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autoimmune diseases

Diseases and Conditions When to see a rheumatologist

10 Warning signs you could have Sjögren’s syndrome

March 1, 2017
Sjögren's syndrome can cause dry eyes and dry mouth as well as many other symptoms. Read on to learn more!

Today is a most bizarre weather-related day.  It’s warm, like you don’t need a coat warm, and there’s a raging thunderstorm.  Did I mention it’s February in upstate New York?  In honor of this most bizarre day, I’d thought I’d write a few words on a somewhat bizarre and illusive autoimmune disease called Sjögren’s syndrome.

Henrich Sjögren gave Sjögren’s syndrome its name.  He was a Swedish physician who first described the disease in 1933.  Sjögren’s syndrome is a common autoimmune disease that primarily causes dryness.  But it’s a lot more complicated than that because Sjögren’s syndrome can involve almost any organ so can present with a myriad of symptoms.  The symptoms arise from infiltration of lymphocytes into glands and affected organs.  Simply put, Sjögren’s syndrome is on the differential diagnosis in any person who has a positive ANA presenting with unexplained symptoms.

10 Warning signs you may be suffering from Sjögren’s syndrome

The following are some of the common manifestations of Sjögren’s syndrome.  Believe me, there are A LOT more but these are some of the common ones.

  1. Dry eyes
  2. Dry mouth
  3. Swollen cheek(s) i.e., parotid gland enlargement
  4. Profound tiredness
  5. Joint pain, sometimes with swelling
  6. Swollen glands
  7. Numbness, tingling, burning of the skin
  8. Raynaud’s
  9. Shortness of breath with minimal work
  10. Having a child that suffered from congenital heartblock

Dry mouth symptoms

The following are some common symptoms of dry mouth.

  1. Difficulty swallowing dry foods
  2. Inability to talk continuously
  3. Change in taste
  4. Burning sensation
  5. Large dentist bill! – Cavities, cracked teeth, loose fillings
  6. Problems with your dentures
  7. Worsening heartburn
  8. Thrush

As you can see the symptoms are a little all over the place and quite frankly are kind of vague.  Furthermore, many different conditions can mimic some of these symptoms: dehydration, depression, various medications, uncontrolled diabetes, multiple sclerosis, hepatitis C, sarcoidosis, etc etc.  Literally.

Classification criteria

Now it’s important to note that the following classification criteria are used for research purposes, and not necessarily for the day-to-day clinic.  Although they are important, there is such a thing called the art of medicine.

As we all know, not everyone fits into a neat little box.

Recently the American College of Rheumatology and the European League Against Rheumatism came up with a new system to classify Sjögren’s.  Basically, a group of hot-shot Sjögren’s specialists got together, looked at the literature, probably had more than one heated discussion, and came up with the following.

To test positive you need to have a score ≥4.  There are five items but they are weighted differently.

  • 3 Points – Anti-SSA/Ro antibody positivity
  • 3 Points – Focal lymphocytic sialadenitis with a focus score of ≥1 foci/4 mm2
  • 1 Point – Abnormal Ocular Staining Score of ≥5 (or van Bijsterveld score of ≥4)
  • 1 Point – Schirmer’s test result of ≤5 mm/5 mi
  • 1 Point – Unstimulated salivary flow rate of ≤0.1 mL/min, each scoring = 1

The sensitivity of this score is 96% and the specificity is 95%.  The sensitivity tells you how likely you are to detect all cases of Sjögren’s syndrome and the specificity tells you how accurate you are with the diagnosis using these set of diagnostic criteria.  These are pretty good figures.

What does this mean?

As you can see, the diagnosis favors objective findings, NOT symptoms.  This is a huge change from the previous set of diagnostic criteria.  You’ll also note that positive ANA, rheumatoid factor, and positive anti-SSB/La antibody positivity are not included in the new classification criteria.

Now I don’t want people thinking that I think symptoms are unimportant.  They are VERY important.  It’s just that symptoms should prompt a workup looking for objective features of the disease.

Now, try to remember the 10 warning signs.  If you find yourself checking a few of these items, check-in to your local rheumatologist.

References

Rheumatology Secrets 3rd edition

Shiboski CH, et al. 2016 American College of Rheumatology/European League Against Rheumatism classification criteria for primary Sjögren’s syndrome: A consensus and data-driven methodology involving three international patient cohorts.Ann Rheum Dis. 2017 Jan;76(1):9-16.

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Diseases and Conditions

Does acupuncture help neuropathy?

February 8, 2017

Does acupuncture help neuropathy?  Good question.  But before trying to answer that question, why does a rheumatologist care about neuropathy anyways?  Isn’t neuropathy more of a neurology thing?  The answer to that question is yes and no.  If you’ve read a few RheumDoctor articles, you’ve probably realized that rheumatology is not just about joints.  It’s about the immune system, and the immune system affects ALL organs including the nervous system.  That being said, innumerable autoimmune diseases affect nerves including: lupus, rheumatoid arthritis, Sjogren’s syndrome, vasculitis, ankylosing spondylitis/axial spondylitis, scleroderma, myositis, sarcoidosis, etc.  I could go on, but I think you get the point?

