Rheumatology

Necrosis means the death of tissue. Avascular necrosis (AVN) is a condition resulting from the death of tissue in the bone. This damage to the bone tissue is due to a lack of proper blood supply. Avascular necrosis can result from an injury or from being more alcoholic or can also be due to the corticosteroid medication to treat some other health problem. Generally, men are more prone to get AVN than women. AVN is more common in the age group of 30-60. The person with avascular necrosis has to undergo treatment. If untreated, the joints have the chance to collapse and bones can lose their shape. Generally, hips get more affected by AVN. The other names for Avascular Necrosis(AVN) are Osteoarthritis, Ischemic bone disease, Aseptic necrosis, Osteonecrosis, and Bone infarction. Associated Anatomy of Avascular Necrosis Bone tissue of the body Alternate Name of Avascular Necrosis The other names for Avascular Necrosis(AVN) are Osteoarthritis, Ischemic bone disease, Aseptic necrosis, Osteonecrosis, and Bone infarction. Avascular Necrosis Causes Although the correct reason for AVN is not known, in most cases, Avascular necrosis is caused by one or a combination of the following factors: Injury: The main reason for Avascular necrosis is slowing down or lack of blood supply to the bone tissue of the injured site. Alcohol consumption: People who consume more alcohol have a higher risk of developing Avascular necrosis. Smoking: People who smoke have a higher risk of getting infected with Avascular necrosis. Blood vessels deposited with fat: Fat deposition in the blood vessels can lead to a lack of blood supply to the bones of the affected organ. Disease: Diseases like Legg-calve Perthes disease can cause AVN Medication: Taking high doses of medications like corticosteroids, as a treatment of any chronic disease for a prolonged time can cause AVN. Less common factors: There are a few other factors which are less common and can be a cause of AVN are listed below Bends disease, decompression sickness Gaucher’s disease Chemotherapy or medications (containing bisphosphonates) to treat cancer Infection by Human Immunodeficiency Virus (HIV) Sickle cell anaemia Lupus Pancreatitis Organ transplant High cholesterol Avascular Necrosis Symptoms Early-stage Avascular necrosis rarely causes any symptoms. In most cases, symptoms may occur as the pain becomes invasive. In the initial stages, the pain will be mild. When you do some work by using the affected area, the pain will be moderate to severe. Then, it starts to hurt more often in the affected joint. The final stage is when the condition worsens and the joint of the affected bone collapses and becomes immovable. Avascular Necrosis Diagnosis Doctors diagnose Avascular necrosis by inquiring about the patient’s medical history, signs, symptoms, and a physical examination, followed by diagnostic imaging tests. The doctor checks your joint by moving it to different positions and checks for the response. To conclude whether it is due to AVN or any other problem, imaging may be done. MRI and CT scan - This can reveal early stages of bone tissue death by AVN. X-Ray - This can reveal the only later stage of AVN. The early stage of AVN appears normal in the X-Ray Bone scan - Using a tracer based technique, defective bone tissue can be detected. Avascular Necrosis Treatment The Avascular necrosis treatment usually depends on the patient’s overall health condition and severity of disease conditions and includes factors such as age, area affected, cause of the AVN, and severity of AVN. Hip bones and knee bones are most commonly affected in the case of AVN. The other less commonly affected bones include the ankle, feet, hands, wrist, and shoulder. Some common treatment options include: Medications like anti-inflammatory non steroids like ibuprofen, naproxen sodium Medications for osteoporosis Blood thinner and cholesterol controlling drugs Electrical stimulation to bring bone reformation Exercise guided by Physiotherapists and proper rest Surgery Options in the Advanced Stage of AVN In the advanced stage of avascular necrosis, surgery is recommended. Some of the options are: Graft or bone transplant (especially kidney transplant) Osteotomy or reshaping of the bone Replacement of the affected joint Core decompression (Removal of the inner layer of the bone enables new bone tissue formation) Stem cell treatment (Stem cells taken from the affected joint can rejuvenate and form new tissues). Risk Factors of Avascular Necrosis Bisphosphonate use - The use of bisphosphonate for treating cancer increases risk of AVN. Alcohol consumption - Excessive use of alcohol and smoking can induce formation of fats in blood vessels Trauma - Injury can result in reduced blood supply to the blood vessels Steroid use - Usage of corticosteroid for a long time or its high dosage can affect the blood supply by fat deposition. Possible Complications of Avascular Necrosis The possible complications of advanced Avascular necrosis are as follows: Persistent pain Broken bone Joint dislocation can happen if untreated Avascular Necrosis Preventions Some of the following measures may help lessen the risk of developing Avascular necrosis: Avoid smoking and consuming more alcohol Consult your doctor in case of taking corticosteroids Keep your cholesterol levels under control. Epidemiology of Avascular Necrosis The estimated incidence of Avascular necrosis is high in men compared to women. Avascular necrosis is highly prevalent in young adults and elderly people (aged between 30 and 60). Expected Prognosis of Avascular Necrosis Fortunately, recent advancements in diagnostic procedures, treatment options, and medication have drastically reduced the number of new cases of Avascular necrosis and its associated complications. Natural Progression of Avascular Necrosis Avascular necrosis doesn’t spread to other organs of the body. With time AVN of the affected site causes severe pain. The patient has to get medical treatment if not, it leaves the affected bone broken, immovable or joint dislocated. Pathophysiology of Avascular Necrosis Avascular necrosis is characterized by the death of bone tissue mostly resulting from trauma or injury.

