ARTHRITIS SOCIETY--QUESTIONS & ANSWERS

[KEKI SHROFF]

	ARTHRITIS SOCIETY—QUESTIONS & ANSWERS SOMEWHAT DATED----2003   I recently fell and shattered my calcaneous. I was told I had very little calcium in my bones. I have been on a Didrocal regime for 5 years, as well as hormone therapy. I have always been a good calcium intake person (lots of milk, cheese, yogurt, etc). I am 57 now. As I age even more, how do I prevent even further decrease in the bone density?
	Medical conditions that could worsen bone density like hyperthyroidism, hyperparathyroidism, malabsorption etc. should be ruled out. Medications like cortisone, too much thyroid replacement, anti-epilepsy drugs, too much vitamins A and D, antacids with aluminium etc could also worsen bone density.   Smoking must be stopped. No more than 3 cups of coffee/tea per day and no more than 4 oz. of alcohol per day should be consumed.    Regular weight bearing and muscle strengthening exercises are important to maintain good bone density. Good activities include walking, swimming and weights. Lying in bed and sitting too much will reduce the bone density.   Daily calcium intake from food and supplements should range between 1000 and 1500 mg per day. Vitamin D intake should be 400 to 800 I.U. per day. Try to get 15 minutes of sunshine per day. You may have to check with a dietician that you are eating the right amount of calcium and vitamin D and that you are not eating too much of something that may interfere with them.   Your bone mineral density should be followed to make sure that therapeutic changes are making a difference.   Your hormone therapy should be reviewed to make sure that you are getting enough estrogens and that there are no risk factors for taking estrogens.   Didrocal may not be helping you enough. You may benefit from switching to another drug like it ( the bisphosphonates) e.g. alendronate, risendronate, pamidronate.   Calcitonin taken by nasal spray or injection is another drug that could help if the bisphosphonates do not pan out. However, a new therapy, parathyroid hormone, may soon become available. It could become one of the most effective treatments for osteoporosis.   Contact the Osteoporosis Society of Canada for more information and ongoing developments. Ask for the book, "The Osteoporosis Book". Phone number is 1-800-463-6842. Web site is www.osteoporosis.ca.
	Answered on: May 26, 2003

	I have been diagnosed with 'lichen planus' and was told it is related to arthritis. Do you have insights into the disease and its relationship with arthritis?
	Lichen planus is a skin condition of unknown cause. It can involve the skin including the vulva and penis, nails and mucus membranes of the mouth. It consists of raised bumps or plaques that may be itchy or painful. It may be associated with liver diseases such as hepatitis C. It is generally not associated with arthritis but can be induced by several drugs used to treat arthritis e.g. nonsteroidal anti-inflammatories, gold, antimalarials like hydroxychloroquine and d-penicillamine. In such cases, it is frequently located in the mouth on the inner cheeks.
	Answered on: May 20, 2003

	I was thinking about purchasing an infrared thermal sauna system, which is a sauna-like booth with infrared heat. Do you think this is safe? Will the infrared heat help my arthritis?
	All forms of heat can reduce pain and stiffness from sprains, strains, fibromyalgia, muscle spasm, back and neck aches, sore non-inflamed joints, tendonitis and bursitis. Heat only relieves these symptoms temporarily without any curative effect on the condition being treated. Heat may also reduce tension caused by stress.  Heat should not be used for very inflamed joints or acutely swollen areas as it can aggravate the inflammation and swelling.   Heat should also be avoided in the presence of fever, poor circulation such as peripheral vascular disease and impaired skin sensation. Generalized heating of the body should be avoided in bleeders as the heat dilates the blood vessels prolonging bleeding; in pregnancy; in persons taking drugs that lower blood pressure as the heat may lower the pressure further causing fainting; and in individuals with neurological conditions that impair the body's ability to control temperature. Deep heat should be avoided in areas of enclosed infection and areas of metal implants.   Superficial heat can be applied using hot packs, heating pads, hot towels (put towel in microwave for 1 minute), hot water bottles, hot baths, pools and showers, paraffin wax, mud packs and baths, hot springs, saunas and whirlpool. Deep heat can be applied using infrared light, ultrasound, short wave and microwave diathermy.   An infrared thermal sauna is easier to breath in and uses less electricity than a regular sauna. There is no evidence that it results in greater medical benefits than any other form of heat.    A physiotherapist experienced in treating arthritis should design a treatment program for you before you purchase this sauna system. Furthermore, you should demo the infrared thermal sauna system for a few treatments before buying it.
	Answered on: May 13, 2003

