Diseases and Conditions When to see a rheumatologist

What is autoimmune back pain?

December 26, 2016

Let’s face it, back pain is terrible and unfortunately for us, very common. According to the 2016 Global Burden of Disease Study, low back pain is the number one cause for disability globally.

So we know back pain is common and debilitating, but the question is, what is the difference between regular and autoimmune back pain?

There are two broad categories: mechanical back pain and inflammatory or autoimmune back pain. Many but not all autoimmune diseases cause back pain. For example, rheumatoid arthritis usually does not cause back pain. Sometimes these disease are very difficult to diagnosis because they progress very slowly. Often times it takes years to decades to diagnose. Yes you heard me, DECADES. Unfortunately, if left untreated, it can cause irreversible spinal damage: joint erosions and spinal fusion also known as ankylosis. Prompt treatment with a disease modifying anti-rheumatic agent (DMARD) often can slowdown or prevent joint damage.

Autoimmune back pain

As I was mentioning before, mechanical and autoimmune back pain are completely different. Mechanical back usually improves with rest, worsens with strenuous activity, and usually begins later in life. People that have autoimmune back pain experience the opposite. Here are some of the key features.

Usually pain starts during the 2^nd or 3^rd decade of life. People usually experience symptoms before the age of 45
Onset is gradual for the most part
Symptoms have been ongoing for more than 3 months
Exercise improves the pain
Rest really doesn’t help. The pain usually worsens with rest
Anti-inflammatory medications like naproxen or ibuprofen helps the pain
Pain wakes you up during the second half of the night
Pain and prolonged stiffness in the morning. Typically, stiffness lasts more than one hour
Alternating deep buttock pain

Risk factors

Autoimmune disease rarely occur in isolation. The following are some of the risk factors pointing towards a diagnosis of autoimmune back pain.

Personal history of uveitis. This is a type of inflammatory condition that affects the eye.
A personal history of psoriasis.
Having a history of dactylitis in your finger or your toes, aka “sausage digitis”.
History of inflammatory arthritis: redness, swelling, and stiffness in any joint
Any first degree relative with any spondyloarthritis (SpA)-associated condition? This means mom, dad, siblings, or your children. SpA-associated conditions include:
- Axial spondylitis also known as ankylosing spondylitis
- Psoriasis
- Psoriatic arthritis
- Reactive arthritis
- Crohn’s disease
- Ulcerative colitis

If you think you could be suffering from autoimmune back pain, please seek your local rheumatologist. But do not jump to conclusions. There are many other diseases that can mimic inflammatory back pain that are not autoimmune in nature.

References

Vos T, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016 Oct 8;388(10053):1545-1602.

Sieper J, et al. The Assessment of SpondyloArthritis international Society (ASAS) handbook: a guide to assess spondyloarthritis. Ann Rheum Dis. 2009 Jun; Suppl 2:ii1-44.

http://www.asas-group.org/publications/ASAS-handbook.pdf

Medical Disclaimer

This information is offered to educate the general public. The information posted on this website does not replace professional medical advice, but for general information purposes only. There is no Doctor – Patient relationship established. We strongly advised you to speak with your medical professional if you have questions concerning your symptoms, diagnosis and treatment.

Diseases and Conditions Featured

What is a positive ANA and what does it mean?

December 12, 2016

What does it mean to have a positive ANA also known as an antinuclear antibody? This is a loaded question and the answer is complex. The answer is usually quite personalized to the person and their symptoms. The answer also usually entails follow-up bloodwork and evaluation by a rheumatologist. But in simple terms, an ANA is an antibody directed towards the nucleus of a cell.

How is an ANA measured?

The ANA is calculated by taking a standardized cell from the lab and mixing it with a person’s blood. If a person has antinuclear antibodies, these will stick to the standardized cells’ nuclei. At this point, there’s no way for us to know whether this has happened, so the lab tech adds fluoresceinated antibodies to the mix. These antibodies bind to ANAs that stuck to a nucleus. With the help of a specialized microscope, the lab tech can now visualize the ANA because the fluoresceinated antibodies make them light up.

My doctor told me my ANA was high. What does that mean?

Unfortunately, the tech cannot count how many ANAs they see. Instead, they see how much they can dilute the blood and still see the fluoresceinated antibodies. So when you see and ANA of 1:80, that means the tech really wasn’t able to dilute very much. This is a low level. If you see a value of 1:640, that means they were able to dilute a lot more. This is a higher level.

