responsible for the inflammation of the joints. For example, TNF is a molecule which is responsible for inflammation of the joint. By giving Anti TNF molecules we can eliminate the effects of the TNF alone and the rest of the immune system is free to fight against the infection. Currently there are 5 biologic medicines available in India. The advent of biologic medicines is a major advancement in the field of Rheumatology and the work in this direction is still ongoing so that better and better biologists are being developed.


+What is Scleroderma?

Scleroderma is an autoimmune disease which affects the skin and internal organs. The name scleroderma means “hard skin”. As the name implies the disease starts in the skin, but goes on to involve other organs like kidney, lungs, heart and gastrointestinal tract. There are two types of scleroderma. Diffuse and limited, which differ in the extent of skin involved.

+Who gets scleroderma?

Scleroderma is a disease affecting approximately 25,000 patients in Kerala or 100,000 patients in India. Of these, 75% percent are women, usually diagnosed between the ages of 30 and 50 years.

+What causes scleroderma?

The cause of scleroderma is not known. Genetic factors appear to increase a patient’s chance of getting the disease. However, some data suggest that exposure to industrial solvents or an environmental agent may play a role in leading to scleroderma.
Clinical Features of scleroderma
Scleroderma is a multi system disorder affecting many systems in the body like,
Skin: Thickening and darkening of the skin.
Blood vessels: Blood vessels shrink and become excessively sensitive to cold. Because of this the blood flow to extremities decreases and the skin of the hands and extremities becomes blue or pale on exposure to cold. This is color change of the extremities call Raynaud’s phenomenon. If not treated properly the blood supply decreases to such an extent that the skin of the extremity becomes dark (dead) and very painful ulcer develops, which is very difficult to heal.
Gastrointestinal tract: Scleroderma affects every part of the GIT from the mouth to the anus. There will be difficulty in opening mouth in these patients. They also have burning in the chest due to excessive acidity. Also food can get stuck in the esophagus. They can have diarrhea or constipation, which vary from person to person.
Lungs: Lungs are one of the major organs which gets affected in scleroderma. The symptoms of this will be coughing and breathlessness. This is due to fibrosis in the lungs. If not treated early the fibrosis becomes very extensive and damages the whole lungs and can result in death of the patient.
Heart:Scleroderma can affect both sides, right and left, of the heart. This result in an increase in pressure on the right side of the heart called Pulmonary artery hypertension. On the left side, it causes impaired pumping, called left ventricular failure.
Kidney: Scleroderma can rarely involve kidney resulting in renal failure.

+How is scleroderma diagnosed?

Scleroderma is diagnosed by clinical examination by an experienced clinician. Then the doctor has to do a series of tests to see for the organ involvements in these patients, including the pulmonary function tests (PFT), CT scan and Scan of the heart.

+What are the treatment options available?

Scleroderma patients can be treated effectively with currently available drugs. The drugs used vary from person to person as the organs affected will be different in each one.
Raynaud’s phenomenon
Don’t smoke. Smoking narrows blood vessels, making Raynaud’s worse.
Avoid the cold when possible.
Dress warmly, in layers.
Use drugs prescribed by your doctor to improve your circulation. (Calcium channel blockers, angiotensin receptor blockers, Tadalafil etc.).
Skin sores and ulcers can be treated with nitroglycerine paste or antibiotic cream
Skin problems
Apply moisturizing creams and lotions frequently, especially after bathing.
Use only warm water in your bath or shower (hot water is too drying)
Avoid harsh soaps, household cleaners and caustic chemicals.
Gastrointestinal problems
Eat small, frequent meals.
Take dinner before 8 pm
Remain standing or sitting at least one hour after eating.
Avoid citrus fruits like orange and lemon at nights
Proton pump inhibitors, such as omeprazole and lansoprazole, can be taken for heartburn.
Lung disease
Immunosuppressive drugs such as cyclophosphamide and Mycophenolate Mofetil, along with low-dose steroids can be used to treat pulmonary fibrosis.
Heart disease
Vasodilators, such as prostacyclin, Bosentan, sildenafil can be used to decrease the pressure in the right side of the heart.

+Can scleroderma patients lead a normal life?

If scleroderma is diagnosed and treated early it can be controlled very well. This is because in scleroderma most of the damage occurs early in the disease and if not controlled early the damage which happens is irreversible.

Sjogren’s Syndrome

+What is sjogren’s syndrome?

