Rheumatology

Arthritis

Arthritis refers to more than 100 rheumatic diseases and conditions that affect joints. These conditions tend to involve pain, aching, stiffness, and swelling in and around one or more joints.
The word “arthritis” means “joint inflammation.” However, inflammation may also affect the tendons and ligaments surrounding the joint. The symptoms can develop gradually or suddenly and may impair a person’s ability to perform everyday tasks.

Types of arthritis

There are more than 100 types of arthritis. Generally, arthritis can be split into the following categories:

Inflammatory arthritis

Inflammation is a normal part of the body’s healing process. It tends to occur as a defence against viruses and bacteria or as a response to injuries such as burns. However, with inflammatory arthritis, inflammation occurs in people for no apparent reason.

Inflammatory arthritis is characterized by damaging inflammation that does not occur as a normal reaction to injury or infection. This type of inflammation is unhelpful and instead causes damage to the affected joints, resulting in pain, stiffness, and swelling.

Inflammatory arthritis can affect several joints, and the inflammation can damage the surface of the joints and also the underlying bone.

Examples of inflammatory arthritis include:

• RA
• reactive arthritis
• ankylosing spondylitis
• psoriatic arthritis
• Degenerative or mechanical arthritis

Degenerative or mechanical arthritis refers to a group of conditions that mainly involve damage to the cartilage that covers the ends of the bones.

The main job of the smooth, slippery cartilage is to help the joints glide and move smoothly. This type of arthritis causes the cartilage to become thinner and rougher.

To compensate for the loss of cartilage and changes in joint function, the body begins to remodel the bone in an attempt to restore stability. This can cause undesirable bony growths to develop, called osteophytes. The joint can become misshapen. This condition is commonly called osteoarthritis.

Osteoarthritis can also result from previous damage to the joint such as a fracture or previous inflammation in the joint.

Connective tissue disease (CTD)

Connective tissues support, bind together, or separate other body tissues and organs. They include tendons, ligaments, and cartilage.

CTD involves joint pain and inflammation. The inflammation may also occur in other tissues, including the skin, muscles, lungs, and kidneys. This can result in various symptoms besides painful joints, and it may require consultation with a number of different specialists.

Examples of CTD include:

• SLE, or lupus
• scleroderma, or systemic sclerosis
• dermatomyositis
• Sjogren’s
• Infectious arthritis

A bacterium, virus, or fungus that enters a joint can sometimes cause inflammation.

Organisms that can infect joints include:

salmonella and shigella, which spread through food poisoning or contamination

chlamydia and gonorrhea, which are sexually transmitted diseases (STDs)

hepatitis C, which is a blood-to-blood infection that may be spread through shared needles or transfusions

A doctor can treat a joint infection with antibiotics or other antimicrobial medication. However, the arthritis can sometimes become chronic, and joint damage may be irreversible if the infection has persisted for some time.

Metabolic arthritis

Uric acid is a chemical created when the body breaks down substances called purines. Purines are found in human cells and several foods.

Most uric acid dissolves in blood and travels to the kidneys. From there, it passes out of the body in urine. Some people have high uric acid levels because they either naturally produce more than they need or their body cannot clear the uric acid quickly enough.

Uric acid builds up and accumulates in some people and forms needle-like crystals in the joint, resulting in sudden spikes of extreme joint pain or a gout attack.

Gout can either come and go in episodes or become chronic if uric acid levels are not reduced.

It commonly affects a single joint or a small number of joints, such as the big toe and hands. It usually affects the extremities. One theory is that uric acid crystals form in cooler joints, away from the main warmth of the body.

Some of the more common types of arthritis are discussed below.

Childhood arthritis

This can refer to a number of types of arthritis. Juvenile idiopathic arthritis (JIA), also known as juvenile rheumatoid arthritis (JRA), is the most common type.

Arthritis in childhood can cause permanent damage to joints, and there is no cure. However, remission is possible, during which time the disease remains inactive.

It may be due to immune system problems.

Septic arthritis

Septic arthritis is a joint inflammation that results from a bacterial or fungal infection. It commonly affects the knee and hip. It typically affects 2-6 people per 100,000.

It may develop when bacteria or other disease-causing microorganisms spread through the blood to a joint, or when the joint is directly infected with a microorganism through injury or surgery.

Bacteria such as Staphylococcus, Streptococcus, or Neisseria gonorrhoeae cause most cases of acute septic arthritis. Organisms such as Mycobacterium tuberculosis and Candida albicans cause chronic septic arthritis. This is less common than acute septic arthritis.

The following conditions increase the risk of developing septic arthritis:

• existing joint disease or damage
• artificial joint implants
• bacterial infection elsewhere in the body
• presence of bacteria in the blood
• chronic illness or disease (such as diabetes, RA, and sickle cell disease)
• intravenous (IV) or injection drug use
• medications that suppress the immune system
• recent joint injury
• recent joint arthroscopy or other surgery
• conditions such as HIV, that weaken immunity
• diabetes
• older age

Septic arthritis is a rheumatologic emergency as it can lead to rapid joint destruction. It can be fatal.

Symptoms of arthritis

The symptoms of arthritis that appear and how they appear vary widely, depending on the type.

They can develop gradually or suddenly. As arthritis is most often a chronic disease, symptoms may come and go, or persist over time.

However, anyone who experiences any of the following four key warning signs should see a doctor.