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Gout is a clinical manifestation of inflammatory arthritis that produces pain and swelling in different joints in the body. The symptoms occur in flares that last a week or two before disappearing. Alternate Name of Gout Gouty Arthritis Associated Anatomy of Gout Several joints (Big toe, ankle, knee, lesser toe joints) Sacs that act as a cushion and connect soft tissues and bones (Bursae) Membranes surrounding tendons offer protection (Tendon sheaths) Kidneys (High uric acid can induce stone formation damaging the kidney). Types of Gout NA Gout Causes High uric acid (Some with high uric acid may remain asymptomatic) Family history of gout, consuming foods (mostly animal proteins) rich in purines (purine breaks down to urate) and fructose, sweetened drinks, alcohol, etc. Gout Symptoms Gout symptoms frequently start in the big toe (metatarsophalangeal joint) or a lower part of the leg. Gout develops when serum uric acid levels are high causing needle-shaped crystals to grow in and around the joints. As a result, the joint becomes inflamed and arthritic. Symptoms of the affected joints are as follows Intense pain Swelling Redness Heat These symptoms alternate between sudden flare and remission. Generally, symptoms of the joints are unilateral, which usually affects one joint. Gout Diagnosis Physical examination Examining the affected joints for swelling, erythema, edema, etc. Laboratory test Checking the serum uric acid level Ultrasound Evaluating crystal deposition and other underlying causes Microscopy Aspired liquid from joints can be examined under the microscope to find urate crystals. Differential Diagnosis of Gout Pseudogout (calcium pyrophosphate deposition) Rheumatoid Arthritis Psoriatic Arthritis Palindromic Rheumatism Reactive Arthritis. Stages of Gout The progression of gout is separated into four phases: Asymptomatic hyperuricemia High uric acid without gouty arthritis. Acute gouty arthritis Onset and flares of pain, restricted range of motion, swelling, erythema, and swelling of the involved joint. Intercritical gout A period between remission and recurrence when the secondary causes of hyperuricemia and prevention must be addressed. Chronic tophaceous gout Deposition of sodium urate crystals (tophi) under the skin. Gout Treatment Gout is managed both by medication and lifestyle modification. Medication Flares can be managed by nonsteroidal anti-inflammatory drugs (NSAIDs) (eg., ibuprofen), anti-inflammatory drugs (eg., colchicine), steroids, and uric acid lowering drugs (febuxostat, allopurinol, and pegloticase). Lifestyle changes Weight loss, dietary modification, less alcohol consumption, avoiding purine-rich food (e.g., red meat), and stopping medications associated with hyperuricemia (like diuretics). Prevention Follow-up with a physician to prevent the formation of tophi (uric acid crystals under the skin) and kidney stones. Risk Factor of Gout Age: People at an older age are at increased risk. Younger people rarely have gout, but they have a severe form. Gender: Gout is three to four times as prevalent among males than females. Family history Lifestyle: Alcohol consumption, eating a high-purine, high-fructose diet increase risk of gout. Heavy metal exposure: Research showed an association between chronic lead exposure and the risk of gout. Medications: Certain medications, such as diuretics, salicylate-containing drugs, cyclosporine, niacin in excess, and a low dose of aspirin, elevate the uric acid level. Obesity: Being overweight and having high levels of body fat may increase the risk of gout. Other comorbidities: Some common health conditions increase the risk of gout, which are as follows Renal impairment/kidney stone Hypertension Diabetes Abnormal cell proliferating conditions, such as hemolytic anemia, psoriasis, and certain types of cancers Kelley-Seegmiller syndrome or Lesch-Nyhan syndrome (Deficient in enzyme regulating urate level). Complication of Gout Without treatment, gout can lead to several complications as follows Chronic gout Obliteration of the joint surface, joint deformity Painless tophi (in the helix of the ear, over the large, thick, protruding part of the ulna, or on the heel cord) Kidney stones and other kidney dysfunctions Gout Preventions Primary Prevention of Gout Gout can be prevented by following some management protocols: Limiting alcohol intake Avoiding purine-rich food (red meat, organ meat, codfish, shellfish, etc.) Consuming a non-dairy, low-fat diet Maintaining permissible BMI Stop smoking Daily workout Staying hydrated Secondary Prevention of Gout After remission from arthritic pain, uric acid lowering drugs should be taken and secondary