Complete blood count with Differential (CBC with DIFF): Lymphocytes

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Lymphocytes are the second most common white cells (20-40%) after neutrophils. They include:
T-cells
B-cells
Natural killer Cells

Lymphocytes are increased in:
– Infections especially viral infections
– Medications
– Autoimmune disease
– Overactive thyroid
– Colitis
– Lymphatic leukemia

Lymphocytes are decreased in:
– Infections
– Medications such as steroids or chemotherapy
– Autoimmune disease
– Lymphoma
– Radiation therapy
– Sarcoidosis

Complete blood count with Differential (CBC with DIFF): Monocytes

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Monocytes are the third most common white cells (<10%).

Monocytes are increased in:
– Infections especially brucellosis, shingles, TB, bacterial endocarditis, Malaria
– Medications such as steroids
– Autoimmune diseases, sarcoidosis,
– Neutropenia
– Colitis
– Leukemia, Lymphoma

Monocytes are decreased in:
– Hairy cell leukemia

Complete blood count with Differential (CBC with DIFF): Eosinophils

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Eosinophils are not as common as the other white cells.

Eosinophils are increased in:
– Allergic conditions such as hay fever, rhinitis, eczema
– Parasitic infections such as trichinosis, Ascariasis
– Fungal infections as in aspergillosis
– Autoimmune diseases such as vasculitis
– Medications such as Aspirin
– Lymphomas such as Hodgkin’s Lymphoma, Leukemia, Mastocytosis
– Immune deficiency
– Colitis
– Adrenal Insufficiency

Eosinophils are decreased in:
– Cushing Syndrome
– Medications such as steroids
– Stress
– Alcohol

Shoulder Pain

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Shoulder is a complicated joint as it involves three bones and four articulations. It is also not a usual place for arthritis and therefore cause of shoulder pain requires prompt investigation. 

Shoulder pain can be either inflammatory or it could be structural. Shoulder inflammation often causes pain at night and is better with activity during the day. These include: 
Polymyalgia Rheumatica 
Rheumatoid Arthritis 
Seronegative Arthritis 

Structural shoulder problems on the other hand cause pain mostly during the day and also at night. These include: 
Bursitis 
Tendonitis 
Rotator Cuff tear 
Shoulder impingement 
Frozen shoulder 
Osteoarthritis
Scapulothoracic syndrome
Neck pain radiating into the shoulder

Evaluation usually involves
– physical examination
– X-rays
– MRI exam
– Local injection with Marcaine to determine the cause of pain in selected cases

Treatment depends on the specific cause and can range from exercise to medication and at time surgery.
– Polymyalgia Rheumatica: Diagnosed by a short trial of steroids. It is treated by Methotrexate or long term low dose prednisone with gradual taper.
– Rheumatoid Arthritis: Diagnosed by a short trial of steroids as well. It is treated by Methotrexate as well as other drugs listed.
– Seronegative Arthritis. These may not respond to steroids. They would usually do respond to NSAIDs.

Structural shoulder problems on the other hand cause pain mostly during the day and also at night. These include:
– Bursitis
– Tendonitis
– Rotator Cuff tear
– Shoulder impingement
– Frozen shoulder
– Osteoarthritis
– Scapulothoracic syndrome
– Neck pain radiating into the shoulder

Temporomandibular problems or TMJ

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1. TMJ problems are not uncommon. The first step here, once you rule out obvious causes, is to see a general dentist and not an oral surgeon. If the general dentist indicate that this is not a dental issue, then I will proceed with further evaluation.

2. MRI I believe is the best imaging modality to look at TMJ. X-rays may show arthritis or dental issues but MRI will give you the best detail.

3. TMJ problems often can be solved once the cause is identified and treated. Treatment include self care activities such as eating soft food, avoiding chewing gum, exercise, relaxation, use of splint, and medications. I have not found physical therapy to be helpful with treatment of TMJ.