	I have had massive amount of swelling and pain in my feet, knees and hands for two months. No one has been able to identify it. Can you get arthritis when you are 20 years old? I play university soccer. Would I still be able to play?
	There are many different types of arthritis and some of them can  occur even in babies, let alone in someone 20 years old.   Some types of arthritis that might occur at your age and as per your description include rheumatoid arthritis, reactive arthritis, psoriatic arthritis, sarcoidosis, scleroderma, eosinophilic fasciitis, lupus and hypertrophic osteoarthropathy. However, a firm diagnosis must be made first before anyone could predict your soccer future. Some types of arthritis can disappear spontaneously and some can respond very well to treatment.   You must see a rheumatologist as soon as possible to determine if your symptoms are due to a form of arthritis and if so, which type is it and what treatment is needed.
	Answered on: May 05, 2003

	I am 35 years old. I am in constant pain. It is excruciating and debilitating. My children have to tie my shoes for me. I had an x-ray done recently and it revealed I have almost non-existent cartilage between two discs in my back. I am taking chondroitin, something called Saturn (with MSM) and Advil. Sneezing is a frightening experience. I am terrified that my back will go completely. I have not slept through the night in almost a year. When I am menstruating, I am brought to tears. Everything I do is too painful. I have gone to my family doctor who does not see the need to refer me to anyone. I have seen several chiropractors. They all tell me to come to them three times a week and that it will take years apparently to gain back some of my previous verve for life. What will I be like when I am 45? 55? Will I still be walking? Any input would be appreciated.
	I assume you mean that the X-ray showed no cartilage or disc between two vertebrae in your back.Your pain may very well be due to the disc disease. The disc may have herniated or protruded. There may be instability of the vertebrae causing abnormal painful movement and accelerated disc damage. Such instability could be due to spondylolisthesis or stress fracture of the posterior parts of one of the vertebra at this level. Low grade infection of the disc is uncommon but should be ruled out with such persistent severe pain and advanced disc damage at one level on the X-ray.   A blood test to measure the white blood cell count, hemoglobin and sed rate should be done regarding the possibility of infection. A CT scan or MRI should be done to look for evidence of instability/stress fracture etc. and for any mass or infection around the disc. You should be seen by a back specialist for further investigation and treatment.    Without a specific diagnosis, it is impossible to predict how you would be when you are older. You should certainly be walking as any sign of neurological involvement would be treated promptly by a back surgeon.
	Answered on: April 28, 2003

	I am 53 years old. I have had rheumatoid arthritis since 1993 and diabetes since 1970. I am taking 25 mgs of methotrexate every Monday and 7 mgs of prednisone every day. I recently went for a yearly eye exam and the optometrist set up an appointment for me to see an eye specialist for further study on the inside of my eyes. The optometrist did not explain anything to me. Is it possible that I have corneal melting? If so, what happens next?
	Both rheumatoid arthritis and diabetes can affect the eyes in several different ways. Corneal melting is a rare complication of rheumatoid arthritis. See the answers to questions dated July 30, 2001 (re:corneal melting) and January 15, 2003 (re: eye complications of rheumatoid arthritis). It affects the cornea, located at the front of the eye covering the pupil and is not "inside of my eyes". Cataracts are much more common especially with diabetes and the use of prednisone. And of course, involvement of the retina is very common with diabetes especially after 33 years. This complication is referred to as diabetic retinopathy and causes no symptoms in the early stages. It is more likely that you are seeing an ophthalmologist because of cataracts and /or diabetic retinopathy.
	Answered on: April 22, 2003