causes of hyperuricemia must be addressed. Epidemiology of Gout One to two percent of men in the western world are affected by gout. The prevalence of gout is 0.12% in India. Gout develops at a higher rate in men and rarely occurs in premenopausal women. Expected Prognosis of Gout An acute gout episode normally disappears in five to seven days without any clinical attention. However, 60% of patients experience a recurrence within a year. Gout patients are more likely to develop other metabolic diseases, such as hypertension and diabetes. Along with metabolic syndromes, renal disease and cardiovascular disease increases mortality. Natural Progression of Gout If not treated and allowed to progress naturally, gout can lead to erosion and destruction of the affected joint. It may cause the formation of urate crystal deposits under the skin. Pathophysiology of Gout Uric acid accumulates and crystalizes in an aberrant purine metabolism causing gout. The crystal in monosodium urate form precipitates creating deposits (tophi) in joints, tendons, and surrounding tissues. Crystal protected by proteinaceous sheath prevents contact with cells and thereby prevents inflammation. Minor joint trauma, medical or surgical stress, or sudden fluctuations in uric acid levels might cause naked crystals to burst out of protein-protected tophi. They cause a local immune-mediated inflammatory response causing major symptoms of gout, such as pain, erythema, and swelling. Related Blogs Painful Joints - Symptoms, Causes, Management and Prevention Tips Foot Pain: Common Reasons and Solutions Understanding Blood Cancer & Its Symptoms Understanding Kidney Stone Causes and Key Prevention Strategies What to Expect After Your Knee Replacement Surgery Common Causes Of Acute Liver Failure You Need To Know

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Rheumatoid arthritis (RA) is an autoimmune condition that involves the immune system attacking the joints and causing inflammation in the lining (the synovium) of the joints. Associated Anatomy of Rheumatoid Arthritis Joints on both sides of the body; can involve any of them: Hands Knees Wrists Fingers Ankles Feet Toes Eventually, RA may affect other parts of the body, such as the eyes, heart, lungs, skin, and blood vessels. Alternative Names of Rheumatoid Arthritis Rheumatoid arthritis is known as RA or referred to as rheumatism. Types of Rheumatoid Arthritis Some additional types of RA include: Seropositive RA: When blood tests are positive for RF or rheumatoid factor, suggesting immune reaction to the tissues. Seronegative RA: If blood tests are negative for antibodies or RF you are seronegative, and need further examination to rule out RA. Juvenile RA: Type affecting children under 16 years of age. Rheumatoid Arthritis Causes The exact causes of RA have yet to be known. Researchers believe that a combination of genetic, hormonal, or environmental factors seems to trigger the immune system to attack the joints. As per some experts, viruses or bacteria modulate our immune system, making it attack our joints. Some others point out habits like smoking. Rheumatoid Arthritis Symptoms Some common symptoms that may be observed in RA include: Pain and swelling in joints Redness on joints Joints feel warm to touch Bumps or nodules under the skin (rheumatoid nodules) Stiffness, particularly in the mornings or after sitting for a long time. Fatigue and weakness Fever Stages of Rheumatoid Arthritis There are four stages of Rheumatoid arthritis: Stage 1: Early RA is characterized by some inflammation in the tissue around the joint(s), with some pain and stiffness. However, there are no evident changes in the bones on the X-ray. Stage 2: The inflammation starts to damage the cartilage in the joints, resulting in a decreased range of motion. Stage 3: Severe inflammation that damages the bones. It is likely to have more pain, stiffness, and further decreased range of motion and some physical changes. Stage 4: Although inflammation may not be evident, the joints keep deteriorating in this stage. You may experience severe pain, swelling, stiffness, and loss of mobility. Rheumatoid Arthritis Diagnosis The differential diagnosis of RA comprises: Fibromyalgia Lyme Disease Psoriatic Arthritis Myelodysplastic Syndrome (MDS) Osteoarthritis Reactive arthritis Paraneoplastic Syndromes Relapsing Polychondritis Polymyalgia Rheumatica Sarcoidosis Systemic Lupus Erythematosus (SLE) Sjogren Syndrome Typical Tests for Diagnosing RA There is no certain test to diagnose RA. It includes a combination of things like: Check up for location and symmetry of painful joints, specifically the hand joints, and the presence of nodules under the skin. Blood tests: