Question: Hello, I am 29 yr male, non-smoking, weight 70kg, physically fit (occasional outdoor/indoor sports, have regularly practiced hatha yoga, stopped 1 year ago when son was born), diet - 5 years without meat, although I eat fish and seafood, take supplements of Omega-3, D3 (for a month or two twice a year), no prescription meds. Sedentary work in the office. Currently experiencing mild to moderate joint pain, which used to be occasional and now is present more often. Joints affected are mostly knees, especially after physical activities, even short bike trip or skiing or ice-skating (such activities never gave knee pain before, only during last few years, with pain intensity increasing), also affected are hips, small finger joints, toe joints, shoulders. First experience of joint pains appeared more than 10 years ago, then subsided, reoccurred from time to time. More significant relapses began 2-3 years ago with pain in one joint lasting 1-2 days, pain migrated from one set of joints (e.g. left hip, right shoulder, couple of finger joints) to other set of joints later. Used to have NO back pain besides some fatigue kind of pain when bending for longer periods (possibly after minor injury with lifting weight 10 years ago). It seems, there's some back pain now during this period (for the very first time) - experiencing it when bathing son and now when sitting in the office. Night sweating for many years (possible since very early childhood or birth). ESR, CRP - within norm, RF - not present, HLA-B27 - positive, antistreptolisine-O - norm (52 IU/ml, norm up to 200IU/ml). Other blood work normal (cell counts, HGB, lipid panel, blood glucose) in normal range (there is some slight dis-balance of WBC for many years, lymphocytes having greater part and neutrophils having smaller part of WBC). Urine - everything within norm. Even though it is quite unlikely (same and only partner for 10 years), unless it is STD transmitted via household items, had a consult for STDs very recently - none present (evaluated for all common, e.g. chlamydia). Visited rheumatologist. Sent for radiology consult. X-ray (there might be some translation inaccuracies, as I am not fully familiar with all the terms in English, in our language we might have a bit different descriptions/expressions) Neck: straightened physiological lordosis, insignificant scoliosis to the left, insignificantly smaller gaps between C5-7 vertebrae, a little bit expressed subchondral sclerosis, a bit sharper edges of the vertebrae; Chest: insignificant scoliosis to the left in the lower part, normal gaps, a bit sharper edges of the vertebrae, a little bit expressed subchondral sclerosis, a bit sharper edges of the vertebrae; Hands: joint gaps normal, even surface, no visible bone structure defects Hips: joint gaps normal, even surface, no visible bone structure defects Result: osteochondrosis of neck and chest parts. No visible defects in hands or hips. After the consult rheumatologist decided it is inflammatory spondyloarthropaty and didn't hesitate to prescribe ciprofloxacine for possible infection, sulfasalazine for management of the disease and dexketoprofen (even though I said I don't have a pain which I would need to manage using drugs). I have also said that I was diagnosed with Crohn's disease earlier and it seems that dexketoprofen wouldn't be the NSAID of choice in this case… Anamnesis (earlier) Some issues with liver in early childhood, would have to doublecheck for exact data. ~1993-1995 - couple of episodes of unexpected vomiting, nausea, severe dizziness lasting for a day. Admited to hospital the second time this happend. Later this has been speculated to be possibly related to micro (hemorrhagic) strokes (although nobody has evaluated neurological signs during these episodes) 1996 (12 yrs) - rupture for angioma in the brain, hemorrhagic stroke (all ventricles were full), no residual neurological defects (nor there have been any significant besides some signs during the hemorrhage). Non-operable (close to corpus callosum), speculated possibilites of treatment with gamma knife radiosurgery but this was never performed. Telangiectasia (no bleeding ever) were present on the body, one quite large on the face. Nosebleeds were quite common. Easily got bruises (e.g. after accidental compression of an arm). Blood clotting seemed to be mostly normal and not related to bruises (there were some blood clotting indicators not within norms, but bruising didn't stop even when they were normal for very long time). Currently (2014) all blood clotting indicators (bleeding time, protrombin activity, platelets, etc.) are normal, although bruises still appear easier than for most individuals. Back then there were specullations about Osler-Weber-Rendu syndrome. Later, telangiectasia just dissapeared and never appeared back again (perhaps at around 1998). Nosebleeds stopped at around year 2000-2001. During this period (early teens up until perhaps 16 years) had significantly elevated levels of alkaline phosphatase which then came back to normal in the age of 16 or around. Puberty signs were always delayed compared to peers. ~1997 was perhaps the first time when I experienced moderate to severe abdominal cramps/pain, fever (39C and above). First episode lasted for about 2-3 days and then subsided by itself. Could be it was accompanied with diarrhea (no data on this). Episodes repeated 1-2 times per year. No other signs or symptoms of cold or similar. Usually always accompanied with diarrhea. During high school years I always recall complaining about how tired (fatigue) I felt occasionally without any known reasons. Sometimes feel this now. ~2000 onwards started noticing occasionall joint pain of short duration (few hours), don't recall which joints exactly, must have been various (small, large) 2003 - went to Ocean City, MD, US (indicating this for climate) for summer job as a programme for students. Small finger joints were painful during all the summer. When came back to Europe, pain was gone. ~ 2004 - admitted to hospital (diagnostic facility) after episode of severe abdominal pain and fever 40.4C. Colonoscopy performed, biopsies taken. Initial diagnosis - ulcerative colitis, later after biopsy results received - differentiated to Crohn's disease. Possibly have uveitis of one eye then, no diagnostic tests, just observation. Some treatment with mesalazines after diagnosis was made. Noticed, that during every flare up with fever, CRP goes to ~50 or above. ~ 2005-2006 - participated in study of Crohn's disease, colonoscopy performed. Intestinal epithelium described as completely healthy, no erosions, biopsies taken from healthy tissue didn't indicate anything. Diagnosis changed to IBS. 2010 - Shigella Sonnei infection after visit to India. Treated with ciprofloxacin until it appeared that this strain is resistant to it. Switched to Chloramphenicol (sensitive). Episodes of severe abdominal pain and fever very rare in later years. Improvement seems to coincide to yogic practices, stress management. All later episodes seem to be related to stress. Family: Grandmother (mother's line) - ulcerative colitis Grandaunt (grandmother's sister) - RA Father - unexplained severe abdominal pain, blackouts, diarrhea during years served in army and later, episodes disappeared in his thirties Mother - ulcerative colitis, HLA-B27 positive, joint pains (mostly fibromyalgia-like during examination), suspected systemic lupus erythematosus (ds-DNA antibodies discovered couple of times, no conclusion made yet, lack of signs), restless-leg syndrome Questions: What are possible conditions having in mind all background? Maybe there is one genetic issue behind all of it? How likely it is for my son to develop the same issues, what are likely triggering factors which enable the genes which might play a role here? Any comments, overview very welcome.