• Pain: Pain from arthritis can be constant, or it may come and go. It may affect only one part or be felt in many parts of the body.
• Swelling: In some types of arthritis, the skin over the affected joint becomes red and swollen and feels warm to the touch.
• Stiffness: Stiffness is a typical symptom. With some types, this is most likely upon waking up in the morning, after sitting at a desk, or after sitting in a car for a long time. With other types, stiffness may occur after exercise, or it may be persistent.
• Difficulty moving a joint: If moving a joint or getting up from a chair is hard or painful, this could indicate arthritis or another joint problem.
• In addition to these general signs, certain types of arthritis may cause their own unique symptoms. For example, Juvenile RA can cause eye problems, including uveitis, iridocyclitis, or iritis.
• Septic arthritis often causes fever and intense joint pain. It can become an emergency if it progresses to sepsis.

Causes of arthritis

There is no single cause of all types of arthritis. The cause or causes vary according to the type or form of arthritis.

Possible causes may include:

• an injury, which can lead to degenerative arthritis
• an abnormal metabolism, which can cause gout and calcium pyrophosphate deposition disease (CPPD)
• a genetic inheritance, which can lead to developing osteoarthritis
• an infection such as Lyme disease, which can trigger arthritis symptoms
• an immune system dysfunction, such as the type that causes RA and lupus
• Most types of arthritis are linked to a combination of factors. However, some have no obvious cause and appear to be unpredictable in their emergence.

Treatment of arthritis

Treatment for arthritis aims to control pain, minimize joint damage, and improve or maintain function and quality of life. A range of medications and lifestyle strategies can help achieve this and protect joints from further damage.

The exact treatment depends on the type of arthritis a person develops. It may involve:

• Medication

Medications will depend on the type of arthritis. Commonly used drugs include:

Analgesics: These reduce pain. However, they have no effect on inflammation. Examples include acetaminophen (Tylenol) and tramadol (Ultram).

Nonsteroidal anti-inflammatory drugs (NSAIDs): These reduce both pain and inflammation. NSAIDs include available to purchase over-the-counter or online, including ibuprofen (Advil, Motrin IB) and naproxen sodium (Aleve). Some NSAIDs are available as creams, gels, or patches, which can be applied to specific joints.

Counterirritants: Some creams and ointments contain menthol or capsaicin, the ingredient that makes hot peppers spicy. Rubbing these on the skin over a painful joint can modulate pain signals from the joint and lessen pain.

Disease-modifying antirheumatic drugs (DMARDs): These are used to treat RA. DMARDs slow or stop the immune system from attacking the joints. Examples include methotrexate (Trexall) and hydroxychloroquine (Plaquenil).

Biologics: These are genetically engineered drugs that target various protein molecules involved in the immune response. Examples include etanercept (Enbrel) and infliximab (Remicade).

Corticosteroids: prednisone and cortisone reduce inflammation and suppress the immune system.

Natural remedies

A healthful, balanced diet, along with appropriate exercise and avoidance of smoking and drinking too much alcohol can help people with arthritis maintain their overall health and reduce symptom severity.

• Diet

Eating some types of food may help reduce inflammation.

The following foods, found in a Mediterranean diet, can provide many nutrients that are good for joint health and can help relieve joint inflammation.

• fish
• nuts and seeds
• fruits and vegetables
• beans
• olive oil
• whole grains

On the other hand, people living with arthritis should avoid or limit eating processed foods, foods that contain added sugar, and refined carbohydrates. These foods may actually make arthritis inflammation worse.

• Physical therapy and exercise

Doctors will often recommend a course of physical therapy to help patients with arthritis overcome some of the challenges and to reduce limitations on mobility.

Forms of physical therapy that may be recommended include:

Physical therapy: specific exercises tailored to the condition and individual needs, sometimes combined with pain-relieving treatments such as ice or hot packs and massage

Occupational therapy: practical advice on managing everyday tasks, choosing specialized aids and equipment, protecting the joints from further damage, and managing fatigue

In addition, although individuals with arthritis may experience short-term increases in pain when first beginning exercise, continued physical activity can effectively reduce long-term symptoms.

People with arthritis can participate in joint-friendly physical activity on their own or with friends. As many people with arthritis have other conditions, such as heart disease, it is important to choose appropriate activities.

Joint-friendly physical activities that are appropriate for adults with arthritis and heart disease include:

• walking
• swimming
• cycling

A healthcare professional can help you find ways to live a healthful lifestyle and have a better quality of life.

Surgery

Depending on the type of arthritis a person has, different surgical treatments on the affected joints may be necessary. It may depend on the degree of a person’s symptoms and whether other treatments have been successful.

Surgery options for arthritis include:

• synovectomy
• total joint replacement (TJR)
• osteotomy
• joint fusion

What is systemic lupus erythematosus?

The immune system normally fights off dangerous infections and bacteria to keep the body healthy. An autoimmune disease occurs when the immune system attacks the body because it confuses it for something foreign. There are many autoimmune diseases, including systemic lupus erythematosus (SLE).

The term lupus has been used to identify a number of immune diseases that have similar clinical presentations and laboratory features, but SLE is the most common type of lupus. People are often referring to SLE when they say lupus.

SLE is a chronic disease that can have phases of worsening symptoms that alternate with periods of mild symptoms. Most people with SLE are able to live a normal life with treatment.

According to the Lupus Foundation of America, at least 1.5 million Americans are living with diagnosed lupus. The foundation believes that the number of people who actually have the condition is much higher and that many cases go undiagnosed.

Symptoms of SLE

Symptoms can vary and can change over time. Common symptoms include:

• severe fatigue
• joint pain
• joint swelling
• headaches
• a rash on the cheeks and nose, which is called a “butterfly rash”
• hair loss
• anemia
• blood-clotting problems
• fingers turning white or blue and tingling when cold, which is known as Raynaud’s phenomenon
• Other symptoms depend on the part of the body the disease is attacking, such as the digestive tract, the heart, or the skin.