	I am a 49-year-old female with osteoarthritis of the total spine. I have had neck fusion and a herniated disc of the lower spine for which I'm told there is no surgery. I also have psoriatic arthritis and fibromyalgia. And lastly, I have type II diabetes. As a result of the psoriatic arthritis, my right index finger and part of my hand had to be amputated. I know that amputations can sometimes be associated with diabetes. But arthritis? I was shocked by my turn of events. Have you heard of such a thing? How common is this?
	This is indeed unusual. Was the reason for the amputation a lack of blood supply due to diseased arteries or infection (both associated with diabetes)? Amputation because of arthritis, or deformity alone is very uncommon. Rarely it might be done for a severe fixed deformity of a finger that interferes with the use of the hand like putting the hand in a pocket or holding something in the palm. Ask your physician exactly why it was done--there may be a good reason.
	Answered on: April 07, 2003

	I am a 47-year-old woman, a full-time student in a Master's Program, very recently diagnosed with severe osteo-arthritis of the knees. I just had my first visit to the specialist and was overwhelmed by the experience. While I was lying on the exam table, the doctor manipulated my legs, bending my knees etc., very quickly and roughly, ignoring my questions and hurting me physically very much. He told me he was going to give me a shot, and just jabbed it deep into my knee, moving the needle vigourously. The pain was excruciating. When I asked if it was cortisone, he impatiently told me it was, but that there were no side effects. When I asked him about nutritional supplements and possible dietary changes, he said it was all hocus-pocus. When I asked about web sites for learning to manage it, he said he didn't have any. After x-rays, I was told to re-join him in his office. As I walked in, he was dictating my diagnosis, including the fact that I require surgery on both knees, into a recording machine - this was how he broke the news to me. I found some web sites on my own, but my question is, do doctors usually give a local anaesthetic before a cortisone shot into a painful area? I left the appointment feeling like I was hit by a truck, and I want to know if this is typical - in other words, is it inappropriate to ask questions of the specialist? Do they confine practice to surgery and medications, hoping that patients research all other helpful information on their own? I am a happy, strong, confident woman with a full life, but this was a degrading, overwhelming and isolating experience. The arthritis has immobilized me to a great degree, and I had held out hope that the visit would give me some hope in terms of coping, but I was devastated. I have no wish to confront the doctor or complain about him - I simply wonder if I should start over.
	Education is a very important part of managing arthritis. Your questions should be answered. The physician should explain things to you. You should have been referred to an arthritis management program e.g. a local branch of The Arthritis Society in Canada. Pamphlets, books and websites are very informative. This Arthritis Society website has a lot of information about osteoarthritis. Two books to consider for further education about osteoarthritis are: The Arthritis Foundation's Guide to Good Living with Osteoarthritis. Atlanta: Arthritis Foundation, 2000.  Living Well with Arthritis. A sourcebook for understanding and managing your arthritis. By Dianne Mosher, Howard Stein, Gunnar Kraag. Viking Canada (Penguin Group, Toronto), 2002. They will discuss medications, physical therapy, injections, diet, nutrition, complementary treatments, surgery, exercise and pain management. Cortisone injections to a joint are very safe but rare complications include joint infection, bleeding and bruising, transient flare-up of joint inflammation and flushes, sweats and fainting. Local anesthetic is often given, but use of a small gauge needle, muscle relaxation, gentleness and very careful positioning of the needle are the main ways to make the injection almost painless. After all, the local anesthetic is given by needle and takes a few moments to work and may cause some stinging. It seems that you got the rough, painful approach.  Here is also a reply to your question from Cheryl Koehn, patient advocate: "The experience you describe was certainly far from ideal, both from a patient and specialist perspective. For treatment to be successful—whether it be an examination procedure, a medication prescription, or an injection such as you describe—it is imperative that the person being treated fully understand the reasoning behind the specialist’s recommendation to be physically and psychologically prepared to receive the treatment. One does this by asking questions before hand (as you did) to determine their willingness to assess whether the benefit of the treatment outweighs any risks it may pose to their health. If a physician, be they a specialist or a general practitioner, is unwilling to take the time to ensure that the person seeking their help is at ease and a willing participant of the advice and treatment being dispensed, you should ask for a referral to another physician rather than possibly subjecting yourself to this type of situation again."
	Answered on: April 01, 2003