Dear Dr. Munish, I am amazed by how much effort you have put in explaining everything, really appreciate it. I forgot to add that I occasionally have ulcers in my mouth since childhood. Does this contribute to AS diagnosis? Also, what most natural treatment/management could you suggest? Any hints which are not very widespread? :) (I.e. besides exercise). Special diet? Any ideas how Omega-3/Omega-6 ratio could play a role in inflammation here? Thanks!

Thank you so much! Could you please give a bit more details on: suppression of natural urges - they should not be suppressed, I understand (just so I don't get it opposite)? Also, is there any possibility that this is also created by dosha imbalance? E.g. vata being too active or something else? Your responses are more than I could expect, I am so pleasantly surprised. Thank you again, Dr. Munish!

Also, you suggested to add fish (for Omega 3 balance), which I already did couple of weeks ago - increased fish intake (herring, which is very rich in Omega 3 and has little Omega 6), but according to Ayurveda view of the causes of this disease, as you explained, I should not consume fish? Which view is more important here? Will I have enough Omega 3 if I stop eating fish? Does this also include all seafood? Animal products in my diet are limited to fish, seafood, eggs and milk, I have stopped eating other meat 5 years ago. Thanks!

Thank you, I keep getting amazed by the depth of your responses :). What is your average prognosis (or range of prognosis) (since you haven't evaluated me directly, so I ask for your general experience with other similar patients) for this condition? In case if it is managed using Western medicine (NSAIDs, immunosupressants, etc.)? In case if it is managed using Ayurveda? Best regards, XXXX

Dear Dr. Munish, Thank you so much again. I understand that my questions will not end :), it will be difficult to close this discussion, but I understand that I have to let you go :). There are many many more I would like to ask, I will limit myself to these, if you are still willing to continue this discussion: 1. How long do you think it could take to manage the disease (teaching, guiding of correct way of life) (AS, SPA) by a Ayurveda practitioner up to the level that patient is more or less able to continue by himself? The stage is perhaps quite early (even if began long time ago, there is no significant damage done). 2. Hot bath / ice packs / cold shower in SPA. a) could heat induce more inflammation? It seems to help with pain. b) You mentioned warm weather, clothes, etc. - would ice cause damage? 3. I have been using cold water after each bath, shower, etc., haven't missed a SINGLE instance of when I had contact with water - I always finish with coldest water available (for up to 10 seconds usually) to train my blood vessels + to develop will power. Could this be counterproductive in SPA? 4. What does Ayurveda suggest for pain in SPA/SA? 5. After sleeping on left side, the earlobe becomes painful, only one ear is affected, seems that rubbing the ear is sometimes painful, symptom appeared just 2-3 weeks ago, first time in my life, seems to coincide with onset of more painful joints). Could it be linked to SPA? 6. TCM would perhaps have very much different approach in treating SPA and would potentially use immunomodulators which come/are fungus, like Cordyceps sinensis. I would imaging mushroom and fungus are "not welcome" in Ayurveda? 7. Do rheumatism diseases (the way they are differentiated in Western medicine/alopathy) differ in Ayurveda views? Do these conditions are recognized as different in the same scope? E.g. RA is different from AS and different from SLE/Lupus. Would all these three be viewed and treated differently in Ayurveda. I am just trying to understand if different manifestations of rheumatism as they are seen in Western world have any significance at all in Ayurveda. I know this might be deep topic, please don't worry about detailed answer. Very brief, something close to "yes" or "no" would suffice. I promise I will close this thread after, I will have one more question which I will ask directly.