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.

What happens right before a C-section?

Cesarean section is the surgical procedure designed to deliver the fetus through the abdomen. It is the only way to deliver a baby when it cannot be delivered through the vagina. Anything that prevents vaginal delivery leads to cesarean section. Conditions such as contracted pelvis, large baby, anatomical abnormalities of the birth passage and obstructed labor prevent safe delivery of the fetus vaginally. These abnormalities leave cesarean section as the only hope to deliver the baby safe without damaging the mother as much as possible.

The preparations for the cesarean section are carried out from the moment the obstetrician decides to deliver the baby by a cesarean section. Then the mother is managed accordingly and a date for the C-section will be booked. The preparations for a C-section are started from the day before the surgery. You will be advised to stay without eating anything. The duration should be not less than 6 hours. This is done to keep your stomach empty at the time of the surgery to prevent regurgitation and aspiration of stomach contents. On the night before the C-section, you will be also given some other medications. These medications include an anxiolitic to ease your anxiety and an anti-emtic to prevent vomiting during the surgery. These medications will help you to sleep well at night.  

Usually an elective cesarean section is done in the morning. They will give you another dose of anxiolytic and anti-emetic. Before you are sent to the operation theatre, the doctor will check you to see how you and your baby are doing. He will check everything you need to undergo a surgery is present. For example, the presence of crossed matched blood is checked. C-section is a surgery that can lose a lot of blood. Therefore, blood should be preserved to give to the mother if such thing happens. He will also explain the procedure and answer any questions that you have. Then you will be sent to the operation theatre.

After you arrive to the theatre, the surgery will not be started right away. Still there are some procedures that you will have to undergo just before the surgery. The obstetrician and the anaesthetist will double check your medical records. Then you will be taken to the anaethetic room where you will be given anaesthesia. An intravenous cannula will be inserted and you will be connected to a saline drip. Usually, C-sections are performed under spinal anesthesia. Spinal anesthesia only anesthetizes the body below the waist line. Then you will be taken to the operating theatre. During this whole time you and your baby’s vital signs will be checked to see whether you two are doing fine. Just before the surgery a urinary catheter will be inserted and the perineal area will be shaved. Meanwhile, you will be connected to various machines to monitor your vital signs throughout the procedure.

C-section is a surgical procedure designed to deliver the baby abdominally when it cannot be done through the vagina. Sometimes the procedure is done when the parents specifically request to deliver the baby by a C-section. Like any other medical procedure, C-section also has some complications. Above mentioned pre-operative preparations are carried out thoroughly to minimize these complications. 

Medical conditions that can lead to a reduction in appetite

Reduction of appetite is an important symptom in medical practice. It is paid more attention because it can indicate an underlying serious illness. Most of these illnesses have treatment at their initial stages. Therefore, it is important to identify them before they advance. Any disease can give rise to reduction of appetite, but a significant reduction of appetite is a characteristic feature for some diseases.

Physicians consider several parameters when analyzing reduction of appetite. The duration is one among them. As mentioned earlier, any illness can result in reduction of appetite, but it is considered serious when it becomes significant. If you are having reduction of appetite for weeks or months, it is considered significant. Your physician will also inquire regarding the type of foods that you have reduced appetite for. The amount of food that you take for a meal is also inquired. Through this information, the physician will confirm the presence of reduction of appetite and the extent of the condition. Reduction of appetite and reduction of weight go hand in hand. So, it is important that you keep track of your weight to help the diagnostic process.

There are several illnesses that can give rise to reduction in appetite. Not only physical illnesses but also psychological illnesses can result in loss of appetite. It is a typical symptom of malignancies and tuberculosis. Loss of appetite is a diagnostic criterion for depression as well.

Malignancies

Reduction of appetite, loss of weight, fatigue and lethargy are characteristic features of malignancies. These symptoms are known as constitutional symptoms. The reason for most of these non-specific symptoms including reduction of appetite is the loss of balance between endogenous cytokines and their natural antagonists. 

Reduction of appetite is subjective, but loss of weight can be measured objectively. Therefore, physicians use the amount of weight lost during a certain period of time to quantify the severity of reduction in appetite.

Even though cancers are generally considered to cause loss of appetite, some cancers do not give rise to this characteristic feature. For example esophageal carcinoma is a malignancy with preserved appetite. This feature is also used for the diagnostic process of cancer. For example, both esophageal carcinoma and stomach carcinoma can give rise to difficulty in swallowing, but physicians can differentiate the two by the presence of reduction of appetite. As mentioned earlier, if the patient is having an esophageal cancer, there will be no reduction in appetite. On the other hand, gastric carcinoma is a well known malignancy to cause significant reduction in appetite.

Tuberculosis

Reduction in appetite is a characteristic feature of tuberculosis. Tuberculosis is a common disease in the developing world. The initial symptoms of tuberculosis can be very non specific. Therefore, there should be a high degree of suspicion to diagnose tuberculosis based on these non specific symptoms. Loss of appetite is a common symptom among them. It is usually associated with other constitutional symptoms such as loss of weight, fever, night sweats, etc.

Depression

Not only medical conditions, but also psychological conditions can cause reduction in appetite. Depression is one such psychological disorder. It is one of the diagnostic criteria of depression according to the ICD 10 classification.

Apart from malignancies, tuberculosis and depression there are many other diseases that can give rise to reduction in appetite. Even simple viral fever, cold, gastroenteritis can have reduction of appetite. So, it is an important symptom that can be used to identify many illnesses.