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Suggest Treatment For Severe Joints Pain And Arthritis
Question: Hi- I really need some help. My history is as follows: Epstein Barr, CMV (bad infection at the time) shigella dysentery. Also have multiple level back fusions low back and C5-6 at neck. Multiple levels of osseo-ossification in the T-spine. Lumbar arachnoiditis L3-S1. Had antibody test (SSA) come back only once at 44 for Sjogrens. Subsequent tests negative however. Take multiple meds including narcotics for arachnoiditis. BLood pressure meds, etc. Have ongoing joint pain in hands, back, elbows, legs, knees, feet, pretty much entire body. Pain is present pretty much all the time at moderate levels. However occasionally I have attacks of severe joint pain, (full body it seems) severe enough that I am unable to get out of bed, last 2-3 days most days. Sitting in very hot water in the tub seems to help a little but very little actually gets rid of this, maybe really nothing that I have tried. Have been on methotrexate, prednisone, Celebrex, Plaquenil, (not now) but it didn't seem to help the months I was on it. I also have some neurological issues, mostly cerebral blood flow issues (poor) that after a brain spect scan was attributed to TBI. I seem to have both Bouchard's and Heberdens nodes in my hands, including the DIP joints. I have 2 brothers, 2 sisters, all younger, I am male, age 59, (history of 30 years heavy labor in a sawmill) and at least 3 of my siblings are having serious issues with arthritis like symptoms. I've been thoroughly worked up but it has been a while since I have seen a good rheumatologist. They are hard to find where I live on the XXXXXXX coast. I would appreciate any input you might have. Thank you. XXXX
Brief Answer:
Intermittent arthritis
Detailed Answer:
Good evening
Thank you for writing on health care magic
Well i have gone through your history. The sort of joint pains you are describing fit s in with intermittent arthritis, known as Palindromic Rheumatism, that is the attacks are intermittent, lasts for a couple of days and improves itself with no residual damage. However the only unusual thing is involvement of multiple joints. I would like to ask you a few questions to get a clearer picture of what exactly is going on:
1. How frequent you get these attacks?Like how many times in a month
2. Do you take any medications for it to subside? or it goes off itself
3. Have you ever noticed swelling of the joints as well??
4. During the episodes, do you get Early morning stiffness?
5. Any other associated symptoms of dry eyes, dry mouth, oral ulcers, excessive hair fall?
6. Could you please check if your blood work has been checked for Rheumatoid factor and Anti CCP antibody.
Do let me know these queries. Will try to figure out if it fits in with the Inflammatory arthritis you have or some other form of joint pains we are dealing with
Await your reply
REgards
DR Naval
Intermittent arthritis
Detailed Answer:
Good evening
Thank you for writing on health care magic
Well i have gone through your history. The sort of joint pains you are describing fit s in with intermittent arthritis, known as Palindromic Rheumatism, that is the attacks are intermittent, lasts for a couple of days and improves itself with no residual damage. However the only unusual thing is involvement of multiple joints. I would like to ask you a few questions to get a clearer picture of what exactly is going on:
1. How frequent you get these attacks?Like how many times in a month
2. Do you take any medications for it to subside? or it goes off itself
3. Have you ever noticed swelling of the joints as well??
4. During the episodes, do you get Early morning stiffness?
5. Any other associated symptoms of dry eyes, dry mouth, oral ulcers, excessive hair fall?
6. Could you please check if your blood work has been checked for Rheumatoid factor and Anti CCP antibody.
Do let me know these queries. Will try to figure out if it fits in with the Inflammatory arthritis you have or some other form of joint pains we are dealing with
Await your reply
REgards
DR Naval
Above answer was peer-reviewed by :
Dr. Yogesh D
Hello and Good evening: To answer your questions: 1. Sometimes I go more than a month without having one. Sometimes several months. 2. Nothing that I have taken so far has helped to get rid of the attacks. Heat seems to relieve the symptoms but I don't think it makes it go away any sooner. 3. I have not noticed any joint swelling just severe pain. 4. Yes I get early morning stiffness but the stiffness seems to be a reaction to the joint pain. 5. I have intermittent on a fair regular basis dry eyes, I've had plugs put in my tear ducts for it. Some dryness of the mouth, I have seriously choked on some food several times the past several years and I think it was lack of moisture related.6. I know I have had my RH factor checked in the past, including the HLA-B27 factor but it has been quite a while and I do not recall the anti CCP antibody being checked, but if a rheumatologist normally does that routinely I likely would have, but it would have been several years ago. I can certainly get those repeated as I am do for other blood work anyway including anything else you might recommend. Thank you so much for your reply, looking forward to your further opinion. -XXXX
Hi-A correction. I have experienced marked swelling of the fingers of both hand and of both feet at times but the swelling most definitely did not correlate with these attacks. It seems like it started off with severe pain in the spine, then the elbows, both of them, then the hands, and it just seemed to go systemic after that.
Hello again, One last thing, the pain that hits me, I have it all the time, at a moderate level, maybe on a scale of 1-10 about a 6-7. It never goes away. I sometime feel it shift from one joint to the other. One shoulder to the other, one knee to the other, one elbow to the other, etc. Sorry for the addendums, but you hadn't asked me if I have similar pain all the time and I wanted to be complete.
THank you, XXXX
Hi-A correction. I have experienced marked swelling of the fingers of both hand and of both feet at times but the swelling most definitely did not correlate with these attacks. It seems like it started off with severe pain in the spine, then the elbows, both of them, then the hands, and it just seemed to go systemic after that.
Hello again, One last thing, the pain that hits me, I have it all the time, at a moderate level, maybe on a scale of 1-10 about a 6-7. It never goes away. I sometime feel it shift from one joint to the other. One shoulder to the other, one knee to the other, one elbow to the other, etc. Sorry for the addendums, but you hadn't asked me if I have similar pain all the time and I wanted to be complete.
THank you, XXXX
Brief Answer:
? Palindromic Rheumatism
Detailed Answer:
Good evening XXXXXXX
Sorry for the delayed reply. Was stuck in hospital shifts
Well the sort of history you have told, it fits in more with Palindromic Rheumatism. It is a prodomal of Rheumatoid Arthritis.It is an intermittent types causing pain, stiffness and swelling in usually 1 set of joints at one time, which lasts for 2-3 days and subsides itself. The next attack can be a week late, a month late or few months late. Now the question comes, Will it be like this or will it become persistent? And how strong of medications you need for it?
I would answer all these questions, but yes one thing I would like you to do is to approach your physician as soon as you get these episodes of pain/swelling. Examination of the joints is the key in this disease and we need to catch it on the right moment to confirm.
Palindromic Rheumatism may go on like this for years and may never become persistent. The strong indicators for it to become persistent are Rheumatoid Factor and Anti CCP positivity. If they are positive, there is 50 % chance it will become persistent. But if negative, it may go on like this. SO, in next Blood tests I would recommend you get these done.
The only indication for starting theraphy is, if the attacks are long lasting and frequent. Considering the frequency of attacks you have, I feel you will do good with NSAIDS once in a while rather than on continous Methotrexate.
Lastly, the symptoms of dry mouth and dry eyes dont fit in with this disease. When you get your blood tests done, repeat ESR< CRP, ANA and ENA profile along with RF and Anti CCP. Sjogrens syndrome can also cause the sort of arthritis you have and if the antibodies come positive, we will need to start you on some medication.
Discuss with your rheumatologist about the Palindromic Rheumatism, in the next meet as well. And do approach your physician during the next attack
I hope the information was useful
Do let me know for more queries
Would be happy to help out
Regards
Dr Naval
? Palindromic Rheumatism
Detailed Answer:
Good evening XXXXXXX
Sorry for the delayed reply. Was stuck in hospital shifts
Well the sort of history you have told, it fits in more with Palindromic Rheumatism. It is a prodomal of Rheumatoid Arthritis.It is an intermittent types causing pain, stiffness and swelling in usually 1 set of joints at one time, which lasts for 2-3 days and subsides itself. The next attack can be a week late, a month late or few months late. Now the question comes, Will it be like this or will it become persistent? And how strong of medications you need for it?