So how much dilution is enough to consider an ANA as positive? That answer really depends on the lab. Every lab has different cut off values, but in general, an ANA of 1:80 is typically considered positive. Whether it’s clinically significant, is a whole different question. This is where the art of medicine comes into play. But before that, let’s talk about patterns because those are important too.

Positive ANA patterns

So let’s take an example. Your doctor runs an ANA and it comes back as 1:320 speckled pattern. So what does that mean? When the lab tech was looking at the fluoresceinated antibodies, it basically literally looked speckled. There are many other kinds of patterns: homogenous, centromere, nucleolar, speckled, rim etc. Each of these patterns possibly indicate the presence of specific nuclear antibodies. For example, the presence of a speckled positive ANA indicates the presence of these specific autoantibodies, SSA, SSB, RNP, Smith, and Ku antibodies. These specific nuclear antibodies are themselves associated with specific autoimmune diseases. It’s important to take ANA patterns with a grain of salt because interpretation highly depends on experience.

I’m not going to go more into details about specific nuclear antibodies because first, there’s about 150 of them and second, they’re all associated with different diseases lupus being one of them. That’s a lot of material to cover in one article.

When is a positive ANA clinically significant?

Now that we understand what an ANA actually is, we can now start to approach the subject of clinical significance AND when you should be tested.

The problem with the ANA is that it can be found in normal healthy people.

ANA 1:40 is found in 20 – 30% of healthy people
ANA 1:80 is found in 10 – 15% of healthy people
ANA 1:160 is found in 5% of healthy people
ANA 1:320 is found in 3% of healthy people
5 – 25% of healthy people with a family member suffering from lupus have a positive ANA
Up to 70% of people aged above 70 years have a positive ANA

To complicate things even more, someone who is about to have and autoimmune disease can have a positive ANA… UP TO 10 YEARS before they actually develop the disease. Cancer and infections can also cause someone to have a positive ANA. It can even be positive when people are taking certain medications. Not terribly helpful right?

Bad example

So someone runs an ANA just because and it’s positive.

Does it mean anything?
Is the person one of those healthy people that has a positive ANA?
Is the person going to develop an autoimmune disease in the future?

In this scenario, I would say that this test is of low clinical significance because that person did not have any symptoms. Because so many people who are completely healthy have an ANA, the test should only be run if a person has a symptom or better yet, multiple symptoms that potentially indicate the presence of an autoimmune disease like lupus, Sjögren’s syndrome, systemic sclerosis, mixed connective tissue disease, etc. In that situation, it is helping rule in or rule out certain diagnoses.

Good example

If you’ve read my earlier post, 8 important warning signs of scleroderma, you’ll remember that Raynaud’s phenomenon is an important red flag for scleroderma. The majority of people suffering from Raynaud’s have no underlying autoimmune disease but a small proportion does. This is the perfect scenario, where an ANA would be useful. If the ANA is negative, the person likely will NOT develop an autoimmune disease. If the ANA is positive, then the person has a high risk of developing an autoimmune disease like lupus, scleroderma or Sjogren’s syndrome.

Let’s wrap things up

Ultimately it all boils down to this simple fact: doctors treat people not numbers.

As a physician I care about symptoms and signs way more than lab tests. Don’t get me wrong, these tests are important. For example, over 99% of people suffering from systemic lupus erythematosus have a positive ANA. It’s pretty much safe to say that if someone tests negative for ANA, they likely don’t have lupus. FYI that other less than 1% usually have a positive SSA, they have a problem with their complement system, or they have a lot of protein in their urine (nephrotic syndrome).

I hope I’ve helped you better understand the elusive and mysterious positive ANA. If you’ve tested positive for an ANA and have more questions, I highly urge you to speak with your physician or local rheumatologist. And remember, doctors treat people not numbers.

References

Rheumatology Secrets 3^rd edition

Medical Disclaimer

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Diseases and Conditions When to see a rheumatologist

Signs you may be suffering from autoimmune joint pain

December 5, 2016

Pretty much everyone at some point in their lives is going to experience some form of joint pain. But when does joint pain become more than just your typical, “I over did it” joint pain? When does it become, “I think there is something really wrong” type of joint pain? Is this joint pain caused by an autoimmune disease?

