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Dr. Andrew Rynne

Family Physician

Exp 50 years

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Suggest treatment for frequent urticaria and joint pains

Answered by
Dr.
Dr. Parin N. Parmar

Allergist and Immunologist

Practicing since :2006

Answered : 870 Questions

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Posted on Mon, 25 Aug 2014 in Asthma and Allergy
Question: In 2009 had a streptococcus infection accompanied by severe body rash and
thereafter body pain and severe back ache.
cRP Levels were high 38 and ESR 127 Was hospitalized and told I have
a slip disk which after 45 days in hospital without relief was sent home.
Thereafter went to a Rheumatologist who recommended Physiotherapy & Vitamin
D supplements and was under control.

suffer FROM ENDOMETRIOSIS AND BLEEDING IS EXCESSIVE DURING THE MENSES.
THE gynecologist HAS RECOMMENDED INSERTION OF MIRENA AND DNC SINCE TAKING
deviry 10mg BEFORE PERIODS HASN'T HELPED.

since the Past 11 months have been experiencing
- Pain in Joints.
- Frequent Allergy/ Itchy Uticaria
- Chronic Fatique
- Feeling sick and tired all the time.

AT pRESANT ESR LEVEL IS 28 AND CRP 18.8
ANA TEST IS BODERLINE.

I cannot pinpoint what is causing the allergy recently met a Physician
who has recommended following Medication after attached Test were done

Montek (Twice a day with Allegra additionalSOS)
Lyrica 75 mg (Thrice a day)
Vitamin A (twice a day)
Vitamin C (thrice a day)
VITAMIN D INJ 60 Lakh once a week

THE PHYSICIAN ALSO MENTIONED I COULD HAVE MURPHYS SYNDROME AS THE ABDOMEN AREA
WAS VERY TENDER.

I AM CONFUSED WHAT I SUFFER FROM AND WHAT FOODS TO EAT AND WHAT TO AVOID.
doctor
Answered by Dr. Parin N. Parmar 7 hours later
Brief Answer:
Continue treatment, avoid hot-spicy-packed foods

Detailed Answer:
Hello madam,

Thank you for asking at HCM.

I went through your history and your reports.

I would like to summarize as an Allergist as - you are having frequent urticaria, with joint pains, endometriosis with excessive bleeding during menses and chronic fatigue. Investigations mainly suggest elevated ESR, CRP, borderline ANA, with possibility of autoimmune disorder.

With above history, I would like to make following suggestions to you:

1. When urticaria occur frequently over a period longer than 6 weeks, it is known as "Chronic urticaria". And in contrast of common belief, chronic urticaria are less likely to be "allergic" by nature. Please do not think your urticaria are surely due to allergies.

2. I would like to know your last reports of complete blood counts, serum SGPT, serum proteins, serum creatinine, blood urea, urine and stool examination. You need not to get these reports done right now. You can let me know the report on follow-up with the dates they were done.

3. Have you observed aggravation of urticaria within 1-2 hours of consuming any food? This is the best way to suspect a food you may be allergic to. Allergy testing for variety of foods is not very helpful in identifying food allergies. Please let me know if you suspect any food. If you suspect any food related to your urticaria, specific testing for that particular food can be performed. However, as I mentioned earlier, I would not think of allergies first for your urticaria.

4. Have you had any signs of thyroid disorder like - weight gain or weight loss, constipation or diarrhea, cold intolerance or heat intolerance, dry cold skin, etc.? Have you ever been tested for thyroid function?

Were I treating you, I would suggest you following tests for thyroid: serum T3, T4, TSH, anti-thyroperoxidase antibodies, anti-thyroglobulin antibodies.

I suggest every female chronic urticaria patient to get above test done because thyroid disorder is very commonly associated with chronic urticaria and especially females. Sometimes treatment of thyroid dysfunction can help treating urticaria also.

Above 4 points will be helpful to you to know what your urticaria can be due to. Please discuss above things with your treating physician and he will be helpful to you to make further decisions.