To assess the number of red blood cells (usually low in RA), C-reactive protein (CRP) levels, Cyclic citrulline antibody test (anti-CCP), and Erythrocyte sedimentation rate (ESR). Rheumatoid factor (RF): Positive in 80% of people Antinuclear antibody test (ANA): This test detects the presence of autoimmune disease. X-ray Ultrasounds MRI scans Rheumatoid Arthritis Treatment Treatment options for Rheumatoid Arthritis comprise: Anti-inflammatory drugs like ibuprofen, aspirin, or naproxen Topical pain relievers Corticosteroids Pain relievers like acetaminophen (Tylenol) Some medications like disease-modifying antirheumatic drugs (DMARDs) Biologic response modifiers for severe cases of RA, where other medications don't help Adequate rest and exercise for joints. Surgery, if RA is very severe Lifestyle changes, occupational therapy Nutritious diet Risk Factors of Rheumatoid Arthritis RA is most likely to happen: If a person has a family history. Women are more likely to develop RA than men. Middle-aged are more likely to get RA. Smoking increases the risk of getting RA and can aggravate the condition. Obesity Possible Complications of Rheumatoid Arthritis RA may lead to several complications by affecting other organs and tissues like: Eyes: Dryness, pain, inflammation, and unclear vision Mouth: Dryness, infection, and gum inflammation. Skin: Rheumatoid nodules or lumps under the skin covering bony areas. Lungs: Inflammation and scarring may cause shortness of breath and lung disease. Blood vessels: Inflammation causing damage to the nerves, skin, and other organs. Blood: Reduced RBC count causing anemia Heart: Inflammation can affect the heart muscle and the associated areas. Painful joints: Reduced mobility of joints causes weight gain, making you likely to develop high cholesterol, diabetes, heart disease, and high blood pressure. Rheumatoid Arthritis Prevention Although it is difficult to prevent RA altogether, certain lifestyle changes can delay its onset and minimize its impact on the quality of life. Some preventive measures are: Quitting smoking Limiting alcohol intake Minimizing bone loss by ensuring a nutritious diet rich in calcium and vitamin D. Taking supplements for bone health if required. Improving oral health Maintaining healthy weight Staying active Taking early action if RA symptoms are observed. Epidemiology of Rheumatoid Arthritis More than 0.5 to 1% of adults (5 to 50 adults in 1 lakh people) are affected by RA every year. RA is 2.5 to 3 times more common in females than males; however, men show more severe symptoms than women. This condition primarily affects the middle-aged population, between 30 to 60 years of age. Some cases of RA are noted after people turn 60, known as later-onset rheumatoid arthritis (LORA). Although less common, even children or young adults (between 16 and 40 years) are likely to get this condition, which is called young-onset rheumatoid arthritis (YORA). RA is relatively rare in under-aged men. Expected Prognosis of Rheumatoid Arthritis Many effective medications and treatment approaches help reduce your pain and inflammation and slow down the progress of the disease. Early diagnosis and aggressive treatment play a vital role in the prognosis of RA. Pathophysiology of Rheumatoid Arthritis RA is a chronic inflammatory condition in which specific cells of the immune system mistakenly target the healthy body tissues, especially the cartilages, which act as a shock absorber in the joints. Unlike wear and tear damage of arthritis, RA affects the joints and tissues that line them (called synovium), causing severe inflammation, pain, and swelling in the joints eventually causing bone erosion and joint deformity. Natural Progression of Rheumatoid Arthritis The damage to cartilage resulting from uncontrolled inflammation in RA can cause a formation of a cushy layer of tissues to cover the end of the bones, resulting in deformation of the joints (misshapenness). It causes chronic or long-lasting pain and may further lead to a lack of balance (unsteadiness). Eventually, the bone erodes and can lead to fusion of the joint (an effort taken by the body to prevent constant irritation). Inflammation associated with RA can affect other body parts like skin, eyes, lungs, heart, and mouth, causing physical disability. Related Blogs How To Cure Rheumatoid Arthritis Permanently? Arthritis Diet: What to Eat And What To Avoid Painful Joints - Symptoms, Causes, Management and Prevention Tips A Knee for Knee Arthritis: Understanding Knee Replacement Surgery Knee Replacement Surgery - What To Expect & How to prepare for it? Basics of Back Pain: Reasons You Should be Aware

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