Ankylosing Spondylitis

A 23 year old male patient was presented to the medical ward with one year history of joint pains. He was mainly complaining of large joint involvement. He complained of back pain, shoulder, elbow, hip and knee joint pains, but there was no small joint involvement. The pain was more in the morning and there was significant morning stiffness.  He was having the symptoms for a long period of time hasn't got any regular treatment up until now.

On examination, he had restricted movements of his spine, but there were no joint deformities. Schoeber's test was positive indicating the presence of significant spinal stiffness. Schoeber's test is performed by marking a spot on the back, at the mid line, at the level of iliac crest. Then two points vertically 10 cm above and 5 cm below this point is marked while the patient is standing. The the patient is asked to bend as much as he can and the distance between the two marked point is measured. A reading less than 5 cm implies spinal stiffness. The reading of this particular patient was only 2 cm. The patient also had reduced chest expansion as a result of costochondral junction involvement (normal chest expansion should be at least 5 cm at the nipple level).

With all these findings, the patient is clinically diagnosed to have ankylosing spondylitis. Three out of four of following clinical criteria should be there to diagnose a patient as having ankylosing songilitis. These clinical features are,

1. Morning stiffness lasting more than 30 min. 
2. Improvement of back pain with movements but not with rest.
3. Awakening because of back pain during second half of the night only
4. Alternating buttock pain.

Ankylosing spondylitis, as the name implies, is a inflammatory disorder of the spine. This is mainly seen among young males who are in their late teen or early twenties. Even though both men and women (2.5: 1) can be affected but symptoms are more prominent in men. The disease has a strong association with HLA B27 gene. These patients are also more susceptible to develop iritis also.

Investigations are performed to confirm the diagnosis.

1. ESR - elevated
• The patient's ESR was 112 mm/1st hour
2. CRP (C reactive proteins) - elevated
• The patients CRP level was 24
3. HLA B 27 testing 
4. MRI - shows sacroilitis before it is seen on X rays
5. X rays 
• X ray lumbar spine
• The fusion of vertebra leads to a
  bamboo spine
• X ray sacroiliac joint
• The following radiograph is taken from our patient. There is sclerosis of either sides of the joint with irregular joint space suggestive of sacroilitis, but there is no ankylosis of the sacroiliac joint.

Ankylosing sondylitis - Sacroilitis

Treatment

• Exercising - Exercising plays a major role in preventing the progression of the disease and improving the symptoms.
• NSAIDs - Sometimes, the pain makes it impossible for the patient to carryout exercises. This is where NSAIDs come in to play. An evening dose of slow releasing NSAID, oral or as a suppository will reveal pain and help in carrying out an active lifestyle and improve sleep.
• Methrotexate is helpful if there is peripheral joint involvement, but will not improve spinal disease.
• Sustained and dramatic reduction of inflammation can be achieved by TNF alpha blocking drugs.
• Rituximab does not help in seronegative arthritis.

Prognosis

The prognosis is good with adequate exercises. Fifty percent of the HLA B27 positive patients have the risk of transmitting the gene to their offspring. Thirty percents of these offspring may get the disease eventually. 

Pneumothorax

Case History

A 30 year old, previously well male patient was admitted to the casualty ward with sudden onset of left side chest pain. The pain was severe in the beginning. On admission the patient was complaining of pleuritic type of chest pain. On examination, his respiratory rate was 18 breaths per minute, and saturation was 100% without oxygen. His vocal fremitus and air entry was reduced on left side of the chest. His heart sounds were difficult to auscultate too. The clinical diagnosis of pneumothorax was made and an emergency chest x ray was taken. The chest x ray showed a left sided pneumothorax. The patient was immediately referred to the chest physician who put an intercostal tube to the left side of the chest to take out the air.

Pneumothorax

Air in the pleural space is called pneumothorax. Air can accumulate within the pleural space as a result of injury to the chest wall or as a result of injury to the lungs.

Spontaneous pneumothorax

Spontaneous pneumothorax is commonly seen among young, tall and thin men. This is mainly due to a rupture of a pleural bleb. The male to female ratio of spontaneous pneumothorax is 6:1.

Pneumothorax in a diseased lung

Pneumothorax is common among people with an already diseased lung. Patients with COPD, asthma, carcinoma of the lung, bronchopulmonary fistula etc are at a higher risk of developing pneumothorax. Pneumothorax in such patients should be taken seriously regardless of the size.

The following x ray shows a right sided small pneumothorax in a COPD lung. This lung also shows a band of bronchiectasis in the right upper zone.