For treatment part, I would make following suggestion to you:

1. You are already taking Montek (montelukast), I would agree with that.

2. I would also agree that Allegra (Fexofenadine) can be taken on as-and-when-needed basis. However, if you have frequent urticaria, you can take it daily/regularly which will reduce frequency of urticaria.

3. If you have more symptoms during night (which may disturb your sleep) than daytime, I would suggest you hydroxyzine before going to sleep.

4. Personally I would suggest you to avoid wearing tight-fitting or woolen or synthetic material clothes as much as possible. Loose-fitting, cotton clothes are best option in my opinion.

5. I would also suggest you activities which may cause excessive sweating. This may aggravate urticaria.

6. Multivitamins and minerals may help. As you are already taking vitamins, please continue taking them as per your doctor's advice.

7. Please avoid medications which may aggravate urticaria like - pain killers (except paracetamol). Paracetamol is the safest analgesic for urticaria.

8. Please do not scratch at the itchy areas, it will aggravate urticaria. I would suggest application of lotion like calamine over the itchy areas to reduce itch.

9. As you have specifically asked for food, I would like to make suggestions for foods as follows:

a. As mentioned above, unless you can specifically observe a close relation between your food and urticaria, you may not be allergic to any food.

b. In general, excessive hot & spicy (and sometimes excessive sour) foods can aggravate any urticaria. So these foods may be avoided in my opinion.

c. Sometimes foods like tomato, spinach, brinjal, cheese, chinese foods, chocolates, some types of fish, etc can aggravate urticaria in some patients. You can observe these food's relation with your own urticaria symptoms and you can avoid them only if you find any correlation.

d. In general, I also suggest my urticaria patients to avoid packed foods, junk foods, etc in order to avoid preservatives, coloring agents and other chemicals. There are no laboratory tests to identify allergies to these chemical additives. If one cannot avoid, one can at least cautiously minimize consumption.

e. In Ayurveda, much emphasis is given on Turmeric for treatment of urticaria. So I generally advise my urticaria patients to consume more turmeric than usual and some of them are benefitted. However, please take an Ayurvedic practitioner's opinion to be on safer side.

Hope above suggestions and answer will be helpful to you.

Should you have any further query, please feel free to ask on follow-up. I will try with best of my knowledge and efforts to be helpful to you.

I would be thankful to you if you could give me your feedback on follow-up.

Wish you the best of the health.

Thank you & Regards.

Dr. Parin N. Parmar
Above answer was peer-reviewed by : Dr. Prasad
doctor
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Follow up: Dr. Parin N. Parmar 13 hours later
Thank you for your reply for my Wife. I appreciate the same.
We had done TSH, T3 and T4 which were normal in January 2014.
(same is attached)
Could my wife have a liver ailment or a bile duct obstruction.
she has lost more than 10Kgs or more in the last year
she is 5 Feet 7 Inches and weighs 70 Kgs)
(However she is very careful of her diet and walks a lot)

PLEASE RECOMMEND ANY OTHER TEST WHICH NEEDS TO DONE AS
I WOULD NOT WANT THE DISEASE TO PROGRESS FURTHER AND NIP
IT IN TIME.

HOW CAN I BUILD UP HER IMMUNITY.

PLEASE ADVISE !

THANK YOU.
doctor
Answered by Dr. Parin N. Parmar 10 hours later
Brief Answer:
Further evaluation, Strengthen Immunity

Detailed Answer:
Hello.

Thank you for your follow-up. I reviewed her reports and would make following suggestions for her:

1. As her T3, T4 & TSH are normal in January 2014, I would not suggest to repeat them at present.

2. I had suggested serum SGPT and serum proteins (albumin, globulin and total) for liver evaluation. In addition, serum alkaline phosphatase, serum bilirubin, prothrombin time can be done for liver evaluation. I think she has had an Ultrasonogram of abdomen in last year, then I would not suggest to repeat them. These investigations almost rule out liver/bile duct diseases.

However, if you are strongly suspecting liver/gall bladder disease, a gastroenterologist consultation may be helpful.