4. Surgery should be avoided if possible. Always ask for MRI first especially if surgery is being considered. No one I believe should be operated on without having an MRI first. Also, find another independent oral surgeon yourself in another town or preferably at a university setting to get a second opinion if surgery is being considered.

5. If still not sure, see a rheumatologist who can do the work-up for you and make a proper referral if needed.

Lyme disease

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Points to consider when you are dealing with Lyme disease:

1. Prevention is very important including using insecticide (acaricides) in the endemic areas, using protective clothing, tick repellent, checking for ticks and taking a shower within two hours of being in the tick habitat.

2. It would take two weeks for Lyme IgM to become positive after development of erythema migrans and two to six weeks for IgG to become positive. With early treatment these test may never turn positive. Also these antibodies may remain positive for a long time despite successful treatment of Lyme disease and resolution of all of the presenting symptoms.

3. False positive Lyme testing can occur in 5% of the normal population with more false positivity seen with IgM than IgG. Western Blot should help as to rule out these as well as other false positive results caused by cross reacting antibodies.

4. PCR can help but it has both false positive and false negative results. PCR can not tell if there is active infection as it measures only the DNA of either live or dead spirochetes.

5. Urine antigen testing for Lyme and PCR of urine are useless.

6. The C6 testing that measures IgG to VlsE (Variable major protein-like sequence-expressed) sixth invariant region can be helpful along with traditional testing by increasing both sensitivity and specificity of these tests with IgG antibodies developing very early (within one week) in the disease process. This test is FDA approved but not endorsed by CDC. C6 testing also can detect both American and European species while the ELISA and Western Blot are optimized for the American species mostly.

7. Reinfection can also occur. This can be diagnosed with presence of new rash of erythema migrans. Repeating Lyme titers are not always helpful as previous titers from earlier infections may remain for a long time.

8. Recommendations for treatment of Lyme disease are outlined here by the Infectious Disease Society of America: Treatment Recommendations and Antibiotic Therapy.

Arthritis, and Rheumatic Diseases

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Regional problems

Temporomandibular joint disorders
Shoulder pain
Elbow pain
Wrist pain
Hand pain
Neck pain
Mid-Back pain
Back pain
Hip pain
Knee pain
Ankle pain
Foot pain
Fibromyalgia
Chronic Fatigue Syndrome
Reflex Sympathetic Dystrophy (RSD)
Neuropathy

Spondyloarthritis
Psoriatic arthritis
Colitis associated arthritis
Ankylosing Spondylitis
Reactive arthritis (Reiter’s Syndrome)

Infections and Arthritis
Viral Arthritis
Lyme disease
Rheumatic fever
Bacterial arthritis
Fungal arthritis
Gonococcal arthritis
Tuberculosis arthritis
Osteomyelitis

Bone diseases
Osteoporosis
Osteomalacia
Paget’s disease
Osteopetrosis
Osteogenesis Imperfecta
Ehlers-Danlos Syndrome
Parathyroid disorders
Osteonecrosis
Osteochondritis
Marfan Syndrome
Hypermobility

Crystal Induced Arthritis
Gout
Pseudo gout
Crystal arthritis

Systemic Diseases
Rheumatoid arthritis
Seronegative Arthritis
Palindromic Rheumatism
Sjögren’s syndrome
Undifferentiated connective tissue disease
Mixed connective tissue disease
Systemic Lupus
Drug Induced Lupus
Scleroderma (Systemic Sclerosis)
CREST Syndrome
Eosinophilic fasciitis
Adult-onset Still’s Disease
Anti phospholipid antibody syndrome

Vasculitis
Temporal arteritis
Polymyalgia Rheumatica
Takayasu’s arteritis
Polyarteritis Nodosa
Wegener’s granulomatosis
ANCA associated vasculitis
Microscopic polyangiitis
Allergic angiitis
Churg-Strauss syndrome
Henoch-Schönlein purpura
Urticarial Vaculitis
Leukocytoclastic Vasculitis
Cryoglobulinemia