Right sided pneumothorax in a COPD lung

Tension Pneumothorax

Sometimes a valve mechanism develops which allows air to fill in the plueral space during inspiration and prevents air from getting out of pleural space during expiration. As a result, each time the patient breaths, the air accumulates within the pleural space and the pressure gradually increases causing the mediustinum to shift to the other side. The patient gradually becomes breathless and tachycardic and can even die unless the pressure is not relieved immediately. This is an emergency and requires immediate aspiration of the air.

Aspiration of pneumothorax

Aspiration of a pneumothorax is performed by first taking informed consent from the patient. Then 2% lidocaine is injected in to the pleural space. Then 3-4 cm of 16 french guage needle is inserted in to the pleural space in the second intercostal space midclavicular line. The cannula is connected to a three way tap and 50 cc syringe. Upto 2.5 liters of air can be aspirated through the syringe.

Treatment of Supraventricular Tachycardia

Tachycardia is defined as heart rate of more than 100 beats per minute. The heart beats as a result of electrical activity that spread throughout the myocardium (heart muscle). This electrical activity normally originates at sinu-atrial node, a focus in right atrium. Tachycardia occurs as result of increased frequency of electrical discharge from the sinu-atrial node (SA node) or from another focus. When this focus in situated in the atrium, it is called supra-ventricular tachycardia. 

Atrial fibrillation, atrial flutter also leads to supraventricular tachycardia. Supraventricular tachycardia can lead to reduced cardiac output and embolisation. When there is tachycardia, the diastolic time reduces. Diastole is the time period where the heart is relaxed. During this period, the atria and ventricles get filled with blood. When there is tachycardia, the amount of blood coming to fill the atria reduces significantly. As a result, the cardiac output reduces. Arrhythmias such as atrial fibrillation creates a turbulent flow. Turbulence results in blood clot formation. These blood clots can shoot in to the systemic circulation and block small blood vessels and give rise to strokes, myocardial infarction etc. Therefore, it is important to treat supraventricular tachycardia.

Medical treatment of supreventricular tachycardia includes several drugs and manures. They can be remembered by the mnemonic ABCDE.

• A - Adenosin

Adenosin is an alpha 1 receptor blocker. It acts on the atrio-ventricular node (AV node). AV node transmits impulses from atrium to the ventricle. When the drug is given intravenously, it blocks excessive impulses passing to the ventricles. As a result the ventricular rate reduces. 

• Beta Blocker

Beta blockers also reduce the heart rate.

• Calcium Channel Blocker

• Digoxin

Digoxin is a cardiac glycoside. It inhibits sodium potasium ATPase pump. As a result the heart rate reduces. It also has a positive inotropic effect (increases myocardial contractility) on the myocardium. Its effect on AV node, prevent excessive impulses passing in to the ventricles. 

• Excitation

Excitation includes manueurs used to stimulate vagal activity. These manuers include carotid massage, sprinkling cold water on to the face etc.

Above medications helps to keep the heart rate down and prevent clot formation. 

Cold and flu symptoms explained

What is Cold?

A viral infection involving the upper respiratory tract is called cold. It is also called rhinopharyngitis, nasopharyngitis and acute coryza. There are over 200 viruses which cause cold. Most of these viruses are rhinoviruses. The symptoms of cold are cough, sore throat, blockage and runny nose, sneezing and fever. Cold is one of the commonest illnesses humans face each year. Everyone gets at lest one attack of cold each year. The symptoms of cold may last seven to ten days.  Even though it is very common, the attacks of cold are self limiting and therefore, does very little harm compared to flu.

What is Flu?

Flu, also known as influenza is an illness caused by influenza viruses. Influenza viruses are a family of RNA viruses called orthomyxoviridae. The symptoms of flu include chills, fever, sore throats, myalgia (muscle pains), severe headache, fatigue, and generalized feeling of ill health.  The word ‘influenza’ may remind you of the recent outbreaks of bird flue and swine flu, which became pandemics.

Cold and Flu Symptoms

Even though the symptoms of flu seem similar to those of cold, flu makes the affected individual severely ill.  The symptoms of cold and flu occur as a result of the immune response against the invading virus. Viruses causing cold and flu enter the body mainly through the air. Some viruses, like rhinoviruses enter the body by direct contact. Once they are entered to the body, they bind to the specific receptors in the cell membranes of the respiratory tract.  The viruses causing cold and mild flu can only bind to the cells in the upper respiratory tract. But, some viruses such as HINI virus bind to lower respiratory tract and therefore, cause more severe diseases such as pneumonia.