	My mother who is 80 suffers severely from arthritis. She takes a blood thinner and we are being told the only thing she can take for pain is Tylenol. Is there is anything else she can take. She is now in a full blown attack and can barely move. It is hard to watch, knowing that her vitals are good, but she has no quality of life due to her pain. To me it does not make sense as the pain has now put her in bed, when she wants to be able to get up and move.
	Physical therapy such as ice, heat, transcutaneous electrical nerve stimulation (TENS), splinting etc. may reduce the pain. A physiotherapist could help with such recommendations.   Stronger analgesics (pain killers) could be used such as codeine (e.g. Tylenol #3), oxycodone and morphine during these attacks.   Conventional nonsteroidal anti-inflammatory drugs (NSAID's) like aspirin, ibuprofen and naproxen may interfere with the blood thinner, alter the platelets to prolong bleeding even further and cause peptic ulcers that could bleed more than usual because of the blood thinners. However, the new COX-2 anti-inflammatory drugs like celebrex and rofecoxib do not affect the platelets and are less likely to cause bleeding peptic ulcers. They usually do not interfere with the blood thinner, but the INR (blood test used to monitor the dose of the blood thinner) should be checked more often when first starting them to make sure no adjustments have to be made to the dose of the blood thinner.   You should also be aware that if too much acetaminophen (about 3500 mg per day or more) is taken, it too can interfere with the blood thinner so that bleeding is more likely.
	Answered on: March 26, 2003

	I am a 27 year old female. For the past ten years my knees have made this horrific cracking noise every time I would bend down. Now, it is at the point of popping noises and the pain in my knees is constant (every day as opposed to 2 - 3 times a week). I went to my doctor last year who told me I had the beginnings of Arthritis. The problem is he never told me what kind it is or what to do except to take it easy on the knees. He is my only doctor although he is near retirement. I have been having some trouble finding a new doctor, especially now with this arthritis. My question is how many different cracks can my knees make and is this an indication of a specific type of arthritis.
	There are many different types of joint cracking. The crunching or catching of folds of synovium (membrane lining joints) can occur due the thickening of the synovium in inflammatory arthritis (synovitis) or to the catching of folds of normal synovium between bones and/or tendons in mechanical joint abnormalities. The loss of the cartilage in a joint as occurs in osteoarthritis can lead to coarse grinding. Sometimes irregularities on the cartilage surface can lead to cracking sounds as can loose bodies (like a torn cartilage). Mild subluxations of joints, e.g. minor dislocations of the kneecap, can also cause popping noises. Tendons snapping quickly over bone or joints can cause popping sounds. Irregularities or abrasions or inflammation of tendons can also lead to noises during movements. Sudden change in the volume of a joint space can cause cracking too as when one cracks their knuckles.    If there are other symptoms in addition to the cracking such as pain and swelling, then a more significant problem is present.    In a young female with symptoms such as yours, the commonest problem would be patellofemoral syndrome. The pain and cracking are coming from the joint between the kneecap (patella) and the end of the thighbone (femur). See the question answered on "Ask the Expert" on December 10, 2002 re: patellofemoral syndrome. In an older person, osteoarthritis would cause similar symptoms.   It would be helpful to be seen by a rheumatologist or orthopedic surgeon to clarify the problem.
	Answered on: March 13, 2003