3. Weight loss of 10 kg in a year is significant but it is difficult to decide whether her efforts to reduce weight are causing it or any disease itself.

4. I had already suggested some tests previously:

complete blood counts, serum SGPT, serum proteins, serum creatinine, blood urea, urine and stool examination, anti-thyroperoxidase antibodies, anti-thyroglobulin antibodies.

These investigations are usually adequate for evaluation of chronic urticaria.

5. For allergy evaluation, I would also suggest specific IgE for suspected food substances (based on correlation with food and symptoms) and tests for physical urticaria which are performed by dermatologists and allergists.

In my opinion, these types of long term urticaria are less likely to have allergic basis. As she has fatigue, joint pain, excess bleeding, etc, I would personally suspect a multisystem/autoimmune disorder. A rheumatologist is usually the best person to suggest complete evaluation of such disorders.

Usually these types of urticaria are managed with regular anti-histamines and montelukast. For severe symptoms, short course of corticosteroids may be required.

6. For boostiing immunity, I would like to make following suggestions to her:

a. A balanced and healthy diet rich in vitamins, minerals & anti-oxidants (adequate amounts of green vegetables, variety of fruits, sprouts, etc) and vitamiin-mineral supplements will be good. She is already taking vitamin A, C & D. I would additionally suggest vitamin E & B Complex, also a multimineral containing zinc and selenium.

b. It is important to maintain her hemoglobin levels 13-14. This prevents repeated infections.

c. A regular exercise schedule, preferable by a personal physical trained is very good for boostiing immunity.

d. Stress (psychological or physical) is very important adverse factor for good immune system. Personally I would suggest Yoga, Pranayama and Meditation for stress reduction.

Hope above suggestions will be helpful to her.

Should you have any further query, please feel free to ask on follow-up.

Wish her the best of the health.

Thank you & Regards.

Dr. Parin N. Parmar
Above answer was peer-reviewed by : Dr. Prasad
doctor
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Follow up: Dr. Parin N. Parmar 6 hours later
Thank you for your email,opinion and recommendations.
Profusely thank you for the same. I have attached blood
Test done today. Should I suspect Celiac disease -
what are the test for the same.
Thank you
Regards,

doctor
Answered by Dr. Parin N. Parmar 59 minutes later
Brief Answer:
No further allergy evaluation, daily antihistamine

Detailed Answer:
Hello sir,

Thank you very much for your follow-up and updating the reports. I went through all your reports and would like to summarize as follows:

1. All the allergy reports of her are negative. So I had mentioned earlier, she has non-allergic urticaria.

After reviewing reports, personally I would not suggest further allergy evaluation for her.

For evaluation of chronic urticaria, important tests which are remaining are anti-thyroperoxidase antibodies and anti-thyroglobulin antibodies. However, these tests are not for allergies.

2. Her liver and kidney functions are normal as well.

3. Her conclusive reports are:

a. Increased ESR, CRP, CA-125.
b. Borderline positive ANA (personally I would suggest you to repeat after 6 months)
c. Hemangiomas in liver & fibroids in uterus. (Hemangiomas are benign tumors made of vessels, please be sure that they are small in size and are not interfering with liver function).

3. So all the reports are suggesting inflammatory/multisystem disorder rather than allergic disorder. So I would personally suggest you to consult a Rheumatologist (who usually deals with such disorders).

4. For treatment of her urticaria, I would suggest her same treatment as mentioned in previous two answers. Were I treating her, I would prescribe her regular antihistamine drugs to prevent urticaria rather than using them on as-ad-when-needed basis.

Also, should she have any severe episode of urticaria, she may need a short course of corticosteroids under guidance of a physician.

5. As you have asked for celiac disease, personally I would not thinking of celiac disease in her. It's common presentation is quite different than from your wife's presentation.

The common tests used to diagnose celiac disease are anti-TTG (tissue transglutamase) antibody, anti-gliadin antibody, anti-endomysium antibody, etc. The confirmatory test for diagnosis is by examination of intestinal specimen which shows improvement after a few weeks of gluten-free diet.