So what is neuropathy anyway?

In medical terms, neuropathy, more specifically peripheral neuropathy, occurs when peripheral nerves are malfunctioning for any number of reasons.  Peripheral nerves are those that DO NOT involve the brain or spinal cord.  When it involves multiple nerves, we call it polyneuropathy.  When it involves one nerve, we call it mononeuropathy.

Symptoms that are suggestive of neuropathy include:

  • Numbness
  • Tingling
  • Burning
  • Pain out of proportion to stimulation (e.g., touching intact skin should not cause pain)
  • Weakness
  • Cramping
  • Itching
  • Temperature dysregulation

Some people describe neuropathy as invisible pain.  Someone can be in terrible agonizing pain, but physically they look perfectly normal.

How do you diagnosis neuropathy?

Peripheral neuropathy can be diagnosed clinically, with nerve conduction tests, and with a special type of skin biopsy called an epidermal nerve fiber density test.  Don’t get me wrong, I’m all about history and physical exam, but when it comes to diagnostics, I like to have some hard data supporting my clinical diagnosis.  This is why a suspicion of peripheral neuropathy typically should be supported by either a nerve conduction test and/or a skin biopsy.

Nerve conduction tests are pretty much the go to test when it comes to neuropathy. The doctor measures the conduction of electrical impulses that go down the nerves.  This type of test is good to diagnose problems with large myelinated nerves.  Not so much for small, unmyelinated nerve fibers like the ones found on the skin.  When the doctor suspects the problem is coming from small fibers, a skin biopsy is the way to go.  In very special and unique cases, an actual biopsy of a large nerve may be required.  In the world of rheumatology, this can happen if there is a suspicion for systemic vasculitis.  This includes really rare diseases like Wegener’s (although we don’t it that anymore)¹, Churg-Strauss (we don’t call it that anymore either)², and microscopic polyangiitis.

What causes neuropathy?

The most common diseases in general include diabetes, chemotherapy, carpal tunnel syndrome, Lyme disease, alcohol abuse, vitamin deficiencies, low thyroid, HIV, and hepatitis C infection.  At that point, you start getting into the weird and rare diseases.  This is where rheumatic autoimmune diseases feature.  Unfortunately, despite exhaustive workups, in about one-third of cases, a specific cause is never found.  This is called idiopathic neuropathy.

Treatment of neuropathy

First, treat the underlying disease.  Unfortunately, in most situations this is not enough.  Medications that are often used include: gabapentin, pregabalin, duloxetine, amitriptyline, topiramate, and carbamazepine. In extreme situations, infusions with immunoglobulin are used particularly with demyelinating autoimmune conditions.  When all else has failed, and I mean, ALL else has failed narcotic medications for breakthrough pain be necessary.  Every person and situation is unique, so it’s important to work closely with your physician to figure out the best plan of action.

It’s important to note that all these medications have potentially serious or undesirable side effects.  Increasingly, people are searching for alternatives treatments.  Long a staple of Chinese traditional medicine, there’s recently been an increased interest in using acupuncture to treat neuropathy.

But is there any evidence and is it safe?

Acupuncture for the treatment of peripheral neuropathy: a systematic review and meta-analysis

Researchers recently sought to determine whether acupuncture was safe and efficacious for the treatment of peripheral neuropathy.  They searched multiple medical databases including Medline, AMED, Cochrane, Scopus, CINAHL, and clinitrials.gov looking for studies that matched stringent entry criteria.  About one thousand studies were identified, but only 13 made the cut.

They selected randomized controlled trials studied acupuncture for neuropathy caused by diabetes, Bell’s palsy, carpal tunnel syndrome, HIV, and idiopathic conditions.  What they found was that acupuncture generally was effective for diabetic neuropathy, Bell’s palsy, and carpal tunnel syndrome.  In these cases, they even found improvement in nerve conduction study parameters in both sensory and motor nerves.  More data was necessary to determine whether acupuncture was effective in cases of HIV-associated neuropathy but there was a positive trend.  With regards to idiopathic neuropathy, there was insufficient evidence.  Then again, there were hardly any trials that looked into this type of neuropathy.

Does this mean that everyone with diabetic neuropathy should start acupuncture ASAP?  Hold your horses.  The researchers also noted that there was A LOT of variability between studies and A LOT of bias.  Evidence-based medicine is all about comparing oranges with oranges and apples with apples in an unbiased way.  If these conditions are not met, then it really becomes difficult to determine what caused what.

The following are some of the problems that the researchers identified.