Here are a few typical scenarios.

Scenario #1

Mr. B is a 65-year-old man who presents to clinic with bilateral knee pain. He first noticed the pain a few years ago. He used to take some over-the-counter ibuprofen when it got real bad and that used to relieve the pain. Over the past few months he has noticed worsening. His left knee sometimes swells up. The ibuprofen isn’t really cutting it anymore. He tells me that the pain is worse after particularly active days. When he sits down he feels pretty good but when he stands up, he feels pretty stiff but generally loosens up after a few steps. He used to work construction and played football in college.

Scenario #2

Mrs. M is a 53-year-old woman who comes to the clinic for joint pain. About 3 months ago, she noticed that she was having a lot of difficulty removing her rings. She really didn’t pay much attention to it. She told herself, “I must be eating too much salt”, “I must be getting old”. Over the course of the next few weeks she began developing pain and swelling involving her knuckles. The pain is particularly worse first thing in the morning and sometimes wakes her up in the middle of night at times. She also states, “My hands feel like a claw in the morning”. The stiffness last well over one hour in the morning and typically, by noon she’s as good as she is going to be for the rest of the day. She’s tried ibuprofen, naproxen, and acetaminophen but nothing seems to work. She also remarks that her hot flashes have gone completely out of control recently.

Sounds familiar?

Inflammatory vs. Non-inflammatory joint pain

In scenario #1, we have a man presenting with non-inflammatory joint pain. This is your common wear and tear arthritis or osteoarthritis. It can involve pretty much any joint you can think of. What is important to note, is that it tends to progress slowly over time. The joint pain tends to worsen with increasing activity and it typically responds, although maybe not completely, to over-the-counter anti-inflammatory medications. Usually there is no joint swelling, but when it comes to the knees, swelling often does occur. A phenomenon called “gelling” can also occur with osteoarthritis. This occurs when the joint has been in a resting position for a while and then becomes active. The joint stiffens up or gels, but then loosens up pretty quickly.

In scenario #2, we have a woman presenting with joint pain that develops over the course of 3 months, or what we call a subacute presentation. She’s experiencing joint swelling involving small joints and it’s associated with prolonged morning stiffness. What I mean by prolonged is over one hour. Her symptoms also are worse in the morning. She also experiences constitutional symptoms, i.e., hot flashes. These are all hallmarks of inflammatory joint pain. There are MANY different autoimmune diseases that present with inflammatory joint pain and they all have their own particular flavor. Some like the knuckles, some like the ankles, some like the knees, some have a symmetrical distribution, and some are simply just random. But they all share these specific key characteristics. Rheumatoid arthritis and psoriatic arthritis are two common types. Please follow the links to learn more about these.

Another important note about autoimmune joint pain. It doesn’t go away. This is very important. There are A LOT of different things that can cause a joint to swell, but most of them get better with time. When it doesn’t, then you have to start wondering.

Summary

Why is this important?

So why should you care? Well, first, walking around with swollen joints isn’t exactly the most pleasant thing in the world. It turns out that it isn’t exactly healthy for your joints either. Autoimmune joint disease at times can cause permanent joint damage and it can happen in as little as 3 months.

Early identification and prompt treatment is essential to prevent joint damage.

So if you think that you or someone you know is suffering from autoimmune or inflammatory joint pain, give your local rheumatologist a buzz.

References

Rheumatology Secrets 3^rd edition

Medical Disclaimer

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Diseases and Conditions When to see a rheumatologist

8 important warning signs of scleroderma

November 28, 2016

Scleroderma is an autoimmune disease that can cause fibrosis of skin and internal organs. Early diagnosis is very important. Read on to learn more!

If I had to pick one autoimmune condition, which causes chills to run down one’s spine, I pick scleroderma. The medical name for this condition is systemic sclerosis. In a nutshell, systemic sclerosis is an autoimmune disease which causes inflammation in small blood vessels, which eventually can cause hardening of the skin and other major organs.

I quick Google search of scleroderma will inevitably present you with a horror show of images and stories from sufferers of this condition.

Yes, scleroderma is a terrible disease, but it’s also a terribly heterogeneous disease meaning that no two cases of scleroderma are the same. There are mild cases and there are life-threatening cases.

Identification of early disease is probably one of the most important determinants of prognosis. Well actually, it’s a little more complicated than that, but it is the one aspect that you can control: The knowledge to know when to ask.

