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Click here to view next page of this article New Treatments for Joint Problems and DiseasesGout. We are going to start out with gout, which is a thing to remember, it is a different disease for both male and female joint pain, gout, arthritis, pseudogout, rheumatoid arthritis, cervical stenosis. Men tend to present at a younger age because of the association with uric acid and antigen levels in the blood. Some are between the ages of 35 and 55, is the average onset of gout in a male patient. Usually it presents Cyclosporin. As we move on, drugs like CellCept and Prograf are replacing cyclosporin, but cyclosporin can take a normal person and give him tophaceous gout in about 24 months. Because it is a causer of renal insufficiency it also inhibits the secretion of uric acid by the kidney and resorption from uric acids, so it is a three-fold toxin in terms of developing gout in patients. It can develop raging tophaceous gout, and one of the problems was is that most patients with renal and heart transplant were on drugs such as Imuran and Cyclosporin, and Allopurinol interact with one another. You have a real difficult time of using Allopurinol on a patient and Azathioprine because of drug interactions and toxicities. These individuals are difficult to treat. Rapid in onset and have severe tophaceous gout. Important items, uric acid levels can be normal enough to half of patients with their first gout attack. Getting a serum uric acid level on a 35 or 38 year old may or may not tell you much. Because it is not uncommon for it to be normal. The most important test to know is the serum creatinine. Because creatinine is important in terms of treatment with anti-inflammatories and subsequent treatment with remitive medications down the line. i.e., A 75 year old male who comes with a creatinine of 2.5 is a great risk if you give Indometh sin for developing hyperkaliemia and sudden death and shutting his kidneys down completely. It is important to know a serum creatinine in individuals. Another clinical pearl, gout can be triggered by infections. Septic joint and gout can co-exist. Anything that causes inflammation of the joint can shake loose crystals so you always have to be absolutely certain your not treating a cellulitis/septic joint. I, not infrequently treat the patients for both until I am absolutely certain over a time course. Meaning they will get antibiotics and their Pseudogout crystals are small enough and dull enough that they’re relatively difficult to see. Well, how do you see them? You take a pallet spin it down or take fluids spin it down to a pallet resuspend it, your chances of seeing pyrophosphate crystals go up about 70% or if you use a pallet. This is clinically an acute podagra. The inflammation is so intense that you actually peel off the skin like a blister. How come this is not cellulitis, sometimes it is difficult to sort out, as I say, the two can co-exist. The location is consistent with gout; in this particular case you can see tophaceous draining. This is chronic polyarticular tophaceous gout in a female patient that mimics rheumatoid arthritis. No history of acute podagra, this patient is 75 years of age, underlying Pseudogout, chondrocalcinosis, again kind of an interesting in a common crystal, usually the onset is about age 60. It can be an acute chronic arthritis. The interesting thing about chondrocalcinosis pseudogout and this is all is confusing. Chondrocalcinosis means there are calcifications on the radiograph that is what it means. Pseudogout means you had an attack of acute arthritis. The confusion, of course, is people using them interchangeably. You can have asymptomatic chondrocalcinosis for years with no symptoms. Suddenly, you can develop acute pseudogout, there are different implications in terms of treatment. The interesting Rheumatoid arthritis is the commonest of the inflammatory arthritides. I have a little note to myself, note: the seronegative arthritis, which we do not have time to talk about, are interesting and fascinating and can cause problems. They are: inflammatory bowel disease with arthropathy, reactive arthritides, status post salmonella, shigella and enteric infections, psoriatic arthritis, ankylosing spondylitis and Reiter’s syndrome. Now this group of arthritides are called seronegative because rheumatoid factor is negative and in a lot of cases they are associated with H LAB27 antigen. They represent a different type of inflammatory arthritis confusion arises in psoriatics and Reiter’s patients, because they can have enough joints and enough inflammation to mimic rheumatoid arthritis pretty closely. The interesting thing is the drugs I am going to talk about in rheumatoid arthritis work on the seronegatives as well. Probably, including the new tumor necrosis factorial medications. That is the subset of arthritis that can cause confusion. Occasionally, the patch of psoriasis in a psoriatic will be in their naval, it will be in the back of their scalp, it will just be nail pits, it will be a small rash on their elbow. That is all the psoriasis they have on their body, you have to have an explosive arthritis. A good general physical examination is quite helpful. You don’t have to have total body psoriasis to have psoriatic arthritis. The occurrence of Cervical stenosis presents with lower extremity weakness and hyperreflexia. It can also present with a much more difficult vertricular basilar insufficiency syndrome. Dysphasia, Diplopia, dizziness, vertigo, all related to compression of the arterial circulation of the back of the neck by osteophytes. You can have a cervical stenosis syndrome with weakness in the legs, you can have a vestibular basilar insufficiency syndrome, which is difficult to diagnose. Then, of course, you can then have the typical cervical radiculopathy with pinched nerves. Meaning, I can either get cervical cord compression in the neck, I can get neural |