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Suggest treatment for constant joint pain

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Posted on Wed, 12 Mar 2014
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 caseā€¦ 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. ~ 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. Episodes of severe abdominal pain and fever very rare in later years. Improvement seems to coincide to yogic practices, stress management. 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? What are possible treatments? Non-classic treatments prefered (as I understand that there's no real cure for this condition, any of the drugs (NSAIDs, sulfasalazines) will cause a lot of other side effects long-term). Any comments, overview very welcome.
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Answered by Dr. Alokkalyani (33 minutes later)
Brief Answer: see a rheumatologist for assessment Detailed Answer: Hi, I am dr XXXXXXX pleased to answer your health related queries If you have confirm lupus, there is no cure for it, but mostly this is a well manageable condition. For joint pain, there are many medicines ilke- NSAIDS, methotrexate, sulfasalazine etc. Without ANA (antinuclear antibody) test it is hard to confirm lupus. If you can provide the reports, I will be better able to help you. For the side effect - there is always a risk benefit calculation. All the drugs for lupus are given after proper assessment for side effect and benefit. With medication, you will be in regular follow up for the side effect of medicines and disease activity. Unfortunately, there is no unconventional medicine Hope this will help If you have further queries, please donot hesitate Dr XXXXXXX
Above answer was peer-reviewed by : Dr. Vaishalee Punj
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Follow up: Dr. Alokkalyani (38 minutes later)
I don't know how Lupus got selected as a category for my question, I have never stated that I have SLE. I have no (specific) signs (e.g. butterfly rash) of Lupus and ANA panel didn't indicate anything. What other conclusions could you draw from the information I have provided? Thank you.
doctor
Answered by Dr. Alokkalyani (16 hours later)
Brief Answer: spondyloarthritis Detailed Answer: OK, so if ANA panel is negative, than SLE is unlikely. As per your history, your pain in joints are seems to be may be inflammatory, although your inflammatory markers like ESR and crp are negative, but HLA b27 positive and pain in joints. Here rheumatologist opinion after clinical examination does matter. But as per your history and investigation, I would keep spondyloarthritis as differential diagnosis. Sulfasalazine, NSAIDs are the treatment initially but methotrexarte may be the alternative.
Above answer was peer-reviewed by : Dr. Shanthi.E
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Follow up: Dr. Alokkalyani (3 hours later)
Thank you, Dr. Alokkalyani, I really appreciate your efforts. Another question - do NSAIDs really help in managing disease / damage to tissue in spondyloarthropathy case (as one would think that by lowering inflammation you could save tissue damage) or is this insignificant and the main benefit is pain management? Also, are there any prefered NSAIDs in this particular case? I was prescribed dexketroprofen, which even seems to be not compatible with Crohn's or UC (even though it is in history), are there better alternatives, like selective COX-2 inhibitors, like meloxicam? Thanks again!
doctor
Answered by Dr. Alokkalyani (26 minutes later)
Brief Answer: Nsaids are good Detailed Answer: Yes, nsaids are not only a pain killer in spondyloarthritis, but they also reduce new bone formation and fibrosis and they are considered as main and anchor drugs in spondyloarthritis, especially in early two years. After two years, they can be prescribed as and when basis There are many NSAIDs, but etoricixib, indomethacin, and naproxyn are considered superior in spondyloarthritis. Personally, I would not give you dexketoropfen Hope this will help
Above answer was peer-reviewed by : Dr. Prasad
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Follow up: Dr. Alokkalyani (3 hours later)
Thank you for a great clarification! I will close this question now.
doctor
Answered by Dr. Alokkalyani (3 minutes later)
Brief Answer: welcome Detailed Answer: Most welcome
Above answer was peer-reviewed by : Dr. Shanthi.E
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Suggest treatment for constant joint pain

Brief Answer: see a rheumatologist for assessment Detailed Answer: Hi, I am dr XXXXXXX pleased to answer your health related queries If you have confirm lupus, there is no cure for it, but mostly this is a well manageable condition. For joint pain, there are many medicines ilke- NSAIDS, methotrexate, sulfasalazine etc. Without ANA (antinuclear antibody) test it is hard to confirm lupus. If you can provide the reports, I will be better able to help you. For the side effect - there is always a risk benefit calculation. All the drugs for lupus are given after proper assessment for side effect and benefit. With medication, you will be in regular follow up for the side effect of medicines and disease activity. Unfortunately, there is no unconventional medicine Hope this will help If you have further queries, please donot hesitate Dr XXXXXXX