Inflammatory Muscle Diseases
Polymyositis
Dermatomyositis
Inclusion-body myositis
Drug induced myopathy
Infectious myositis

Rheumatic diseases
Relapsing Polychondritis
Behçet’s Syndrome
Amyloidosis
Whipple’s disease
Sarcoidosis
Diabetic arthropathy
Immunodeficiency syndromes
Raynaud’s phenomenon

Pediatric Rheumatic Diseases
Juvenile Idiopathic Arthritis
Juvenile Spondyloarthritis
Juvenile connective tissue diseases
Dermatomyositis
Vasculitis
Scleroderma

Anti-Rheumatic Medications

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
Aspirin (Ecotrin, Salicylic Acid) Bufferin
Celecoxib (Celebrex)
Diclofenac (Voltaren, Cataflam, Voltaren-XR)
Diflunisal (Dolobid)
Etodolac (Lodine)
Fenoprofen (Fenopron, Nalfron)
Flurbiprofen (Ansaid)
Ibuprofen (Advil, Motrin)
Indomethacin (Indocin)
Ketoprofen (Orudis, Oruvail)
Ketorolac (Toradol)
Meclofenamic acid (Meclomen)
Mefenamic acid (Ponstel)
Meloxicam (Mobic)
Nabumetone (Relafen)
Naproxen (Aleve, Anaprox, Naprosyn, Naprelan)
Oxaporozin (Daypro)
Piroxicam (Feldene)
Salsalate (Salflex, Disalcid, Trilisate)
Sulindac (Clinoril)

Steroids
Prednisone
Methylprednisolone
Hydrocortisone
Solumedrol
Celestone
Kenalog
Decadron
Aristospan
Depomedrol

Disease Modifying Drugs (DMARDs)
abatacept
adalimumab
azathioprine
Certolizumab pegol
chloroquine
Cyclosporin
Cyclophosphamide
D-penicillamine
etanercept
golimumab
gold salts
hydroxychloroquine
infliximab
leflunomide
methotrexate
minocycline
rituximab
sulfasalazine
Tocilizumab
Tofacitinib
Ustekinumab

Hypouricemic Drugs
Allopurinol
Colchicine
Uloric
Probenecid
Sulfinpyrazone

Osteoporosis Drugs
alendronate
risedronate
ibandronate
Pamidronate
zoledronic acid
raloxifene
denosumab
teriparatide

Rheumatology in pictures
Sternoclavicular joint swelling

Hydroxychloroquine (Plaquenil)

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This is an anti-malarial drug that is used primarily to treat:
– Systemic Lupus
Rheumatoid Arthritis

Hydroxychloroquine (Plaquenil) is started at 6.5 mg/kg of the ideal body weight to no more than 400 mg per day. The usual doses are between 200 to 400 mg daily either once a day or twice daily. The dose should be reduced in liver and kidney disease.

Eye exams are required in patients starting Plaquenil. Patient should have eye examination before starting Plaquenil and then every six to twelve months for as long as taking this treatment.

This treatment is generally well-tolerated. Half life of this drug is 32-50 days. This treatment should be stopped if not effective after six months. Toxicity does increase after five years and it is rare before that. Therefore I usually reduce the dose to 200 mg daily as condition becomes stable and as tolerated. I have even reduced the dose to 2-3 times per week in many patients.

The use in pregnancy is classified as category C where one need to look at risks and benefits in each individual case. It is found in breast milk but amount is very small.

Precautions should be taken in patients with Psoriasis and Porphyria as it may exacerbate these conditions. G6PD deficiency may result in renal failure and hemolysis.

7. Presence of liver disease, kidney disease, obesity, and being older than 70 years of age all increase risk of Plaquenil toxicity. More information here.

Rheumatoid Arthritis

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Description:
This is an inflammatory arthritis involving upper and lower extremity joints.

