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Suggest Treatment For Severe Heel Pain While On Azithromycin
Question: Hi
Approximately six weeks ago i woke up in the morning with severe heel pain in both ankles. I was unable to seek treatment as i was traveling however started taking ibuprofen. Two weeks later i sought help from the hospital and was referred to an orthopaedic surgeon. He prescribed me arcoxia and dyclofinac which i continued to take. Two weeks back i had an MRI which showed no bone damage no infection but severe inflammation and edoema around my ankles. He changed me to vimovo and arcoxia and submitted blood tests. I was then advised i had Strep A positive. My GP then prescribed me azithromycin for five days which i completed on friday. Today however i noticed a small painful rash on my stomach near my belly button attached in the photo. My question is does this look like rheumatic fever or would this type of rash start in this location and would it be sore? It feels like a cigarette burn from a pain similarity but only upon touching. I'd appreciate your advice thank you!
Approximately six weeks ago i woke up in the morning with severe heel pain in both ankles. I was unable to seek treatment as i was traveling however started taking ibuprofen. Two weeks later i sought help from the hospital and was referred to an orthopaedic surgeon. He prescribed me arcoxia and dyclofinac which i continued to take. Two weeks back i had an MRI which showed no bone damage no infection but severe inflammation and edoema around my ankles. He changed me to vimovo and arcoxia and submitted blood tests. I was then advised i had Strep A positive. My GP then prescribed me azithromycin for five days which i completed on friday. Today however i noticed a small painful rash on my stomach near my belly button attached in the photo. My question is does this look like rheumatic fever or would this type of rash start in this location and would it be sore? It feels like a cigarette burn from a pain similarity but only upon touching. I'd appreciate your advice thank you!
Brief Answer:
VIral fever
Detailed Answer:
Good evening
thank you for writing on health care magic
Well, the sort of pain and swelling you are describing looks like more of a inflammatory enthesitis( that is the tendon inflammation) which may be preceded by a viral or bacterial infection .
I would like to know a few more details before guiding you further:
1. How is the swelling of the ankles...After painkiller course..Is it better or still the same
2. Was your chest X Ray done???
3. Which area do you reside?and where were you travelling??
4. WAs there any fever at the start of the pain
5. ANy history of previous backache or neck pain?
6. Did they do your ESR and CRP?
as per your query, This doesnt look like Rheumatic Fever.. I belong to XXXXXXX and we have the highest prevalence here. Firstly your age is against it...It rarely happens after the age of 25..Secondly, We expect migratory arthritis in it rather than a constant one...
As for the lesion and arthritis, it is very common after any streptococcal infection( Post streptococcal reactive arthritis). But just to be sure we are dealing with it, we need to rule out other possible causes as well..
DO let me know these queries. Would guide you further from here
Regards
Dr Naval
VIral fever
Detailed Answer:
Good evening
thank you for writing on health care magic
Well, the sort of pain and swelling you are describing looks like more of a inflammatory enthesitis( that is the tendon inflammation) which may be preceded by a viral or bacterial infection .
I would like to know a few more details before guiding you further:
1. How is the swelling of the ankles...After painkiller course..Is it better or still the same
2. Was your chest X Ray done???
3. Which area do you reside?and where were you travelling??
4. WAs there any fever at the start of the pain
5. ANy history of previous backache or neck pain?
6. Did they do your ESR and CRP?
as per your query, This doesnt look like Rheumatic Fever.. I belong to XXXXXXX and we have the highest prevalence here. Firstly your age is against it...It rarely happens after the age of 25..Secondly, We expect migratory arthritis in it rather than a constant one...
As for the lesion and arthritis, it is very common after any streptococcal infection( Post streptococcal reactive arthritis). But just to be sure we are dealing with it, we need to rule out other possible causes as well..
DO let me know these queries. Would guide you further from here
Regards
Dr Naval
Above answer was peer-reviewed by :
Dr. Veerisetty Shyamkumar
Thank you further details per your request..
1. The antiflammatories eased it slightly when i was on arcoxia and diclofinac. When he switched me to vimova and arcoxia the vimovo seemed to make a big difference the pain dropped from about a 10/10 without drugs to an 8/10 with arcoxia to a 6/10 with vimovo added. Without any anti-inflammatories the swelling increases and the pain progressively comes back to the level after 3 days (twice i ran out of meds).
2. No i have not had a chest xray should i?
3. I live in singapore and had traveled to XXXXXXX XXXXXXX (27 hour flight via germany)
4. No fever that i recall however i was tired and out of sorts but assumed that was jetlag. The ankle issue occured approx 4 days after landing in XXXXXXX It started with both ankles the left being worst and my left is now about a 3/10 with the right being more painful
5. Occasional neck pain but that is from a pinched nerve and bad posture at the office :)
6. Yes and both were normal
1. The antiflammatories eased it slightly when i was on arcoxia and diclofinac. When he switched me to vimova and arcoxia the vimovo seemed to make a big difference the pain dropped from about a 10/10 without drugs to an 8/10 with arcoxia to a 6/10 with vimovo added. Without any anti-inflammatories the swelling increases and the pain progressively comes back to the level after 3 days (twice i ran out of meds).