Lupus symptoms are also symptoms of many other diseases, which makes diagnosis tricky. If you have any of these symptoms, see your doctor. Your doctor can run tests to gather the information needed to make an accurate diagnosis.

Causes of SLE

The exact cause of SLE isn’t known, but several factors have been associated with the disease.

• Genetics

The disease isn’t linked to a certain gene, but people with lupus often have family members with other autoimmune conditions.

• Environment

Environmental triggers can include:

• ultraviolet rays
• certain medications
• viruses
• physical or emotional stress
• trauma
• Sex and hormones

SLE affects women more than men. Women also may experience more severe symptoms during pregnancy and with their menstrual periods. Both of these observations have led some medical professionals to believe that the female hormone estrogen may play a role in causing SLE. However, more research is still needed to prove this theory.

How is SLE diagnosed?

Your doctor will do a physical exam to check for typical signs and symptoms of lupus, including:

• sun sensitivity rashes, such as a malar or butterfly rash
• mucous membrane ulcers, which may occur in the mouth or nose
• arthritis, which is swelling or tenderness of the small joints of the hands, feet, knees, and wrists
• hair loss
• hair thinning
• signs of cardiac or lung involvement, such as murmurs, rubs, or irregular heartbeats
• No one single test is diagnostic for SLE, But screenings that can help your doctor come to an informed diagnosis include:
• blood tests, such as antibody tests and a complete blood count
• a urinalysis
• a chest X-ray
• Your doctor might refer you to a rheumatologist, which is a doctor who specializes in treating joint and soft tissue disorders and autoimmune diseases.

 Treatment for SLE

No cure for SLE exists. The goal of treatment is to ease symptoms. Treatment can vary depending on how severe your symptoms are and which parts of your body SLE affects. The treatments may include:

• anti-inflammatory medications for joint pain and stiffness, such as these options available online
• steroid creams for rashes
• corticosteroids to minimize the immune response
• antimalarial drugs for skin and joint problems
• disease modifying drugs or targeted immune system agents for more severe cases

Talk with your doctor about your diet and lifestyle habits. Your doctor might recommend eating or avoiding certain foods and minimizing stress to reduce the likelihood of triggering symptoms. You might need to have screenings for osteoporosis since steroids can thin your bones. Your doctor may also recommend preventive care, such as immunizations that are safe for people with autoimmune diseases and cardiac screenings,

Long-term complications of SLE

Over time, SLE can damage or cause complications in systems throughout your body. Possible complications may include:

• blood clots and inflammation of blood vessels or vasculitis
• inflammation of the heart, or pericarditis
• a heart attack
• a stroke
• memory changes
• behavioral changes
• seizures
• inflammation of lung tissue and the lining of the lung, or pleuritis
• kidney inflammation
• decreased kidney function
• kidney failure

SLE can have serious negative effects on your body during pregnancy. It can lead to pregnancy complications and even miscarriage. Talk with your doctor about ways to reduce the risk of complications.

What is the outlook for people with SLE?

SLE affects people differently. Treatments are most effective when you start them soon after symptoms develop and when your doctor tailors them to you. It’s important that you make an appointment with your doctor if you develop any symptoms that concern you. If you don’t already have a provider, our Healthline FindCare tool can help you connect to physicians in your area.

Living with a chronic condition can be difficult. Talk to your doctor about support groups in your area. Working with a trained counselor or support group can help you reduce stress, maintain positive mental health, and manage your illness.

Scleroderma

What is scleroderma?

Scleroderma is a chronic, although rare, autoimmune disease in which normal tissue is replaced with dense, thick fibrous tissue. Normally, the immune system helps defend the body against disease and infection. In patients with scleroderma, the immune system triggers other cells to produce too much collagen (a protein). This extra collagen is deposited in the skin and organs, which causes hardening and thickening (similar to the scarring process).

Although it most often affects the skin, scleroderma also can affect many other parts of the body including the gastrointestinal tract, lungs, kidneys, heart, blood vessels, muscles and joints. Scleroderma in its most severe forms can be life-threatening.

Forms of scleroderma

There are 2 major forms of scleroderma, localized and systemic. Systemic scleroderma can be broken down into two main types: diffuse and limited.

• Localized scleroderma

The more common form of the disease, localized scleroderma, affects only a person’s skin, usually in just a few places. It often appears in the form of waxy patches or streaks on the skin, and it is not uncommon for this less severe form to go away or stop progressing without treatment.

• Diffuse scleroderma

As its name implies, this form affects many parts of the body. Not only can it affect the skin, but it also can affect many internal organs, hindering digestive and respiratory functions, and causing kidney failure. Systemic scleroderma can sometimes become serious and life-threatening.

• Limited scleroderma

Also known as CREST syndrome, each letter stands for a feature of the disease:

C alcinosis (abnormal calcium deposits in the skin)

R aynaud’s phenomenon (see the symptoms section)

E sophageal dysmotility (difficulty swallowing)

S clerodactyly (skin tightening on the fingers)

T elangectasias (red spots on the skin)

Patients with limited scleroderma do not experience kidney problems. The skin thickening is restricted to the fingers, hands and forearms, and also sometimes the feet and legs. Digestive involvement is confined mostly to the esophagus. Among later complications, pulmonary hypertension, which can develop in 20% to 30% of cases, can be potentially serious. In pulmonary hypertension, the arteries from the heart to the lungs narrow down and generate high pressure on the right side of the heart, which can ultimately lead to right sided heart failure. Early symptoms of pulmonary hypertension include shortness of breath, chest pain, and fatigue.

How common is scleroderma?

Approximately 250 persons per million American adults are affected by scleroderma. It usually develops between the ages of 35 and 55, although a pediatric form also occurs. Scleroderma is four times more common in women than it is in men.