	I use Celebrex for my osteoarthritis. Is this medication safe to be used for long periods?
	Celebrex has been on the market for about 4 years now and has been used by thousands of people. There have not been any unexpected side-effects so far. However, one cannot be absolutely certain that an unexpected problem might not show up later with more surveillance.    The side-effects of Celebrex are similar to those of the currently available non-steroidal anti-inflammatory drugs (NSAID's) like naproxen and diclofenac except that it causes less stomach side-effects. The incidence of  symptomatic and complicated (e.g. bleeding) peptic ulcers appears to be less. In addition, it does not interfere with the function of the platelets so that bleeding is not prolonged.   One still has to be monitored for high blood pressure, abnormalities of the kidneys, fluid retention, bleeding from the stomach and bowel, rashes and allergies etc. just like the other NSAID's.   In conclusion, Celebrex can be used for long periods. It appears to produce less problems with peptic ulcers and platelets than conventional NSAID's, but it should still be monitored carefully for side-effects as regular NSAID's are.
	Answered on: March 06, 2003

	I had a total hip replacement (right hip) in January 1994 when I was 52 years old. It was a non-cemented replacement, which my surgeon described as a procedure in which bone would grow around the prothsesis, ensuring a more secure and durable joint. Since then, I have not had any problems whatsoever -- I exercise seven days a week with weights and on a treadmill, bike and essentially enjoy all activities -- except running which I previously enjoyed doing very much. How long can I expect my hip replacement to last? If I have problems, what will be the symptons? Will a new hip replacement be a problem? Are there any age limits to having a hip replacement, particularly with respect to age-related health concerns and limited resources in the health care system?
	It is very difficult to predict how long one's hip replacement will last--perhaps 10 to 15 years. It depends on many factors including the amount of stress put on the joint by activities and weight, the strength of the underlying bone, any deviations in positioning of the implants at surgery etc. etc.   There are 2 problems that may occur that do not have symptoms at first: wearing away of the plastic socket liner and resorption of bone from around the implants. These changes are detectable by X-rays. Therefore it is important to be followed on a regular basis by the surgeon.    Otherwise, the commonest symptom of a problem is pain. Usually the pain is in the groin with a socket problem and in the thigh with a stem problem. The pain is worse with bearing weight on the leg. The problems include loosening of the implants, bone resorption, wearing of the socket liner with varying degrees of dislocation and infection. With significant wearing of the socket liner, pain, clunking and buckling may occur on getting up to walk and then improve as walking continues.   Although revisions of hip replacements may not be as good as the original hip implants, considerable progress has been made. Sometimes it may be difficult to remove the stem from the femur. If there has been too much bone loss, then the revision will be more difficult.   There are no upper age limits for having a hip replacement. However, the presence of other medical illnesses and the frailty of the patient are important factors  in limiting surgery. Hopefully limited resources in the health care system will never be a limitation to hip replacements particularly since this procedure is so dramatically effective in reducing pain, restoring function and improving quality of life.
	Answered on: March 03, 2003

	Are you aware of any organization or professional society in the world which supports supplying artificial knee joints to needy people?
	I am not aware of any. You might want to contact the companies that manufacture artificial knees e.g. Zimmer Inc., DePuy Orthopaedics Inc., Smith and Nephew, Stryker Howmedica Osteonics etc. The Shriners Hospitals do charitable orthopaedic surgery for children. You may want to call them to see if they know of any comparable organization for adults.
	Answered on: February 25, 2003