2. No i have not had a chest xray should i?
3. I live in singapore and had traveled to XXXXXXX XXXXXXX (27 hour flight via germany)
4. No fever that i recall however i was tired and out of sorts but assumed that was jetlag. The ankle issue occured approx 4 days after landing in XXXXXXX It started with both ankles the left being worst and my left is now about a 3/10 with the right being more painful
5. Occasional neck pain but that is from a pinched nerve and bad posture at the office :)
6. Yes and both were normal
Brief Answer:
Reactive arthritis
Detailed Answer:
good evening
Singapore is such a nice country..I was trained there..would move there anyday given a chance..
As for your ankle joint swelling, it is usually a reactive forms..that is the process is going on somewhere in the body and it throws a reaction somewhere....
In your case, rheumatic fever is not the cause. we need to look on other differentials:
1. get a chest x ray done..rule out tuberculosis vs sarcoid as in asian population ankle arthritis is due to it. Sarcodiosis is not so common in singapore as compared to other asian countries.
2. but the mosr common looks to be post streptococcal reactive arthritis. you will need a short course of steroids to settle it. Something for a 10 to 14 days as pain killers wont stop the process and it will bounce back.
I dont think you need any long term treatment, but a x ray chest is mandatory.
Hope the information was useful
do let me know for more queries
regards
dr naval
Reactive arthritis
Detailed Answer:
good evening
Singapore is such a nice country..I was trained there..would move there anyday given a chance..
As for your ankle joint swelling, it is usually a reactive forms..that is the process is going on somewhere in the body and it throws a reaction somewhere....
In your case, rheumatic fever is not the cause. we need to look on other differentials:
1. get a chest x ray done..rule out tuberculosis vs sarcoid as in asian population ankle arthritis is due to it. Sarcodiosis is not so common in singapore as compared to other asian countries.
2. but the mosr common looks to be post streptococcal reactive arthritis. you will need a short course of steroids to settle it. Something for a 10 to 14 days as pain killers wont stop the process and it will bounce back.
I dont think you need any long term treatment, but a x ray chest is mandatory.
Hope the information was useful
do let me know for more queries
regards
dr naval
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Hi Dr Naval
Thank you for your reply. I went to my GP today for another opinion and shared with him my MRI results (attached) for another opinion. After reviewing my history and the scan results including bloods which were mainly normal exept for the strep antibody being positive, his view was it appeared to be more a bone issue and recommended i speak to my specialist about a bone density or nuclear scan of my calcaneum bone. His view was it is indeed perplexing as per my specialist view and suggested the potential for a differential diagnosis. Based on my presenting symptoms he doesnt believe it to be reactive arthritis nor rheumatic fever. His only thoughts were possible calceum fracture which my specialist ruled out, lyme disease as an unusual diagnosis or possible cancer? Further to my results i wanted to confirm i did no exercise and spontaneously awoke with this issue. Any further thoughts or do my MRI results provide any further thoughts for you? The pain has definitely returned today to previous levels despite the anti inflammatory meds. Also I'm an expat in singapore for the past 10 years originally from NZ if that helps not a singaporean :)
Thank you for having another look thanks!
Thank you for your reply. I went to my GP today for another opinion and shared with him my MRI results (attached) for another opinion. After reviewing my history and the scan results including bloods which were mainly normal exept for the strep antibody being positive, his view was it appeared to be more a bone issue and recommended i speak to my specialist about a bone density or nuclear scan of my calcaneum bone. His view was it is indeed perplexing as per my specialist view and suggested the potential for a differential diagnosis. Based on my presenting symptoms he doesnt believe it to be reactive arthritis nor rheumatic fever. His only thoughts were possible calceum fracture which my specialist ruled out, lyme disease as an unusual diagnosis or possible cancer? Further to my results i wanted to confirm i did no exercise and spontaneously awoke with this issue. Any further thoughts or do my MRI results provide any further thoughts for you? The pain has definitely returned today to previous levels despite the anti inflammatory meds. Also I'm an expat in singapore for the past 10 years originally from NZ if that helps not a singaporean :)
Thank you for having another look thanks!
Brief Answer:
MRI Report Reviewed
Detailed Answer:
Good evening
I have gone through the MRI report...
1. As per the view of your GP, I really dont feel it is calcaneal fracture.. Firstly, it is unusal for it to happen at both sides at the same time unless you sustained a fall from the height. Secondly, if it was fracture you wouldnt have been able to walk... The MRI does show a magnified report but it does show a lot of edema around the bones...That can be present in any arthritis as well..
Also they didnt cover the foot and the remaining joints of the foot...
2. No cancer for sure..IT never presents this way.
I dont think it is lyme disease either..It wont present without fever...