Types of Scleroderma

This is how rheumatologists breakdown scleroderma:

Basically, systemic sclerosis is when the disease affects the skin and internal organs and localized scleroderma is when it only involves the skin. A lot of rheumatologists, included yours truly, believe that localized scleroderma and systemic sclerosis are actually two completely different diseases.

I’m going to concentrate on systemic sclerosis going forward.

Now we’re left with scleroderma sine scleroderma, limited systemic sclerosis, and diffuse systemic sclerosis. Scleroderma sine scleroderma is systemic sclerosis involving the organs but not involving the skin. This is super rare.

People that have limited systemic sclerosis have hardening of the skin that does not go past the elbows or knees. They also tend to NOT have kidney involvement or inflammation of the lungs. The disease course usually is insidious and sometimes is very difficult to detect, particularly during a 15 minute doctor’s appointment.

The last type is called diffuse systemic sclerosis. It’s important to detect REALLY fast because it can progress quickly, because it can be deadly, and people simply do better when they’re treated early. People suffering from this type of scleroderma can have whole body hardening and are more prone to develop lung inflammation and kidney involvement.

Raynaud’s phenomenon

Almost everyone with any form of systemic sclerosis has something called Raynaud’s and esophageal reflux. They also tend to appear early during the disease process, so these two symptoms are important to watch out for.

They say a picture is worth a thousand words. Here’s an example of Raynaud’s… not the most dramatic example but that’s kind of the point.

Raynaud’s can involve your fingers and your toes. Exposure to cold can cause it as well as a rapid change in temperature, and stress. Raynaud’s is very common in women and for the most part is annoying but nothing serious. The picture above is actually my hand. This has been going on since my teens. Let me tell you, I grew up in Canada. Shoveling snow was kind of brutal.

About 15% of women have primary Raynaud’s (i.e., Raynaud’s without any underlying autoimmune condition). Primary Raynaud’s typically first appears during one’s teens or early adulthood. People with scleroderma tend to develop it later in life and the intensity is A LOT more severe. Sometimes the skin can become so ischemic (poor circulation) that it can cause an ulcer. I have a lot of patients whom I’ve diagnosed with systemic sclerosis that told me that they thought that they had purple fingers because they were getting old… This is NOT part of the normal aging process.

Onset of Raynaud’s at a later stage in life.
Raynaud’s complicated by ulcers.

Heartburn

Another symptom found in almost all people suffering from systemic sclerosis is heartburn. This can present as chest pain, burning pain up your esophagus, nighttime cough, an acid taste in your mouth in the morning. Sometimes people may have difficulty swallowing food and water. Now, a lot of people have heartburn. Just because you have heartburn, does not mean you have scleroderma. You have to look at the entire picture.

Heartburn
Difficulty swallowing

Other common symptoms

Here is a list of other symptoms to watch out for:

Puffy fingers, VERY high yield symptom
Red spots all over your face, chest, and/or palms
Hardening of the skin
Shortness of breath with exercise

Conclusion

There are a lot more symptoms that I haven’t gone over. But sometimes less is more. If you can remember these 8 warning signs, you have a really good chance of detecting early disease on your own, and maybe even save your life or the life of a loved one. Having more than one of these symptoms should prompt you to consult a rheumatologist for further evaluation and testing.

For more information, I highly urge you to visit the Scleroderma Foundation website. They provide useful information about scleroderma for both the newly diagnosed and those that have had the disease for a long time. They’re also involved research and patient advocacy. Needless to say, I highly recommend them!

If you want to learn more about Raynaud’s phenomenon and ways how to treat it, read on.

References

Rheumatology Secrets 3^rd edition

van den Hoogen F, et al. 2013 classification criteria for systemic sclerosis: an American college of rheumatology/European league against rheumatism collaborative initiative. Ann Rheum Dis. 2013 Nov;72(11):1747-55.

Minier T, et al. Preliminary analysis of the very early diagnosis of systemic sclerosis (VEDOSS) EUSTAR multicenter study: evidence for puffy fingers as a pivotal sign for suspicion of systemic sclerosis. Ann Rheum Dis. 2014 Dec;73(12):2087-93.

Scleroderma Foundation: http://www.scleroderma.org/site/PageServer#.WTC56WjytPY

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