Methodological problems with standardization

  • Point selection
  • Number of needles used
  • Needle retention time
  • Needling depth
  • Needle manipulation
  • Use of moxibustion
  • Use of electroacupuncture vs. manual acupuncture

Methodological problems with sample size

  • Only two of the studies stated sample size
  • Many trials were likely underpowered (You cannot make generalizations from a small group of people)

Methodological problems with improper control and blinding

  • In many cases researchers were not blinded
  • In many cases participants were not blinded

Methodological problems with outcome measures

  • Most trials assessed improvement with subjective measures of improvement instead of hard evidence.
  • Only 4 out of 13 trials actually did nerve conduction tests before and after, to see whether anything changed.

On the up side, acupuncture was found to be safe.  Serious side effects only occurred in people suffering from HIV-associated neuropathy.  Otherwise, acupuncture seems pretty safe.

Conclusion

Basically, the meta-analysis demonstrated that acupuncture is generally safe and that it may help in people suffering from diabetic neuropathy, Bell’s palsy, and carpal tunnel syndrome.  Autoimmune disease-associated neuropathy is a big unknown.  However, these results should be taken with a grain of salt.  Although the meta-analysis in itself used good methodology, the researchers were not working with the studies with the best methodological practices in the world.

This brings me back to my first question.  Does acupuncture help neuropathy?  My answer to that questions is as follows.

As always, think for yourself!  You now have the tools to make an educated, unbiased, objective, informed decision regarding health.

References

UpToDate

Dimitrova A, Murchison C, Oken B. Acupuncture for the treatment of peripheral neuropathy: a systematic review and meta-analysis. J Altern Complement Med. 2017 Jan 23. doi: 10.1089/acm.2016.0155.

Notes

Wegener’s = granulomatosis with polyangiitis.  And they wonder why people still call it Wegener’s?

Churg-Strauss = eosinophilic granulomatosis with polyangiitis

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Featured Overcoming Inflammation

10 powerful life lessons to help overcome adversity

January 2, 2017

2017 is upon us and is gearing to be very interesting.  It’s going to be a year of change.  Lots of changes.  Whether for the better or for the worse remains to be determined… but I’m NOT going into any politics.  Lol!

We can’t deny that 2016 is over and it’s been a whirlwind both in the world of foreign and domestic affairs.  These events may even have affected your life in some way or another: ridiculous increase in your insurance premiums?  Your insurance company decided to not cover your medications anymore without any real justification? Maybe your health took a turn for the worse?  While we can’t control everything that happens around us, we certainly can look inwards and develop strategies to not only cope with adversity, but overcome and thrive.  Why be a victim when you could be a conqueror?

So far, I’ve been blessed with perfect health.  Living with with a chronic illness is tough.  It can devour you and unfortunately, sometimes it comes to define you.  But it doesn’t need to be that way.

I’d like to share with you a very personal story about the bravest, noblest, most compassionate, and selfless person I have ever met: Paul Feeney.  Maybe you may find some positive inspiration learning from his struggles but I secretly hope you learn most from his struggle.

Back in 2013, after fighting esophageal cancer for just shy of 2 years, my husband Paul passed away.  His passing is not the point of this post, but rather what he has to teach each one of us about adversity, courage, dignity, and the genuine love of life.

Here’s a picture of Paul doing dips at the gym.  Sorry for the poor graphics.  My phone was kind of basic and not that great back then.  But I digress.  That little pack he has around his waist, that’s chemo. More precisely fluorouracil (5-FU), and it’s pumping directly into his veins.  I believe I took this picture during his second or third month of chemotherapy with cisplatin and 5-FU.  This regimen is downright nasty.  He probably felt like shit, pardon my French, but you would never know because he would never let you know.  Some of you may know someone like this.  The eternal stoic.

After he passed away, I had to clean out his office.  In the process, I found treasure.  He never kept a diary, just thousands of random pieces of paper with incredibly insightful messages, intermixed with tax receipts, and to-do lists.  Here is a list of his 10 powerful life lessons.

 

 

Like most people’s fight with cancer, Paul’s was both brutal and bloody for his mind, body, and soul.  Despite all odds, throughout his illness he successfully continued running a business, he continued his Marine Corps exercise regimen x5 days a week, maintained an active social life, and continued being a doting son and husband.  During his struggle, he never let the disease define him.  It was something that he needed to overcome:

I have plans!

But sometimes, no matter how positive you are, no matter how proactive you are, and no matter how much you try, you simply can’t win them all.

The day before he passed, when there really was no hope, his physician walked into his room and told him there was nothing more he could do.  We had exhausted all avenues.  He had maybe two more weeks to live.  Paul calmly stood up, shook his doctor’s hand like a true gentleman and thanked him for everything he had done.

We may not choose to suffer, but we can choose how to face suffering.  Be kind, hold yourself to a higher standard, choose to be happy.  How will you face your Goliath?

Capt. Paul W. Feeney (July 23, 1963 – May 4, 2013)

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Diseases and Conditions When to see a rheumatologist

Signs you may be suffering from autoimmune joint pain

December 5, 2016
Signs you may be suffering from autoimmune joint pain

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

The difference between inflammatory versus non-inflammatory joint pain

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 3rd edition

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.

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