Causes scleroderma

The exact cause of scleroderma is unknown. Although rarely, scleroderma can run in families. Most cases do not show any family history of the disease. Scleroderma is not contagious.

Symptoms of scleroderma

In addition to the thickening of skin, the following other symptoms may occur in a person with scleroderma:

• Swelling of the hands and feet
• Red spots on the skin (telangectasias)
• Excessive calcium deposition in the skin (calcinosis)
• Joint contractures (rigidity)
• Tight, mask-like facial skin
• Ulcerations on the fingertips and toes
• Pain and stiffness in the joints
• Persistent cough
• Shortness of breath
• Heartburn (acid reflux)
• Difficulty swallowing
• Digestive and gastrointestinal problems
• Constipation
• Weight loss
• Fatigue
• Hair loss

In addition to these symptoms, 2 other conditions—Raynaud’s phenomenon and Sjögren’s syndrome—also affect patients with scleroderma. Approximately 85% to 95% of scleroderma patients experience Raynaud’s phenomenon. However, primary Raynaud’s phenomenon is common and often occurs by itself without any underlying connective tissue disorder. Only 10% of patients with Raynaud’s phenomenon will develop scleroderma.

Sjögren’s syndrome is manifested by dry eyes and mouth. This dryness is due to lack of secretion of tears and saliva as a result of immune damage and destruction of the moisture-producing glands of the body. This condition is named after the Swedish eye doctor, Henrik Sjögren, who first described it. It is seen in approximately 20% of patients with scleroderma.

How is scleroderma diagnosed

The diagnosis of scleroderma is not always easy. Because it can affect other parts of the body — such as the joints — scleroderma may be initially mistaken for rheumatoid arthritis or lupus.

After discussing your personal family medical history, your doctor will perform a thorough physical examination. In doing so, he or she will be looking for any of the symptoms mentioned above, especially thickening or hardening of the skin around the fingers and toes or discoloration of the skin. If scleroderma is suspected, tests will be ordered to confirm the diagnosis, as well as to determine the severity of the disease. These tests may include:

• Blood tests: Elevated levels of immune factors, known as antinuclear antibodies, are found in 95% of patients with scleroderma. Although these antibodies are also present in other autoimmune diseases such as lupus, testing for them in potential scleroderma patients is helpful in assisting with an accurate diagnosis.
• Pulmonary function tests: These tests are done to measure how well the lungs are functioning. If scleroderma is suspected or has been confirmed, it is important to verify whether or not it has spread to the lungs, where it can cause scar tissue formation. An X-ray or computed tomography (CT scan) may be used to check for lung damage.
• Electrocardiogram: Scleroderma can cause scarring of the heart tissue, which can lead to congestive heart failure and defective electrical activity of the heart. This test is performed to see whether the disease has affected the heart.
• Echocardiogram (an ultrasonogram of the heart): This is recommended once every 6 to 12 months to evaluate for complications like pulmonary hypertension and/or congestive heart failure.
• Gastrointestinal tests: Scleroderma can affect the muscles of the esophagus as well as the walls of the intestine. This can cause heartburn and swallowing difficulty, and can also affect the absorption of nutrients and movement of food through the intestine. An endoscopy (the insertion of a small tube with a camera on the end) is sometimes performed to view the esophagus and the intestines, and a test called manometry can measure the strength of the esophageal muscles.
• Kidney function: When scleroderma affects the kidneys, the result can be an increase in blood pressure as well as the leakage of protein into the urine. In its most serious form (called scleroderma renal crisis), a rapid increase in blood pressure may occur, resulting in kidney failure. Kidney function can be assessed through blood tests.

MANAGEMENT AND TREATMENT

How is scleroderma treated?

Currently, there is no cure for scleroderma. Instead, treatment is directed at controlling and managing the symptoms. Because scleroderma can have many symptoms, a combination of approaches is often needed to treat and manage the disease effectively.

• Skin treatments: For localized scleroderma, topical medications often are beneficial. Moisturizers are used to prevent the skin from drying out, as well as to treat hardened skin. To improve blood flow so that sores in the fingers can heal, nitrates such as nitroglycerin are prescribed. Nitrates work by relaxing the smooth muscles, causing the arteries to dilate (widen). Smooth muscles are those that generally form the support blood vessels and some internal organs. Nitrates can have side effects such as dizziness, nausea, rapid heartbeat and blurred vision, so it is important to discuss with your doctor whether or not they may be right for you.
• Digestive remedies: A variety of medications may be prescribed to help patients with heartburn and other digestive difficulties. These include over-the-counter and prescribed antacids, proton pump inhibitors (like Prevacid®, Protonix®, or Nexium®) and H 2 receptor blockers (like Zantac® or Pepcid®). Proton pump inhibitors work by preventing the proton or acid pump in the stomach from allowing stomach acid to be secreted. H 2 receptor blockers work by blocking histamine, a body chemical that promotes the production of acid in the stomach.
• Treatment of lung disease: For patients with scleroderma who have rapidly worsening pulmonary fibrosis (scarring of the lung tissue), the drug cyclophosphamide (Cytoxan®) – a form of chemotherapy – has been proven to be useful in a recent NIH study. This study showed the effectiveness of oral cyclophosphamide in improving lung function and the quality of life in scleroderma patients with interstitial lung disease.
• For pulmonary hypertension, the most successful treatment is continuous intravenous infusion of epoprostenol (Flolan®), a prostaglandin, through a pump. Subcutaneous infusion of treprostinil (Remodulin®) – a related prostaglandin – is an acceptable alternative. Prostaglandins are hormone-like substances found in the body that, among other things, help relax the smooth muscle, and hence dilate blood vessels. Other forms of therapy that are currently FDA approved for pulmonary hypertension include oral bosentan (Tracleer ®), sildenafil (Revatio ®) and inhaled iloprost (Ventavis®).