Sjogren’s syndrome is a chronic autoimmune disease in which people’s white blood cells attack their moisture-producing glands. It is a common problem affecting around 0.5 % of the adult population.

+Whom does it affect?

Nine out of ten Sjogren’s patients are women. The average age of diagnosis is late 40s, although it can occur in all age groups, including children, and in both sexes.

+What are the most common symptoms?

  • ⇒ a dry, gritty or burning sensation in the eyes

  • ⇒ dry mouth

  • ⇒ dry or burning throat

  • ⇒ dry or peeling lips

  • ⇒ a change in taste or smell

  • ⇒ increased dental decay

  • ⇒ joint pain

  • ⇒ fatigue

+What causes the dryness in Sjogren’s syndrome?

In the autoimmune attack that causes Sjogren’s, disease-fighting white blood cells called lymphocytes target the glands that produce moisture – primarily the lacrimal (tear) and salivary (saliva) glands. Although no one knows exactly how damage occurs, damaged glands can no longer produce tears and saliva, and eye and mouth dryness result.

+How is this diagnosed?

There is no single test that will confirm diagnosis. Rheumatologists have primary responsibility for diagnosing and managing Sjogren’s syndrome and can conduct a series of tests, including Schirmer Test blood tests like ANA as well as a small biopsy from the lower lip.

+How is Sjogren’s syndrome treated ?

Dry eyes and dry mouths are really a nuisance in these patients and are treated with simple steps like tear substitutes as well as frequent sips of water. If the dryness is very severe drugs which increase the secretion like Pilocarpine and cevimeline may be required. In addition to these drugs like Methotrexate and Rituximab may be helpful in patients who have joint pains as well as other manifestations of Sjogren’s syndrome.

Systemic Lupus Erythematosus (SLE)

+What is SLE?

SLE (Systemic Lupus Erythematosus) is a chronic, autoimmune disease. Autoimmune means your immune system cannot tell the difference between the foreign invaders like bacteria or virus and your body’s healthy tissues and attacks healthy tissue. It can affect any part of the body starting from the skin, joints, to major organs like kidney, heart, lungs and brain.

+Who are affected?

Lupus is about nine times as common in women as in men. Lupus is more common in women of reproductive age group that is 15-45 years. Lupus also affects children, but only rarely. Although SLE is considered a rare disease, it is much more common than leukemia. Its prevalence is 1/1000. There are approximately 120,000 patients with SLE in India and 30,000 patients in Kerala at a time. It can affect any age, although it predominantly affects females of age 15-35.

+What are the symptoms of SLE?

Although it can affect any part of the body starting from the skin, joints, to major organs like kidney, heart, lungs and brain, it is not a must that all the organs are affected in every patient. Some patient has only skin and joint involvement, some others have kidney and brain involvement along with skin and joint. So, it can have a wide variety of manifestations which vary from patient to patient.

  • ⇒ The symptoms depend on which are the organs affected.

  • ⇒ extreme fatigue (tiredness)

  • ⇒ painful or swollen joints

  • ⇒ fever

  • ⇒ anaemia ( Low Haemoglobin)

  • ⇒ swelling (oedema) in feet, legs

  • ⇒ Skin rash

  • ⇒ sun- or light-sensitivity (photosensitivity)

  • ⇒ hair loss

  • ⇒ mouth or nose ulcers

+What are the organs affected in lupus patients?

SLE can affect any organ in the body. The most common internal organs affected are kidney and brain. So SLE can cause seizures or it can result in kidney failure. It can also affect the heart, lungs, blood vessels etc.

+How is SLE diagnosed?

SLE is diagnosed by a physician based on the clinical situation and positive results for ANA (Antinuclear antibody). After diagnosing SLE physician try to see which are the systems affected by SLE. For this some blood and urine tests have to be done.
Importance of diagnosing and treating lupus
It is extremely important to diagnose lupus early and as a missed diagnosis may cost the patient his/her life. If SLE is diagnosed early it can be very effectively treated and more than 90 % of patients have very good results.

+How is SLE treated?

As we have mentioned earlier the immune cells are attacking different organs of the body. To decrease the attack, we have to modify the function of the immune system. There are lots of them available them now. Although Steroids are required to control the disease fast, proper use of other drugs early in the disease will prevent the overuse of steroids and damage to the joints. Hydroxychloroquine is used to treat skin rash as well as many other manifestations of SLE. Other drugs like steroids, azathioprine, cyclophosphamide, mycophenolate etc. are often used by doctors to treat Lupus. The drugs and modality of treatment depends on the organ involved. Which drug to use and for how long is decided by your rheumatologist. It is extremely dangerous to take or to stop these drugs on your own. Further, you require regular follow up with your doctor and blood/urine tests as advised by your doctor. Please keep your doctor informed about any problems while taking them or in case you develop new illness.