However, I would personally not suggest you to self-investigate for celiac disease unless suggested by a gastroenterologist or rheumatologist.

To summarize,

a. Personally I would think of non-allergic inflammatory/autoimmune cause for chronic urticaria.
b. I would not suggest further allergy evaluation at present.
c. For treatment of urticaria, I would suggest her regular daily antihistamines like fexofenadine/cetirizine/levocetirizine/hydroxyzine rather than on as-and-when-needed basis. She may need to take them for a few weeks/months.
d. I would also suggest you to follow other non-medicinal measures for urticaria (in answer 1) as well as measures to improve immunity (in answer 2) which will be helpful to her in a long run.
e. In my opinion, looking at her investigations, Rheumatologists/Autoimmune disorder specialists may be the best persons to evaluate the whole symptom complex together.

Hope above suggestions will be helpful to you.

Should you have further query, please feel free to ask at HCM.

Wish her a very good health.

May God bless both of you and your family.

Thank you & Regards.

Dr. Parin N. Parmar
Above answer was peer-reviewed by : Dr. Vaishalee Punj
doctor
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Follow up: Dr. Parin N. Parmar 2 days later
Dear Doctor.
I met the MD Physician who is treating my wife today, He mentioned that on
physical examination and alongwith the reports he was very sure that she
doesn't have any autoimmune disease such as SLE, Lupus, RA etc,
but mentioned it is atopic uticaria and we could safely take montelukast and Alegra long term till the allery subsides which could take at times months or a year to subside. ( Incidentally my wife had this allergy in 2009 which vanished
after a couple of months and has returned in 2013)

He has also mentioned that the following vaccines would be worth giving.
Influenza Vaccine.
Gardasil Vaccine.
HEP A + HEP B Vaccine

Are these Vaccines safe.

Your valuable inputs would be much appreciated.
Thank you.


doctor
Answered by Dr. Parin N. Parmar 6 hours later
Brief Answer:
Continue antihistamines, can go for vaccines

Detailed Answer:
Hello sir,

Thank you for follow-up.

Your treating physician is the best person to make the diagnosis. Personally I would suggest you to follow your regular physician's advise.

However, my concerns not favoring atopic urticaria are:

a. Atopic urticaria usually do not last for more than 6 weeks. (only less than 10%)

b. Atopic urticaria are not accompanied by raised ESR & Raised CRP. (ESR & CRP are raised in inflammatory systemic conditions or autoimmune conditions or chronic infections like tuberculosis)

c. All her allergy tests including Phadiatop allergic screening tests are negative.

d. She does not have any accompanying other allergic condition.

From above view-point, personally I would not think of allergic cause.

I would agree that long term montelukast and Allegra (Fexofenadine) are safe for long term use unless one experiences side effects like nausea, vomiting, headache (montelukast) or sedation, drowsiness (Allegra).

If above medicines are not controlling her urticaria adequately, were I treating her, I would increase/add an antihistamine (because it is the most effective group of drugs for urticaria) rather than montelukast-type drug.

Regarding vaccinations, she may be given the vaccines suggested by your physician after discussing in detail possible usefulness and side effects of each vaccine.

Personally I would agree with Hep A, Hep B and HPV (Gardasil) vaccines, but I would not think she has additional risk to get infected with influenza. Decision regarding influenza vaccination also depends on how commonly it is seen in your region.

Common side effects of all injectable vaccines are local - pain, tenderness, swelling, etc.

Influenza vaccine (if nasal spray type) can cause mild fever, running nose, sore throat like symptoms for 2-3 days, which are mild and subside by themselves.

Long term/serious side effects of these vaccines are rare and not commonly seen in practice.

Hope above information and suggestions will be helpful to you.

Should you have any further query, please feel to share.

I hope, I have been able to help you taking better decisions and knowing more about your condition. Please share your feedback, it will be my humble pleasure.

Wish your wife the best of the health.

Thank you & Regards.

Dr. Parin N. Parmar
Above answer was peer-reviewed by : Dr. Prasad
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