3. Oh since you are not from singapore, it is important we Rule out Sarcodiosis for you..I would suggest you a few more tests which I feel are needed to reach your diagnosis.
1. X ray chest PA view
2. HLA B 27( PCR)
3. If possible Ultrasound of the foot...MRI though superior hasnt let us to any diagnosis..Even bone Scan will be helpful, as it will indicate if their any arthritis or not...
Also, seek an Opinion from a Rheumatologist.. If you want I can suggest you to a good one...
Do let me know for more queries...PS: I believe short course of steroids are needed to solve the edema...But it is important we rule out where exactly the etiology lies.
Regards
Dr Naval
MRI Report Reviewed
Detailed Answer:
Good evening
I have gone through the MRI report...
1. As per the view of your GP, I really dont feel it is calcaneal fracture.. Firstly, it is unusal for it to happen at both sides at the same time unless you sustained a fall from the height. Secondly, if it was fracture you wouldnt have been able to walk... The MRI does show a magnified report but it does show a lot of edema around the bones...That can be present in any arthritis as well..
Also they didnt cover the foot and the remaining joints of the foot...
2. No cancer for sure..IT never presents this way.
I dont think it is lyme disease either..It wont present without fever...
3. Oh since you are not from singapore, it is important we Rule out Sarcodiosis for you..I would suggest you a few more tests which I feel are needed to reach your diagnosis.
1. X ray chest PA view
2. HLA B 27( PCR)
3. If possible Ultrasound of the foot...MRI though superior hasnt let us to any diagnosis..Even bone Scan will be helpful, as it will indicate if their any arthritis or not...
Also, seek an Opinion from a Rheumatologist.. If you want I can suggest you to a good one...
Do let me know for more queries...PS: I believe short course of steroids are needed to solve the edema...But it is important we rule out where exactly the etiology lies.
Regards
Dr Naval
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Hi Dr Naval
Thank you for the reply above :) I went to Mt E this morning and didn't advise them of your view as i wanted to get another unbias opinion from the emergency dept. It was their view that a rheumatologist was the best course of action so they referred me this morning. After going to him he concluded very similar to yourself with no guidance or view of your opinion, i told him after he had reached his diagnosis of your view. He has prescribed prednisone, celebrex, colcitrex and two weeks of zithromax and thinks similar to you it is a reactive athritis. He was most interested to know who you would have referred me too :) Thank you very much for your advise and guidance and i hope one of the tests provides further insight to the cause!! I do feel that the redirection of testing might find some outcome. He also completed an ultrasound and i had him check both ankles. He confirmed it is a soft tissue inflammation and whilst the right is worse the inflammation is still showing in the left. If you have an email i'd love to keep you updated of the eventual diagnosis, your help has been invaluable!
Thanks!
Thank you for the reply above :) I went to Mt E this morning and didn't advise them of your view as i wanted to get another unbias opinion from the emergency dept. It was their view that a rheumatologist was the best course of action so they referred me this morning. After going to him he concluded very similar to yourself with no guidance or view of your opinion, i told him after he had reached his diagnosis of your view. He has prescribed prednisone, celebrex, colcitrex and two weeks of zithromax and thinks similar to you it is a reactive athritis. He was most interested to know who you would have referred me too :) Thank you very much for your advise and guidance and i hope one of the tests provides further insight to the cause!! I do feel that the redirection of testing might find some outcome. He also completed an ultrasound and i had him check both ankles. He confirmed it is a soft tissue inflammation and whilst the right is worse the inflammation is still showing in the left. If you have an email i'd love to keep you updated of the eventual diagnosis, your help has been invaluable!
Thanks!
Brief Answer:
Further course
Detailed Answer:
Good evening
Well, that s good that we do have a diagnosis now and at least 2 people think the same way. He has started you on the steroids course which is a good sign and it should get better in a couple of weeks.
And there is definitely no fracture..Sometimes MRI can guide you the wrong way as well...
As for the medications, use Celebrex on SOS basis..Since prednisolone will do the needful for the inflammation you have and you may not feel the pain after it...You have already taken good amount of painkillers so far..
Lastly, we just need to see it is a single episode and not a prolonged one, so the medications can go off soon.
You can always contact me here.. We are not allowed to share personal details on site..Sorry about it...
Do take care..Wish you speedy recovery...
REgards
Dr Naval
Further course
Detailed Answer:
Good evening
Well, that s good that we do have a diagnosis now and at least 2 people think the same way. He has started you on the steroids course which is a good sign and it should get better in a couple of weeks.
And there is definitely no fracture..Sometimes MRI can guide you the wrong way as well...
As for the medications, use Celebrex on SOS basis..Since prednisolone will do the needful for the inflammation you have and you may not feel the pain after it...You have already taken good amount of painkillers so far..
Lastly, we just need to see it is a single episode and not a prolonged one, so the medications can go off soon.
You can always contact me here.. We are not allowed to share personal details on site..Sorry about it...
Do take care..Wish you speedy recovery...
REgards
Dr Naval
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Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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