+Anything more that I should know?

Keep out of the sun:As ultraviolet rays in the sunlight aggravates SLE it is advisable to avoid sun exposure or by doing activities ether in the morning hours or evenings. If it is unavoidable, it is advisable to use long sleeved dresses, umbrellas, etc. Also use a sun-blocking cream, SPF 25 or greater once you have to go to the sun Infections: If you have Lupus, and especially if you are on immunosuppressive drugs, then you will be more prone to infection. Take sensible precautions and avoid contact with family and friends who are known to have fever, cough etc.
Fatigue: Fatigue can result in significant problem in SLE patients. It can be due to many causes like anemia, hypothyroidism or SLE peers. Let your doctor know that fatigue is causing your problem and he may be able will do the necessary tests to find out the cause and treat it.
Pregnancy and Lupus:If you're thinking of having a baby, discuss your plans with your doctor well before conception. If the disease is well under control at the time the baby is conceived pregnancy usually will be uncomplicated. Some of SLE patients are at higher risk of miscarriage and requires Heparin injections to prevent this. Some of the drugs used to treat SLE will harm the fetus and has to be stopped before pregnancy.

+What is the outlook for SLE patients?

It has considerably improved over the last 2 decades so. Thanks to dedicated researchers making major breakthroughs. These advancements have definitely resulted in improvement in care as well as quality of life of lupus patients.


+What is Vasculitis ?

In medicine, ‘it is’ is a suffix that means inflammation; for example appendicitis is inflammation of the appendix. Vasculitis is inflammation of the vasculature (blood vessels), including the arteries and/or the veins. Inflammation of the blood vessels is characterized by white blood cells (leukocytes) infiltrating the vessel wallsThis inflammation and the body’s subsequent reactions to it can cause the vessels to become weakened and can impair the integrity of the vessel walls, which in turn can prevent adequate flow of blood through the affected vessels. This can cause ischemia (lack of oxygen) of the organ and body tissues fed by this blood supply, and this is responsible for many of the problems that the different types of vasculitis can cause.

+What are the types of Vasculitis?

Based on the size of blood vessels involved and the organs affected there are different types of Vasculitis

  • ⇒ Churg Strauss Syndrome

  • ⇒ Cryoglobulinemia

  • ⇒ Giant Cell Arteritis

  • ⇒ Henoch-Schönlein Purpura

  • ⇒ Kawasaki Disease

  • ⇒ Microscopic Polyangiitis

  • ⇒ Polyarteritis Nodosa

  • ⇒ Polymyalgia rheumatica

  • ⇒ Takayasu’s Arteritis

  • ⇒ Wegener's Granulomatosis
+What is the cause of vasculitis?

Causes of autoimmune vasculitis are largely unknown, but thought to be due to a combination of factors, including infection, genetic predisposition, and environmental.

+What are the symptoms?

These patients have nonspecific symptoms like Fever, weight loss, lack of appetite, body aches, joint pains, etc. Each type of vasculitis can also have manifestations based on which organs are involved. Vasculitis patients can develop red spots on the skin and when blood flow decreases, the skin can turn dark resulting in the death of the cells of the affected parts. Similar lesions can affect internal organs like kidney, lungs, heart, etc. This can lead on to renal failure or paralysis.

+How is the diagnosis made?

The diagnosis of Vasculitis is not very easy. There are criteria proposed by the American College of Rheumatology (ACR) for diagnosis. The diagnosis can only be made by an experienced physician. Presence of an antibody called ANCA helps in diagnosing certain types of Vasculitis.

+What is the importance of making early diagnosis?

Despite the difficulty making a definitive diagnosis of vasculitis, early diagnosis is important as these diseases do respond to appropriate treatments. For example, untreated Wegener’s disease has 100% mortality with an average survival of only 5 months. However, treatment of this disease achieves very good results in 80-90% of patients. This illustrates the importance of being persistent to get a definitive diagnosis in patients with possible vasculitis.

+What are the treatment options available?

During the initial years steroids were the only drugs used in the treatment of these diseases. Currently there are newer drugs like Mycophenolate mofetil, Cyclophosphamide and Rituximab being used to treat these patients effectively. If these diseases are diagnosed early and treated effectively most of the patients get cured.