• Lung transplant is a viable option for both severe (drug refractory) interstitial lung disease and pulmonary hypertension.

• Joint difficulties: For patients with scleroderma who experience joint problems, anti-inflammatory drugs may be prescribed. These drugs work by reducing inflammation and hence the pain and swelling. Physical therapy to prevent joints from contracting can sometimes be helpful.
• Raynaud’s phenomenon: Effective medications include vasodilators like calcium channel blockers (Procardia ® or Norvasc®), nitroglycerine patches/ointment, alpha blockers and sildenafil. Anti-platelet drugs such as aspirin are often added. For ischemic digital ulcers oral agents like sildenafil (Viagra®) or preventive use of bosentan (Tracleer®) can be useful. For fingers with severe ulceration or impending gangrene, hospitalization for a trial of intravenous epoprostenol (Flolan®) or alprostadil is appropriate. Infected ulcers need local wound care and a prolonged course of appropriate antibiotics.
• Sjögren’s syndrome: Although it cannot be cured, the symptoms can be relieved. Dry eyes can be treated with artificial teardrops, and cyclosporine eye drops (Restasis®). Dry mouth can be alleviated by sipping liquids or chewing gum. In more severe cases of dry mouth, drugs that stimulate the production of saliva (Evoxac® or Salagen®) may be prescribed.
• Kidney problems: Depending on the severity of the disease, kidney problems related to scleroderma can be managed and treated using medications (especially Angiotensin Converting Enzyme (ACE) inhibitors) and dialysis.

Management of scleroderma

In addition to taking prescribed medications correctly and regularly, there are many steps a person with scleroderma can take to better manage the disease. These include:

• Exercise

Regular exercise will not only help improve your overall physical and spiritual well-being, but it will also help keep your joints flexible and improve circulation. Consult your doctor or physical therapist for appropriate exercises.

• Joint protection

When your joints hurt, avoid lifting heavy objects or performing chores that may place a strain on them, thus risking further injury. A physical therapist can help you learn new ways to perform daily activities without placing undue strain on your joints.

• Skin protection

Taking proper precautions and care of your skin can be beneficial not only for symptoms of Raynaud’s phenomenon, but also in taking care of the dry, thick patches of skin that result from localized scleroderma. There are many ways to accomplish this, including:

During the colder months, be sure to dress appropriately. Keeping your body warm and protected from the cold weather with boots, a hat, gloves and a scarf will help keep the blood vessels in your extremities open and your circulation flowing.

Wear multiple thin layers. These will keep you warmer than wearing one thick layer.

Wear loose-fitting boots or shoes to keep the blood supply moving to your feet.

Put a humidifier in your house to help keep the air moist.

Use soaps and creams that are designed especially for dry skin.

• Diet

Aside from eating healthy foods to get the proper amounts of vitamins and nutrients, it is important to eat foods that do not aggravate existing stomach problems. Ways to do this include:

Avoiding foods that cause heartburn.

Drinking water or another liquid to soften food further.

Eating high fiber foods to cut down on constipation.

Eating more, smaller meals as opposed to three large meals. This enables the body to digest the food more easily. If you eat a large meal, wait at least four hours before lying down.

Raising the head of your bed about six inches by placing blocks or bricks underneath it. This will prevent stomach acid from entering the esophagus while you are sleeping.

• Dental care

For those patients with scleroderma who also have Sjögren’s syndrome, proper dental care is essential. Sjögren’s syndrome increases the risk of developing cavities and tooth decay.

• Stress management

Because the effects of stress can play a part in reducing your blood flow, as well as affect many other aspects of your emotions and health, it is important to learn to manage or reduce stress. This can be done by taking the following steps:

Getting proper sleep and rest.

Avoiding stressful situations when possible.

Eating a healthy diet.

Learning methods to control anxieties and fears.

• ·        
  Exercising.

Although no cure has been found for scleroderma, the disease is very often slowly progressive and manageable, and people who have it may lead healthy and productive lives. Like many other conditions, education about scleroderma and local support groups can be the greatest tools for managing the disease and reducing the risk of further complications.

What is Sjögren’s syndrome?

Sjögren’s syndrome is a lifelong autoimmune disorder that reduces the amount of moisture produced by glands in the eyes and mouth. It is named for Henrik Sjögren, a Swedish eye doctor who first described the condition. While dry mouth and dry eyes are the primary symptoms, most people who have these problems don’t have Sjögren’s syndrome. Dry mouth is also called xerostomia.

There are two forms of Sjögren’s syndrome:

• Primary Sjögren’s syndrome develops on its own, not because of any other health condition.
• Secondary Sjögren’s syndrome develops in addition to other autoimmune diseases like rheumatoid arthritis, lupus and psoriatic arthritis.

Who might get Sjögren’s syndrome?

An estimated one to four million Americans have Sjögren’s syndrome. The disease affects people of all races, ethnicities and ages. However, women are nine times more likely to develop this condition than men.

What causes Sjögren’s syndrome?

Sjögren’s syndrome is an autoimmune disease, which means something triggers your immune system to attack healthy cells. This attack damages the tear system in your eyes and the salivary glands in your mouth.

Exactly what causes this abnormal immune system response is not clear. These factors may play a role:

• Environmental factors.
•  Genetics.
• Sex hormones (the condition affects more women than men).
• Viral infections.

What are the symptoms of Sjögren’s syndrome?