After binding to the cell membrane, the virus enter into the cell and start replicating and producing molecules they require. The host cell identifies these viruses as foreign bodies and release inflammatory mediators (cytokines and chemokines). These mediators goes and act on other cells and start an inflammatory process which finally gives rise to the symptoms.

1) Sneezing and Runny Nose

The inflammatory mediators start an inflammatory process within the respiratory epithelium. As a result the edema develops and the cells start secreting mucus. The produced mucus comes out of the nostril. That is what is experienced as runny nose. It also causes irritation of the nerves which starts the sneezing reflex. The impulses are carried to the sneezing center of the brain, which commands the chest muscles, the diaphragm, the abdominal muscles and the muscles of the larynx to contract. This ultimately results in a violent blowing of air out of the nose. The high velocity of the air carries some of the mucus out along with the viruses. The process finally helps to quicken the healing process by reducing the viral load. But, it also creates a route for the virus to find another host.

2) Chills and Fever

The inflammatory mediators released by the cells go and act on the hypothalamus. Hypothalamus is the centre for thermoregulation. These inflammatory mediators increase the temperature set point.  So, the hypothalamus sends signals to the body to produce more heat. Heat is produced by contraction of the muscles. This finally causes fever. In the same way the patient has chills when the hypothalamus is set to a lower temperature.

3) Sore throat

Viral infection itself and breathing through the mouth damage the epithelium of the throat. This starts an inflammatory process in the throat. The patient feels this as sore throat.

4) Cough

As mentioned above, the infection of the respiratory tract starts an inflammatory process. One of the components of the inflammatory process is excess mucus secretion. This excess mucus is passed in to the throat. The mucus irritates the throat mucosa. This triggers the cough reflex. The violent coughing helps to bring the excess mucus out from the lower respiratory tract and expel them out.

5) Enlargement of the LymphNodes

Lymph nodes are the places where most of the lymphocytes lie. These lymphocytes proliferate and produce antibodies to fight against the invading organisms. This process causes the lymphoid tissues to swell.

6) Generalizes feeling of ill health

The inflammatory mediators released during an attack of flu or cold act on almost all the cells in the body. They alter the normal cellular functions. It finally results in generalized body weakness.

How hormone replacement therapy works

Hormone replacement therapy is a method of treatment that involves replacement or substitution of naturally occurring hormones. It is used in instances where there are deficiencies of certain hormones. Examples of commonly used methods of hormone replacement therapy are post menopausal hormone replacement therapy, hormone replacement for transgender gender variant and transsexuals, and androgen replacement therapy. Out of these, post menopausal hormone replacement therapy is the most widely used and well known type of hormone replacement therapy.

Exposed to Radiation? Can you get Leukaemia?

Ionizing radiation is a one of the main aetiological factors of leukaemia. So, if you have exposed to higher amount of radiation, you can get leukaemia. The good news is that everybody who get exposed to radiation does not develop leukaemia. Only a proportion does. It has been found that only a  1 per 60 heavily irradiated patients have developed leukaemia.

What are the ways that you can get exposed to radiation? Who are the people that get exposed to radiation?

There are different kinds of radiation, at different levels in the environment we live. But, all of these radiations are not powerful enough to cause leukaemia in our body. The body should get exposed to a very high amount of radiation to develop leukaemia. There are people who were exposed to full body radiation who did not develop leukaemia. Following are some major ways of getting exposed to radiation.

·         Survivors of nuclear bomb explosions.

·         Patients with ankylosing spondylitis. They are treated with radiation therapy to the spine.

Such people do not develop leukaemia right after. There is a latent period of about 5 years.

Out of the four types of leukaemia, only three are caused by irradiation. They are,

1.      Acute lymphoblastic leukaemia

2.      Acute myeloblastic leukaemia

3.      Chronic myeloid leukaemia

Chronic lymphcytic leukaemia is not caused by irradiation.

How radiation cause leukaemia?

Leukaemia is a cancer of white blood cells. Cancers are abnormally proliferating cells. The white cells in our body, just like many other cells in our body age and die. So, there are cells which proliferate and generate new cells to replace the dead cells. This process occurs in the bone marrow, which is situated within the cavities of the bones. In leukaemia these cells proliferate abnormally, so they produce a lot of cells more than the normal number. This abnormal proliferation is triggered by radiation.

To understand this more clearly you should have a general idea about how the cell proliferation is controlled. The velocity of a division is controlled by the genes, which are present is the nucleus of the cells. When these genetic material gets exposed to radiation, their structure changes. So, the genes that stop cell division becomes defective. This allows the cells to proliferate abnormally.