Rheumatology

Rheumatology

RHEUMATOID ARTHRITIS
Patients, who present to Rheumatology Clinic, mostly complain of rheumatoid arthritis. The condition is more common in women. Although the condition generally occurs between 40-50 years of age, it may occur at any age including childhood. The condition may lead to pain and swelling in the small joints of hands and feet, wrist, ankle, knee, elbow and shoulder joints. Articular manifestations are generally long term and may result in permanent damage in the joints and disability if left untreated. Rheumatoid arthritis may involve extra-articular organs like the lung and eye, besides of the joints. Sedimentation rate and CRP elevate which, are indicatives of inflammation. Rheumatoid factor and anti-CCP antibodies may be tested positive. At diagnostic phase, direct x-ray, joint ultrasound and magnetic resonance imaging (MRI) can be used. Relevant medications can be used alone or in combination with other medications. Although the use of steroid/cortisone is not a must, it can be administered at low dose for a while in the early stage of the disease. In case positive outcomes cannot be obtained with these treatments, biologic medications consisting of 9 different agents can also be administered. The decision regarding treatment must be made jointly by the patient and the physician. If the complaints can be managed with treatment, follow-up is required to be made at 4-6 month intervals. During follow-up period, the activity of the disease, treatments and side effects are evaluated and complete blood count is analyzed.

SPONDYLOARTHRITIDES
The most common types of spondyloarthritides are ankylosing spondylitis, psoriatic arthritis, enteropathic arthritis (arthritis secondary to Chron’s disease and ulcerative colitis) and reactive arthritis. Patients with ankylosing spondylitis mostly complain of inflammatory low back pain. This type of pain generally occurs between 20-30 years of age, may regress or worsen from time to time and persist for months and even years. Patients may suffer from nocturnal low back pain-hip pain, neck pain and back pain or may wake up with stiffness in the morning. Also, heel pain and swelling may develop. Minimal kyphosis may develop in time in a low number of these patients.

PSORIASIS
Psoriasis is a skin disease. Articular and spinal rheumatism may occur in one out of every four patients with psoriasis at any phase of their lives. Chron’s disease and ulcerative colitis are inflammatory bowel diseases. Inflammatory rheumatism may develop in about 10% of these patients. Reactive arthritis is characterized by pain and swelling in the joints which emerge 1 week or 1 month after an infection. The risk of this condition is very high in family members of patients with spondyloarthritis. Genetic tests, like HLA-B27, can be used to diagnose the condition. Direct sacroiliac and spinal joint x-ray and MRI of these regions, if required, can be scanned. Painkillers, relevant medications and biologic drugs can be used in treatment process.

GOUT AND OTHER CRYSTAL ARTHRITIDES
Although they can develop at any age, gout and crystal arthritides are mostly seen at advanced ages. The prevalence is slightly higher in men. The most prominent complaint in gout diseases is pain, swelling and redness in the big toe. Patients identify this pain as “a scorpion sting-like pain”. In this disease, the complaints related to joints develop in form of attacks. There may be months and even years between the attacks. As the disease progresses, swellings in joints like hand joints, elbows and shoulders may associate to the joint swellings in feet. The most important underlying factor is nutrition. Although there is a direct relation between elevated uric acid level in blood and the disease that does not mean that all patients with gout have high uric acid levels. Gout disease is also associated to cardiovascular diseases. Often, it may be seen in disorders like hypertension, diabetes mellitus, cholesterol disorders and overweight. A diet to lower the uric acid level is absolutely recommended for treatment. Colchicine and painkillers are used during the attack and drugs to lower uric acid level are prescribed to prevent the attacks.

CONNECTIVE TISSUE DISEASES
The process of diagnosis covers a large variety of diseases, some of which are not easy to identify. This type of diseases is seen more frequently in females. Patients may show symptoms which include joint pain, fatigue, tiredness, wounds in oral cavity, dry mouth, dry eye, discoloration in hands with cold (Raynaud’s Phenomenon), sun allergy, thickening or thinning of skin, rashes in various body parts. Moreover, the disease may affect internal organs in some cases. It can involve all internal organ systems such as lungs, heart, kidney, nervous system, liver, spleen and intestines. Identifying involvement in these regions requires a serious and attentive rheumatologic evaluation. Many blood tests, primarily anti-nuclear antibody (ANA), are studied in cases of these diseases. Treatment significantly varies depending on the severity and location of the involvement.

BEHCET’S DISEASE AND FAMILIAL MEDITERRANEAN FEVER
Behcet’s disease is a rheumatic disease which was identified by Turkish physician Hulusi Behçet in 1937, as it can be understood from its name. It generally effects younger population. Behcet’s disease leads to wounds in oral cavity (apthous lesion), wound leading to scar formation in genital region, swelling in joints, erupted red colored wounds which appear more prominent under knee level. Moreover, the clinical picture named uveitis which includes congestion of arteries and veins, redness in eyes, pain and blurred vision and in some cases inflammation in brain stem may occur. Treatment method depends on the location of involvement. Medications which regulate or suppress immune system may be used in cases of severe organ involvement.

“Familial Mediterranean Fever”, which is a genetic disease, occurs in childhood period for most patients. But the first signs may develop in adulthood in some patients. Complaints with recurring character are observed. Abdominal pain persisting for several days, chest pain associating with sensation of stinging in chest, swelling of knee or ankle joints and fever are frequently seen symptoms. The disease may similarly occur in other family members. The presence of the disease can be verified with a genetic test called MEFV. Colchicine is used for its treatment. Biological therapies are used in resistant cases.

VASCULITIDES 
Vasculitis basically implies the inflammation around a vessel and the condition has approximately 10 sub-groups. Those disorders can affect small, moderate and large vessels. When there is an inflammation in vessel, blood flow to the related organ decreases and causes complaints in the region. In small vessel vasculitis, ANCA test may result positive in blood tests. In addition to the effect on joints and skin, visceral organs may also be affected by the disease. Sometimes, fever, weight loss, fatigue and loss of appetite may develop. Ears, nose, throat, lung, kidney, heart and nervous system can also be affected by the disease. Treatment methods vary depending on the affected organ. Large vessel vasculitis, called Takayasu’s arteritis and giant cell arteritis, causes inflammation in aorta and its branches. Inability to measure pulse and blood pressure at young ages, sudden-onset headache at advanced ages, inability to chew due to pain in jaw, vision loss are potential complaints. Angiographic imaging with tomography or MRI may be necessary for diagnosis in those patients. Sometimes, evaluation with PET-CT is also beneficial. Although modality of treatment varies depending on severity and involvement of the disease, steroids –cortisone and immunosuppressive drugs- are frequently used.