In addition to extremely dry eyes and mouth, some people experience muscle pain and joint pain all over the body, similar to fibromyalgia. Other symptoms include:

• Abnormal sense of taste.
• Burning or redness in eyes, or grittiness (like sand).
• Blurry vision.
• Difficulty chewing, swallowing or talking.
• Dry cough or hoarseness.
• Dry, itchy skin.
• Enlarged salivary glands.
• Fatigue.
• Tooth decay or early tooth loss.
• Vaginal dryness.

How is Sjögren’s syndrome diagnosed?

If you have dry mouth, dry eyes or other signs of Sjögren’s syndrome, your doctor may use these methods to confirm a diagnosis:

• Blood tests: These tests detect specific antibodies in the blood. They look for anti-nuclear antibodies (ANA), anti-Sjögren’s syndrome antibodies (anti-SSA, also called anti-Ro) and anti-Sjögren’s syndrome type B (anti-SSB, also called anti-La). A blood test can also detect rheumatoid factor, an antibody found in many people who have rheumatoid arthritis.
• Biopsy: Your doctor may remove tissue or cells from a salivary gland or the inside of your lip. This biopsy sample goes to a lab to check for signs of inflammation.
• Eye exam: An eye specialist, such as an ophthalmologist, can measure tear production. During an eye exam, your doctor will examine the cornea, the clear part of the eye, for dryness.
• Imaging tests: These include sialometry, which measures how much saliva you produce by using X-rays that can see dye injected into salivary glands. There is also salivary scintigraphy, a way to track how long it takes for a radioactive isotope to travel from an injection point in your vein to your salivary glands.
• Health history: If you have a pre-existing autoimmune disease, plus dry eyes and dry mouth, your doctor may conclude that you have developed secondary Sjögren’s syndrome.

How is Sjögren’s syndrome managed or treated?

There is no cure for Sjögren’s syndrome, but treatments can relieve symptoms. Depending on your specific issues, your doctor may recommend one or more of these therapies

Treatments for dry eyes:

• Artificial tears: Over-the-counter artificial tear eye solutions and artificial tear eye ointments moisturize dry eyes. These products relieve irritation and discomfort.
• Prescription eye drops: Cyclosporine (Restasis®) and lifitegrast (Xiidra®) prescription eye drops soothe inflamed tear glands and stimulate tear production.
• Punctal plugs: An ophthalmologist inserts tiny silicone plugs into the tear ducts. The plugs block the ducts so tears stay on the eyes, keeping them wet.
• Surgery: If punctal plugs work for you, your doctor may recommend surgery to close the tear ducts permanently.
• Autologous serum drops: Your doctor can make customized artificial tears. The process involves mixing your blood serum (a clear liquid separated from your blood) with a sterile liquid solution. You receive a one-of-a-kind tear substitute unique to your body. While effective, the pricey treatment isn’t always covered by insurance.

Treatments for dry mouth:

• Saliva producers: Products such as gum and hard candies that contain sweeteners like sorbitol or xylitol can stimulate saliva production. You can also use an over-the-counter or prescription saliva substitute. Prescription products include sorbitol oral lozenges and sorbitol oromucosal solutions (solutions that are directed toward the cheeks).
• Prescription medications: Pilocarpine (Salagen®) and cevimeline (Evoxac®) pills increase the natural production of saliva.
• Dental care: A dry mouth increases the risk of dental cavities, infections and tooth decay. Your doctor may recommend a prescription toothpaste and mouthwash, as well as regular fluoride treatments.

Treatments for joint or organ problems:

• Over-the-counter pain relievers: Acetaminophen (Tylenol®) and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Motrin®) and naproxen (Aleve®), can relieve joint pain and muscle aches.
• Anti-rheumatics: Hydroxychloroquine prescription pills can diminish pain from rheumatoid arthritis or lupus. This medication may also reduce salivary gland swelling.
• Immunosuppressants: These prescription medications slow the immune system’s response. They lessen inflammation and prevent organ damage.
• Steroids: Prednisone prescription pills soothe inflammation of the joints, skin and organs.
• Antifungals: These medications treat yeast overgrowth in your mouth (oral thrush) or in your vagina (vaginal yeast infection).

Treatments for vaginal dryness:

• If your vagina is always dry, itchy and sore, you should check with your healthcare provider to make sure that the issue is not something more than hormonal changes. You might have some type of infection or skin issue. These conditions would require specific treatments. In general, though, women with Sjögren’s syndrome are two to three times more likely to have issues with vaginal dryness and atrophy than women of similar ages around and after menopause. Tips for helping with everyday vaginal dryness include:
• Trying vaginal moisturizers or lubricants to add moisture to the vagina daily and to ease sexual intercourse.
• Using unscented soaps for cleansing. Perfumes and other additives can cause irritation.
• Asking your healthcare provider about vaginal estrogen therapy.

What are the complications of Sjögren’s syndrome?

Most people who have Sjögren’s syndrome live their lives without any significant problems. However, a dry mouth means that you are more likely to have dental problems, such as tooth decay and infection. Dry eyes can also place you at risk for eye infections.

If you have secondary Sjögren’s syndrome, you may also have problems like joint paint caused by rheumatoid arthritis or lupus.

Rarely, people with Sjögren’s syndrome develop these complications:

• Abnormal liver or kidney function.
• Lymphomas (cancerous tumors in the lymph nodes).
• Lung problems that may be mistaken for pneumonia.
• Neurological problems that cause weakness or numbness.
• Skin rashes (red skin).

How can I prevent Sjögren’s syndrome?

Because no one knows exactly what causes Sjögren’s syndrome or other autoimmune diseases, there is no known way to prevent it.

Sarcoidosis

Sarcoidosis is an inflammatory disease that affects multiple organs in the body, but mostly the lungs and lymph glands. In people with sarcoidosis, abnormal masses or nodules (called granulomas) consisting of inflamed tissues form in certain organs of the body. These granulomas may alter the normal structure and possibly the function of the affected organ(s).