I would answer all these questions, but yes one thing I would like you to do is to approach your physician as soon as you get these episodes of pain/swelling. Examination of the joints is the key in this disease and we need to catch it on the right moment to confirm.
Palindromic Rheumatism may go on like this for years and may never become persistent. The strong indicators for it to become persistent are Rheumatoid Factor and Anti CCP positivity. If they are positive, there is 50 % chance it will become persistent. But if negative, it may go on like this. SO, in next Blood tests I would recommend you get these done.
The only indication for starting theraphy is, if the attacks are long lasting and frequent. Considering the frequency of attacks you have, I feel you will do good with NSAIDS once in a while rather than on continous Methotrexate.
Lastly, the symptoms of dry mouth and dry eyes dont fit in with this disease. When you get your blood tests done, repeat ESR< CRP, ANA and ENA profile along with RF and Anti CCP. Sjogrens syndrome can also cause the sort of arthritis you have and if the antibodies come positive, we will need to start you on some medication.
Discuss with your rheumatologist about the Palindromic Rheumatism, in the next meet as well. And do approach your physician during the next attack
I hope the information was useful
Do let me know for more queries
Would be happy to help out
Regards
Dr Naval
Above answer was peer-reviewed by :
Dr. Vaishalee Punj
Hello Dr. Mendiratta and Good Afternoon:
Thank you very much for your response. I have just a couple of questions in regard to what you suggest. 1. Given the first line NSAIDS I have already taken (prescribed by a rheumatologist) and the lack of luck that I had with them (Prednisone, Methotrexate, Plaquenil, Celebrex), and the ongoing pain that I am having, what about trying one of the injectable meds like Enbrel?, (Assuming I can get my ins. to pay, I know they are expensive). I will get the blood work done that you suggest. It is my understanding that the SSA factor is not real sensitive meaning that you can have a positive, then a neg., but actually have the condition. An SSA of 44 which according to what I was told, is twice the antibodies you need to get diagnosed with Sjogrens, and that is really the only thing that has turned up in the blood work done so far along the RH lines.
Of course I realize that doesn't mean my next set won't show something. I guess what I am asking is since I have ongoing pain that flares, what would be the best medication to take ongoing for the chronic portion of the disease? I understand you want me to get an urgent appt. with a rheumatologist my next flare so he can check my joints. Frankly, there are none here in town and access I have on short notice would likely be my family physician who is an M.D., PhD. (in microbiology). Thank you in advance for you help. Best regards, XXXX
Thank you very much for your response. I have just a couple of questions in regard to what you suggest. 1. Given the first line NSAIDS I have already taken (prescribed by a rheumatologist) and the lack of luck that I had with them (Prednisone, Methotrexate, Plaquenil, Celebrex), and the ongoing pain that I am having, what about trying one of the injectable meds like Enbrel?, (Assuming I can get my ins. to pay, I know they are expensive). I will get the blood work done that you suggest. It is my understanding that the SSA factor is not real sensitive meaning that you can have a positive, then a neg., but actually have the condition. An SSA of 44 which according to what I was told, is twice the antibodies you need to get diagnosed with Sjogrens, and that is really the only thing that has turned up in the blood work done so far along the RH lines.
Of course I realize that doesn't mean my next set won't show something. I guess what I am asking is since I have ongoing pain that flares, what would be the best medication to take ongoing for the chronic portion of the disease? I understand you want me to get an urgent appt. with a rheumatologist my next flare so he can check my joints. Frankly, there are none here in town and access I have on short notice would likely be my family physician who is an M.D., PhD. (in microbiology). Thank you in advance for you help. Best regards, XXXX
Brief Answer:
Management of the disease
Detailed Answer:
Good evening XXXXXXX
Well, here first thing I would like to confirm is the presence of intermittent arthritis, that is the swelling and tenderness documented by a doctor during the flare of episodes you have. It gives the license to hit the disease for the doctors. Other possibility is you can get a Musculoskeltal ultrasound done during the episodes if there is no trained rheumatologist around. Ultrasound will pick up the signals early and give us the fair idea.