	I am 62-years-old. Over the years I have done a lot of knitting, etc. Has this activity led to arthritis in my fingers. And, even though the joints are painful, by continuing this activity, am I doing more harm than good?
	No one can say for sure whether the knitting led to the arthritis in your fingers or not. There are inherited, age-related and hormonal factors related to the development of osteoarthritis (OA) in the fingers. However, overuse of these joints in a physically demanding and repetitive way may contribute to the development of OA in the fingers. The work done by cotton pickers, diamond cutters and seamstresses has been implicated, though not proven for sure, to cause OA of the fingers. However, reasonable recreational activities, done within the limits of comfort, should not lead to joint damage.    If the knitting is actually increasing or causing the pain, then it should be stopped or done less rigorously. Doing the knitting for shorter spells at a time may be helpful. If the pain in the joints is not worsened by the knitting, then just carry on. Seeing an occupational therapist may help you deal with this problem better.
	Answered on: February 19, 2003

	I have had two scopes and five cortisone injections since last October. Nothing has helped. I am always in pain due to the inflammation. My surgeon is reluctant to do a total knee because I am only 46. I'm scheduled to have a radical synovectomy in the near future. What is this exactly?
	The joint is lined by a membrane called the synovium. In many types of arthritis it is the target of the inflammation (synovitis). With chronic inflammation the synovium becomes very thick and redundant. Reducing the inflammation with drugs like cortisone injections can help to a certain extent. Surgically removing the thickened synovium (synovectomy) can be done through an arthroscope (arthroscopic synovectomy) but not all the synovium can be removed for technical reasons. Synovectomy can be done through a large incision (open synovectomy) rather than by arthroscopy in order to remove more of the synovitis but the complications are greater such as the loss of  some of the range of movement and a longer time to recover. An open synovectomy of the knee is done through an incision at the front of the knee (anterior). A radical synovectomy is done through two incisions: at the front (anterior) and back (posterior) of the knee in order to remove the maximum amount of synovitis.   I am not sure exactly how your surgeon will do it. One way is to do a two-stage procedure. Firstly, an open synovectomy is done  through an anterior incision and then allowed  to heal with physiotherapy to get the range of movement back. Then, an open synovectomy is done through a posterior incision. Sometimes radiation is applied to the knee to reduce the inflammation and growth of any residual synovium. Complications include haemorrhage into the knee, infection and loss of movement.   You will have to ask your surgeon which of these steps he is doing for your radical synovectomy as the technique does vary.
	Answered on: February 10, 2003

	I have a seven-year-old child who has just had a synovitis removed from his foot and ankle. He is now in a cast and just developed another one on the other foot. My child also has cystic fibrosis. He has complained for about two years of having foot and knee pain. Only once did he have swelling on his knee. His foot pain became worse and I noticed a big lump on the top of his foot. Two weeks later it had spread to his ankle. Othorpedic specialists think it's related to his cystic fibrosis. CF specialists say it's not. When I asked whether it was arthritis, I was told it did not show up during biopsy and therefore couldn't be. I'm now being told that my child will require surgery on his other foot. Is synovitis something children usually get? Should I have my child seen by a rheumatologist?
	Three types of arthritis are associated with cystic fibrosis (CF). The first type is called hypertrophic osteoarthropathy (HPO). It is associated with significant lung involvement. It can occur with other types of lung disease. Its features include clubbing of the fingers;  pain with or without swelling of the joints of the hands, wrists, feet, ankles and knees; and pain and tenderness of the long bones of the feet, shins, hands and forearms due to periostitis (inflammation of the membrane covering the bones) which can be seen on X-rays and bone scans.   The second type of arthritis (CF-associated arthritis) occurs in 5 to 10% of persons with CF. It is characterized by short periods (usually less than 1 week) of pain and swelling of joints. Joints rarely become damaged. Larger joints like knees, ankles, wrists, elbows and shoulders are involved. Sometimes it is accompanied by rash and fever. Anti-inflammatory drugs like ibuprofen can help.   The third type of arthritis is rare. It is associated with pancreatitis that might complicate CF. It is an acute transient arthritis that involves just a few joints which can become red, hot, swollen and tender. There are often tender, red skin nodules too. It subsides as the pancreatitis settles.   The presence of synovitis as described in your child suggests that there is some form of joint disease probably not related to the CF. Your child should definitely be seen by a rheumatologist.
	Answered on: February 05, 2003