Presentation:
– Pain
– Stiffness
– Swelling in multiple joints including hands, wrists, elbow, shoulders, hips, knees, ankles, and feet
– Night pain
– Morning as well as rest stiffness
– Fatigue
– Insomnia because of pain

Evaluation:
– History and physical examination
– Tests are then ordered for confirmation of the diagnosis.

Testing:
– Blood tests: Rheumatoid Factor, Anti-CCP, ANA, HLA-B27, Lyme titers, ESR, CRP, Hepatitis C Antibody
– X-rays: Hands, wrists, ankles, feet and other involved joints

Diagnosis: This is based on the following criteria listed below:
– Type and number of joints involved
– Positive Rheumatoid factor or Anti-CCP
– Elevated CRP or ESR
– Duration of joint involvement more or less than six weeks
– The criteria might be fulfilled over time

Treatment:
– Sulfasalazine. I do not use this a whole lot and when I do it is mostly along with Plaquinel and Methotrexate in combination. I use a lot more of Sulfasalazine overseas along with Plaquinel, Methotrexate, and low dose prednisone 5 mg daily for lack of better or cheaper treatment.
– Plaquinel. This can be effective by itself in mild cases and in combination with moderate involvement. I have seen studies claiming the combination therapy of Plaquinel, Methotrexate, and Sulfasalazine work as good as biologic therapy. But in real life patients, I have not seen this to be true. I have seen heavy use of these drug combination along with Prednisone 5 mg daily overseas. Unfortunately, this only works for a number of years and most of these patients end up with severe deformity, terrible osteoporosis, obesity, diabetes, very difficlut ending and I can even say that their life span is shortened by at least 10 if not 20 years.
– Methotrexate. This is the first treatment I use in most patients with moderate to severe disease. It often requires use of biologic in combination to achieve desired effect.
– Arava. This I use if Methotrexate is not effective by itself or I use it in combination with Low dose Methotrexate or Humira.
– Enbrel. This works very well and brings this terrible disease under excellent control especially along with Methotrexate.
– Humira. This is also an excellent choice along with Methotrexate as well. Humira has the advantage of treating Psoriasis and colitis as well as uveitis over the Enbrel.
– Remicade. This works very well with Methotrexate especially in medicare patients who can not afford the self injectables such as Humira. I also use this as a first choice in severe cases when you need rapid control of the rheumatoid arthritis. It is also very useful when Enbrel or Humira are only partially effective.
– Simponi. This is also an excellent choice but most insurances do not want to cover it and they all insist that the patient be on Methotrexate at the same time.
– Cimzia. This can be very effective but being a late comer, it has not gotten the attention it deserves.
– Orencia. This can also be a great choice. I do not see many infections with Orencia but this could be because I do not use it as much as Enbrel and Humira.
– Xeljanz. My initial use of this drug was disappointing as I was using it in those who have failed previous DMARDs listed above. But using it as a first line drug along with Methotrexate has been very promising with rapid and excellent results.
– Rituxan. This is undoubtedly the best treatment for Rheumatoid Arthritis. It takes time to work but once it starts working, it does very well. I have seen the benefits last for as long as 2 1/2 years after one or two treatments. This also help one distinguish the true
– Actemra. This I believe is a very good drug but it is a late comer. It was also mismanaged by the drug company keep emphasizing liver enzyme elevation with this drug early with its release. I yet to see any problem with this drug. It does need a more closer monitoring because of potential for interactions with other drugs. I believe I will be using more of this drug in the future.

Lupus and Pregnancy outcome

Patients with Lupus who become pregnant can be at risk for developing flare-ups during pregnancy. These risks include:
1. Having a positive Lupus anticoagulant test
2. Taking blood pressure medication
3. Being Hispanic or non-White
4. Platelet count

Those patients with above risk factors had a negative pregnancy outcome rate of 58% compared to 7.8% in those without risk factors.