Secondly, Enbrel is a bit too strong for the Palindromic Rheumatism. What we need to understand is, that even Enbrel is not a cure. It can help subside the flare episodes and the disease but it does come with side effects. Eventually, how long can you take it? Cause once you stop, maybe there is a chance you will get a relapse few months later. The best drug we suggest if the episodes are 2 frequent is Methotrexate.I am not sure on what dosage you were given, but it is definately worth a try for the full dose of MEthotrexate before switching to another drug. Even if you opt for Enbrel, Methotrexate still has to be given along with it. So my choice would be that. If uncontrolled, we normally Add Leflunomide.
For the Sjogrens, yes 40 % cases can have antibody negative disease as well. The definite diagnosis lies with the Salivary Gland biopsy. But considering you have severe symptoms of dry eyes and dry mouth, I would recommend you can restart Plaquenil. Also Pilomax you can try which helps the glands to increase the secretions.
Hope the information was useful. But yes, first and foremost thing is documentation of arthritis either by examination or by ultrasound during the episodes. If seen, then even if the tests results are negative still it gives us license to treat.
Do let me know for more queries
Would be happy to help you out
Regards
Dr Naval
Management of the disease
Detailed Answer:
Good evening XXXXXXX
Well, here first thing I would like to confirm is the presence of intermittent arthritis, that is the swelling and tenderness documented by a doctor during the flare of episodes you have. It gives the license to hit the disease for the doctors. Other possibility is you can get a Musculoskeltal ultrasound done during the episodes if there is no trained rheumatologist around. Ultrasound will pick up the signals early and give us the fair idea.
Secondly, Enbrel is a bit too strong for the Palindromic Rheumatism. What we need to understand is, that even Enbrel is not a cure. It can help subside the flare episodes and the disease but it does come with side effects. Eventually, how long can you take it? Cause once you stop, maybe there is a chance you will get a relapse few months later. The best drug we suggest if the episodes are 2 frequent is Methotrexate.I am not sure on what dosage you were given, but it is definately worth a try for the full dose of MEthotrexate before switching to another drug. Even if you opt for Enbrel, Methotrexate still has to be given along with it. So my choice would be that. If uncontrolled, we normally Add Leflunomide.
For the Sjogrens, yes 40 % cases can have antibody negative disease as well. The definite diagnosis lies with the Salivary Gland biopsy. But considering you have severe symptoms of dry eyes and dry mouth, I would recommend you can restart Plaquenil. Also Pilomax you can try which helps the glands to increase the secretions.
Hope the information was useful. But yes, first and foremost thing is documentation of arthritis either by examination or by ultrasound during the episodes. If seen, then even if the tests results are negative still it gives us license to treat.
Do let me know for more queries
Would be happy to help you out
Regards
Dr Naval
Above answer was peer-reviewed by :
Dr. Prasad
Good Evening Dr. Mendiratta!
I am going to close our discussion as I believe you have given me the necessary information I will need to try and wrestle down my symptoms in a better fashion. This consult has been most useful and I very much appreciate your time and effort expended on this case.
Best regards,
XXXX
I am going to close our discussion as I believe you have given me the necessary information I will need to try and wrestle down my symptoms in a better fashion. This consult has been most useful and I very much appreciate your time and effort expended on this case.
Best regards,
XXXX
Brief Answer:
Further discussion
Detailed Answer:
Good evening XXXXXXX
I am glad I can be of some assistance to you. Hope the information has been useful. Do let me know if you need any help in the future
Take care
Wish you a healthy life ahead
Regards
Dr Naval
Further discussion
Detailed Answer:
Good evening XXXXXXX
I am glad I can be of some assistance to you. Hope the information has been useful. Do let me know if you need any help in the future
Take care
Wish you a healthy life ahead
Regards
Dr Naval
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Above answer was peer-reviewed by :
Dr. Prasad
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