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Experiencing ankle swelling and having lower back pain. Has temperature. Suffer obesity, periods of ETOH dependence. Suggestions?

Jul 2013
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Answered by

Orthopaedic Surgeon, Joint Replacement
Practicing since : 1996
Answered : 2148 Questions
Hi! My husband is 55 yo of Russian-Jewish descent. He is experiencing right ankle joint swelling, swelling of both hands, but worse in the right & lower back pain. His right ankle is visibly swollen & very painful for him to walk. He has a temp of 100.3.
Recent Hx: He was previously deficient in vit D but is currently taking 10,000 iu. He recently found out he has retinal damage due to lack of Vit A absorption due to a gastric bypass sg several years ago. When he has had these flares in the past (usually a couple of a year), his PCP has done blood work & ruled out gout and RA.
PMH: obesity, periods of ETOH dependence (red wine - I was wondering allergic??), ambien dependence, sleep apnea (good about using cpap at night).
He's fussing at me about not going to the doc again since he didn't find anything. I suggested a rheumatologist & let that doc r/o some type of auto-immune or inflammatory process. Obviously there is something wrong! In spite of his hx, he's been relatively healthy ie, good cholesterol, BP, no cardiac issues, etc

Posted Sat, 3 Aug 2013 in Bones, Muscles and Joints
Answered by Dr. K. Naga Ravi Prasad 1 hour later
Hi, thanks for writing to XXXXXXX
Before I answer your questions, I need a bit more information regarding your husbands symptoms to arrive at a possible diagnosis. Please answer the below mentioned questions as elaborate as possible -
*Since how long are the swellings and pain present?
*Have all the joints involved at the same time?
* Has he suffered any sort of systemic illness or infection ?(eg:dental,urinary,abdominal infections or any type of fever)
*list of drugs presently taking?
*Nature and pattern of pain ? (Is it present continuously throughout the day? or occurs only during physical activity?

Above answer was peer-reviewed by
Follow-up: Experiencing ankle swelling and having lower back pain. Has temperature. Suffer obesity, periods of ETOH dependence. Suggestions? 2 days later
Hi Dr. Prasad: Thanks for getting back to me. I will do my best to answer your questions:
1. When I probed more, he says he recalled that his feet "would kill him" even when he was a kid. However, the pain was never this intense until the last couple of years. He seems to get these bouts once or twice a year. He says the pain is typically of a gradual onset but that it elvolved into very painful the last few bouts. As I mentioned previously, the pain became so acute that he can barely walk. The pain abates some at rest when his legs are elevated but hurts worse during mobility, standing & ambulation. He takes vicodin which helps some but not totally. He took an OTC diutetic last night which he said helped some but the right ankle edema is still present. It didn't seem pitting but I'm not sure.
2. I am not clear as to how to desribe the pain: he says the bottom of his feet burn but that his ankle just "really hurt." He is not diabetic but I wondered about neuropathy?? His circulation is reportedly good based on some type of vascular tests - I think some ultrasound.
2. This last bout of acute painful swelling started about July 3 & is just starting to ease up some. He has been afebrile since I initially wrote you. When he's had these in the past, the most painful bouts abate but he ofen has residual swelling in his fingers. The right ankle & hand are the most edematous & but both ankles are tender. I don't see any redness.
3. I feel stupid for not mentioning this the other day, but he does have an infected anal fistula or fissure that has been painful & bleeding. He's proscrastinated but finally saw a proctologist who recommends surgery. I was worried that he was becoming septic or at least having a mass inflammatory response to a low grade infection. He has not been on ant ATB tx recently. He had this problem a few years ago & required surgery.
4. The only meds & supplements that he takes routinely:
- Testosterone cypionate Inj. 2000mg/10 mL; I give him 1 mL QOW. We wondered at one time if it was the suspension they mix the testosterone in that could be a problem.
- Generic ambien 5 to 10 mg QHS w/ 25 mg Benadryl for sleep. He does use his cpap at night. Sonetimes he drinks it w/ red wine. Yes, we know this is not a good idea!
- Vit D 3 soluble gel cap30,000 iu (He runs low)
- Vit A 8000 iu just started due to retinal damage (see above)
- Lutein & zeaxanthin (25mg & 5)
-Vit B 12 2500mcg
- ASA 81 mg QD
- Multivitamin
- Fiber capsules for constipation
It seems in the past, a doc suggested that it was a form of "pre-gout" or other type of gout but he did not show elevated uric acid in his blood work. He never took meds for gout.

What do you think about him seeing a rheumatologist? Any suggestions are appreciated!

Answered by Dr. K. Naga Ravi Prasad 59 minutes later
Hi, thanks for your feedback.
From the given data, I feel that the symptoms of your husband could be due to two possibilities -
(1) Reactive arthritis - It is a sterile form of arthritis secondary to any infection of either gastrointestinal ( in your husbands case, an infected anal fistula ) or genito urinary infection. Lower limb assymetric oligoarthrits (affecting only one side and one joint) involving either ankles or knee joint is typical presentation. Majority of the first attacks resolve completely within 20 weeks but attacks can recur. I suspect this condition in your husband.
(2) Seronegative spondyloarthropathies - This encompasses number of conditions affecting the joints and will be negative for RA factor ( as in your husbands case ). For establishing proper diagnosis, these conditions need thorough evaluation.

So i suggest you to consult a rheumatologist ( as you thought of ) as seek his advice.

Happy to help if you need any more clarifications. Good day
Above answer was peer-reviewed by
Follow-up: Experiencing ankle swelling and having lower back pain. Has temperature. Suffer obesity, periods of ETOH dependence. Suggestions? 5 hours later
Thank you Dr. Prasad! I appreciate your input.

Answered by Dr. K. Naga Ravi Prasad 17 minutes later
Welcome. Its my pleasure to serve you.
Above answer was peer-reviewed by
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