What Are the Symptoms of Sarcoidosis?

The symptoms of sarcoidosis can vary greatly, depending on which organs are involved. Most patients initially complain of a persistent dry cough, fatigue, and shortness of breath. Other symptoms may include:

• Tender reddish bumps or patches on the skin.
• Red and teary eyes or blurred vision.
• Swollen and painful joints.
• Enlarged and tender lymph glands in the neck, armpits, and groin.
• Enlarged lymph glands in the chest and around the lungs.
• Hoarse voice.
• Pain in the hands, feet, or other bony areas due to the formation of cysts (an abnormal sac-like growth) in bones.
• Kidney stone formation.
• Enlarged liver.
• Development of abnormal or missed heart beats (arrhythmias), inflammation of the covering of the heart (pericarditis), or heart failure.
• Nervous system effects, including hearing loss, meningitis, seizures, or psychiatric disorders (for example, dementia, depression, psychosis).
• In some people, symptoms may begin suddenly and/or severely and subside in a short period of time. Others may have no outward symptoms at all even though organs are affected. Still others may have symptoms that appear slowly and subtly, but which last or recur over a long time span.

Who Gets Sarcoidosis?

Sarcoidosis most often occurs between 20 and 40 years of age, with women being diagnosed more frequently than men. The disease is 10 to 17 times more common in African-Americans than in Caucasians. People of Scandinavian, German, Irish, or Puerto Rican origin are also more prone to the disease. It is estimated that up to four in 10,000 people in the U.S. have sarcoidosis.

What Causes Sarcoidosis?

The exact cause of sarcoidosis is not known. It may be a type of autoimmune disease associated with an abnormal immune response, but what triggers this response is uncertain. How sarcoidosis spreads from one part of the body to another is still being studied.

How Is Sarcoidosis Diagnosed?

• There is no single way to diagnose sarcoidosis, since all the symptoms and laboratory results can occur in other diseases. For this reason, your doctor will carefully review your medical history and examine you to determine if you have sarcoidosis. The main tools your doctor will use to diagnose sarcoidosis include:
• Chest X-rays to look for cloudiness (pulmonary infiltrates) or swollen lymph nodes (lymphadenopathy).
• HRCT scan (high resolution CT) to provide an even more detailed look at the lungs and lymph nodes than provided by a chest X-ray.
• Pulmonary function (breathing) tests to measure how well the lungs are working.
• Bronchoscopy to inspect the bronchial tubes and to extract a biopsy (a small tissue sample) to look for granulomas and to obtain material to rule out infection. Bronchoscopy involves passing a small tube (bronchoscope) down the trachea (windpipe) and into the bronchial tubes (airways) of the lungs.

How Is Sarcoidosis Treated?

There is no cure for sarcoidosis, but the disease may get better on its own over time. Many people with sarcoidosis have mild symptoms and do not require any treatment. Treatment, when it is needed, is given to reduce symptoms and to maintain the proper working order of the affected organs.

Treatments generally fall into two categories — maintenance of good health practices and drug treatment. Good health practices include:

• Getting regular check-ups with your healthcare provider
• Eating a well-balanced diet with a variety of fresh fruits and vegetables
• Drinking enough fluids every day
• Getting six to eight hours of sleep each night
• Exercising regularly and managing your weight
• Quitting smoking
• Drug treatments are used to relieve symptoms and reduce the inflammation of the affected tissues. The oral corticosteroid prednisone is the most commonly used treatment. Fatigue and persistent cough are usually improved with steroid treatment. If steroids are prescribed, you should see your doctor at regular intervals so that they can monitor the disease and the side effects of treatment. Other treatment options include hydroxychloroquine (Plaquenil), methotrexate(Otrexup, Rheumatrex), and other drugs.

What Can Happen As the Disease Progresses?

In many people with sarcoidosis, the disease appears briefly and then disappears without the person even knowing they have the disease. Twenty percent to 30% of people have some permanent lung damage. For a small number of people, sarcoidosis is a chronic condition. In some people, the disease may result in the deterioration of the affected organ. Rarely, sarcoidosis can be fatal. Death usually is the result of complications with the lungs, heart, or brain.

Dermatomyositis

What Is Dermatomyositis?

Dermatomyositis is an autoimmune disorder. It affects the skin and muscle. It also impacts blood vessels. This condition causes muscle weakness and a skin rash. Most people who get it are between the ages of 60 and 80. Twice as many women get it as men.

It’s not a common condition. Fewer than 10 of every 1 million people in the United States have it.

Dermatomyositis. Dermatomyositis is a rare autoimmune disease that is characterized by a distinctive red or purplish rash as well as muscle weakness. It usually shows up where muscles are used to straighten joints like knuckles, elbows, knees, toes or even eyelids. Hard painful lumps can occur, most often in children.

Dermatomyositis Causes

Doctors aren’t exactly sure what causes it. It may come from a gene or be triggered by your environment, or both.

It acts mostly like an autoimmune disorder. That means your body mistakes its own tissues as the enemy and attacks itself. When you have dermatomyositis, your immune system goes after the blood vessels inside your muscles and the connective tissues in your skin.

Dermatomyositis Symptoms

• Changes in your skin and weakness in your muscles are the two main things that show up.
• A dermatomyositis rash is easy to spot. It’s patchy and purple or red in color. It shows up on your eyelids and anywhere you use muscles to straighten joints, including your:
• Knuckles
• Elbows
• Knees
• Toes

This rash is typically the first sign. You may get other rashes, too, which typically are red and show up on your:

• Face
• Neck
• Shoulders
• Upper chest
• Back

Your skin may look like it’s sunburned. It can feel scaly, dry, and rough.