	I have been experiencing painful joints in my fingers and toes. I stopped my hormone replacement therapy about a month ago when the media reported the adverse effects. I have a high oxalate level in my urine and as a result have had kidney stones and gallbladder removed. I do take 25mg of hydrochloothiazide daily. Would the loss of estrogen and the diuretic effect these joints?
	About 50% of perimenopausal women experience various types of aches, pains and stiffness. In my experience, hormone replacement therapy (HRT) will help sometimes. Osteoarthritis starts most commonly in the perimenopausal period but studies on the effect of HRT on the arthritis are inconclusive. Again, in my experience I have seen some women improve with HRT, worsen off HRT and then improve again with restarting HRT. The loss of estrogen could be contributing to your joint pains.   Hydrochlorthiazide may contribute to the development of gout by causing the retention of uric acid in the body. It does not sound like you have gout. Otherwise, this drug should not play a role in causing painful joints.   Rarely the combination of high oxalate production and dialysis for kidney failure can lead to the deposition of calcium oxalate crystals in joints. The joints may become acutely or chronically inflamed. X-rays will show calcium deposits in and around the joints and in the blood vessels. However, as long as the kidneys are removing the oxalate in the urine (as measured by the high oxalate level in the urine), it will not deposit in the joints.  Large doses of vitamin C (ascorbic acid) should be avoided as they are metabolised to oxalate.
	Answered on: January 30, 2003

	About a year ago, I received the third of three injections of Synvisc in both knees. Within a hour I experienced extreme discomfort in my left leg , extending up into my left glut and numbness down into into my foot. By vigorously rubbing the back of my knee I managed to reduce the pain extending upwards, but to this day I have only very slight sensation south of the knee into the foot where the siatic nerve extends. I'm wondering whether or not the old synovial fluid is typcially removed before adding the three injections of 2 ml each. If not, wouldn't adding more volume to the existing fluid cause the capsule to press against the siatic nerve.
	The old synovial fluid should be removed before the Synvisc is injected. Generally 2 ml of fluid is a very small amount and should not stretch the joint capsule. Furthermore the Synvisc is resorbed from the joint space within a few days. However, it is possible that the small amount of fluid entered an already tense popliteal cyst (or 'Baker's cyst': a cyst in the hollow behind the knee that has a one-way valve allowing fluid to flow from the knee into the cyst  but not from the cyst back into the knee). The cyst could press on the popliteal nerve, a branch of the sciatic nerve, causing neurological symptoms in the leg below the knee.   Further investigation might include consultation with a neurologist, nerve conduction studies and diagnostic imaging such as ultrasound of the calf and back of the knee and thigh.
	Answered on: January 24, 2003

	Could you please advise me on the occurence of episcleritis and other eye conditions related to rheumatoid arthritis. Can episcleritis present as visual diplopia and how common is it? What treatment options are available?
	EPISCLERITIS presents as a minor discomfort in one or both eyes. There may be a patch of redness on the white of the eye (sclera) near the cornea and iris. It does not affect the vision or cause diplopia (double vision). It is associated with vasculitis (inflammation of blood vessels) elsewhere as well as worse rheumatoid arthritis (RA), that is worse joint disease and more non-joint complications such as nodules. Episcleritis is transient but may recur. It usually needs no treatment but steroid eye drops may help. It is not uncommon in RA but can also occur with other conditions such as Wegener's granulomatosis and inflammatory bowel disease.   SCLERITIS affects the sclera of one or both eyes in RA but it is rare. It is due to a similar process as the rheumatoid nodule. It can be associated with eye pain, altered vision (but not diplopia), a patch of purple or blue discoloration of the white sclera and rarely perforation of the eyeball. It requires potent treatment of the RA with immunosuppressants etc.   CORNEAL MELT SYNDROME is a rare complication of RA in which the cornea is gradually destroyed. Vision is reduced or lost but there is no diplopia. It requires potent drugs like cyclosporin and sometimes cornea transplants.   RETINAL VASCULITIS is an inflammation of the blood vessels in the retina of the eye. It usually causes no symptoms other than blind spots sometimes.   SJOGREN'S SYNDROME causes dryness of the eyes (keratoconjunctivitis sicca--KCS).  It is the commonest eye problem due to RA. It is helped by artificial tears etc. Persistent dryness can lead to corneal ulcers and scarring.   BROWN'S SYNDROME is rare. It is an inflammation of the tendon sheath of one of the muscles that moves the eyeball (superior oblique muscle). It usually affects only one eye. It causes diplopia on looking upward and inward (towards the nose).   OCULAR NEUROPATHY is also rare. It is due to the RA vasculitis blocking the blood supply to a cranial nerve that innervates the muscles that move the eyeball. It can present as diplopia. This type of eye problem is most commonly caused by diabetes mellitus (sugar diabetes), however.   DRUGS used to treat RA can affect the eyes too. Steroids like prednisone can hasten the development of cataracts. Antimalarials like chloroquine and hydroxychloroquine can permanently damage the retina causing a loss of central vision. Chloroquine can also deposit in the cornea (keratopathy) causing visual problems like blurring and halos around lights but it is reversible. Gold can deposit in the cornea and conjunctiva but no symptoms or damage result.   In summary, episcleritis will not cause visual diplopia but Brown's syndrome (tendonitis of eyeball muscles) and ocular cranial neuropathy (loss of nerve supply to eyeball muscles) will cause visual diplopia.
	Answered on: January 15, 2003

	I was born deaf. I'm now 44 years old. I have had a severe case of rheumatoid arthrits for 27 years. My deformed joints with subcutaneous nodules, especially my hands, are already damaged. I also have osteoporosis, inflammatory bowel syndrome (IBS) and some gastric erosions. I'm taking Arava, Tenoxicam, Actonel, Ranintide, calcuim and multivitamins with minerals. Do you have any suggestions on how someone might be able to prevent IBS and gastric erosions? Also, I cherish the use of my hands because I use American Sign language. Any thoughts on what might be done to stop my hands from getting worse in the future would be appreciated.
	To prevent your hands from worsening, the arthritis must be well controlled. Adding a biological agent like anti-tumour necrosis factor (anti-TNF e.g. etanercept) could lead to better control of the inflammation and joint damage. Cortisone injections into any inflamed hand and wrist joints could also be helpful. A physiotherapist and occupational therapist could provide you with an exercise program, splints and joint protection education and aids for your hands. Periodic consultations with a hand surgeon could detect problems at an early stage so that only minor surgery would be needed.    The gastric erosions might improve by switching the tenoxicam (a nonsteroidal anti-inflammatory drug) to a COX-2 anti-inflammatory drug like celecoxib or rofecoxib and switching the ranitidine to a PPI (protein pump inhibitor) like omeprazole.    I am not sure what you mean by IBS. There is "Irritable Bowel Syndrome" which is treated by diet and sometimes medications. There is also "Inflammatory Bowel Disease" which includes ulcerative colitis and Crohn's disease. The medications used are much like the medications used to treat rheumatoid arthritis. Crohn's disease can be helped by anti-TNF drugs. Inflammatory bowel disease can sometimes be made worse by nonsteroidal anti-inflammatory drugs. Also Arava can cause diarrhoea.   Consultation with a gastroenterologist about your stomach and bowel is advisable.
	Answered on: January 10, 2003

[Previous] [11] [12] [13] [14] [15] [16] [17] 

--
Keki B. Shroff

ksh...@auracom.com