Other things that can happen include:

• Weight loss
• Low-grade fever
• Inflamed lungs
• Sensitivity to light

Sometimes, dermatomyositis causes calcium to build up in hard bumps under your skin or in a muscle. This may show up 1 to 3 years after your first symptoms start. Children are more likely to get calcium deposits than adults.

It also causes muscle weakness that gets worse over time. This happens first to the muscles closest to your center of your body, including those in your hips, thighs, shoulders, upper arms, and neck.

You’re usually weak on both sides of your body. You may also have joint pain, and your muscles may become thinner.

Dermatomyositis Diagnosis

Your doctor has several tools they can use to figure out if you have dermatomyositis, including the following:

• Blood tests. After taking a little bit of your blood with a needle, your doctor will send it to a lab to see if you have high levels of certain enzymes. This can tell them if your muscles are damaged.
• Chest X-ray. This can show whether your lungs are damaged, a possible sign of dermatomyositis.
• Electromyography: This test looks at the electric output of your muscles to see where the weakness is. Your doctor puts a thin needle with an electrical impulse into your muscle, then records how much electric output there is when you tighten and relax.
• Magnetic resonance imaging (MRI): Your doctor will use this to see where your muscles are inflamed.
• Biopsy of your skin or muscle: By removing a small part of your skin and looking at it under a microscope, your doctor can see if you have dermatomyositis. They also can rule out other diseases, like lupus. This test can show whether your muscles are inflamed or damaged.

Dermatomyositis Treatment and Home Remedies

• You can’t cure this condition, but you can treat your skin and muscle symptoms. You may need to see more than one doctor or medical professional, depending on your symptoms. Any of the following specialists might play a part in your care:
• Internist (for general care)
• Rheumatologist (for problems with connective tissues like muscles and joints)
• Immunologist (for immune system problems)
• Physical therapist (to help you regain muscle strength)
• Speech therapist (to help you with speaking or swallowing problems due to muscle weakness)
• Dietitian (for help finding easy-to-eat foods when swallowing is hard)

The most common medications for dermatomyositis include:

• Corticosteroids, such as prednisone. You take these by mouth or through an IV.
• Corticosteroid-sparing agents. These help lower the amount of corticosteroid you need, and that cuts down on your side effects. They include azathioprine (Azasan, Imuran), methotrexate (Trexall) and mycophenolate mofetil (Cellcept).
• Immunosuppressant drugs, such as azathioprine and methotrexate. These help reduce your inflammation if prednisone doesn’t work.
• Rituximab (Rituxan) is a rheumatoid arthritis medication.
• Antimalarial medicines like hydroxychloroquine (Plaquenil) treat rashes that won’t go away.

Osteomalacia

What is Osteomalacia?

The word osteomalacia means “soft bones.” The condition keeps your bones from mineralizing, or hardening, as they should. That makes them weak and more likely to bend and break. Only adults have it. When the same thing happens in children, it’s called rickets.  Osteomalacia is more common in women and often happens during pregnancy. It’s not the same as osteoporosis. Both can cause bones to break. But while osteomalacia is a problem with bones not hardening, osteoporosis is the weakening of the bone.

Causes

Your bones rely on certain minerals to grow strong and stay solid. If your body isn’t getting enough of them, you can get osteomalacia. There are different reasons it can happen. The main ones are:

You’re not taking in enough vitamin D. You need this vitamin to absorb calcium from your diet.You can get it from sunlight or certain foods or supplements. Lack of vitamin D can take a toll on your bone health.

Your body has a hard time absorbing vitamin D. Gastric bypass or other surgeries that remove part of your stomach or intestines, celiac disease, and certain liver or kidney disorders can all affect your body’s ability to take in vitamin D or convert it to its active form.

Some seizure medications may cause it. You also can get it if your kidneys aren’t handling acids correctly. Over time, extra acid in your body fluids can slowly dissolve bone.

It’s rare, but some people have a genetic condition that causes osteomalacia.

Symptoms

If you have soft bones, you may have symptoms, including:

• Easily broken bones
• Feeling tired
• Pain
• Stiffness
• Trouble getting up from sitting or walking up stairs
• Weak muscles in your arms and thighs
• People with osteomalacia may walk with a waddling, side-to-side stride.

Diagnosis

Your doctor probably will recommend:

• Blood tests to measure the level of vitamin D in your body
• X-rays to look at your bone structure
• Bone mineral density scans to test the amount of calcium and phosphate in your bones
• It doesn’t happen often, but your doctor may want to do a bone biopsy. This involves taking a piece of your bone tissue to check it.

Treatment

If osteomalacia comes from not getting enough vitamin D, you can treat it by getting more of it in your diet through certain foods and supplements.

• Foods with vitamin D include:
• Cereal
• Cheese
• Eggs
• Fish (tuna, salmon, swordfish, sardines)
• Liver
• Milk
• Orange juice (fortified with vitamin D)
• Yogurt
• You also can get more vitamin D by spending time in the sun. But talk to your doctor about it, and be sure to wear sunscreen. Too much sun can boost your chance of skin cancer.
• If your body has trouble absorbing vitamin D, your doctor will need to treat the cause, if possible. You’ll also need to take larger doses of calcium and vitamin D than the normal daily recommendation.
• To treat broken or deformed bones from osteomalacia, your doctor may give you a brace to wear. If the problem is severe, you may need surgery.

Fibromyalgia

What is fibromyalgia?

Fibromyalgia is a chronic, long-term illness. It causes all-over muscle pain, joint pain and fatigue. The pain may come and go. There’s no known cause, although certain factors such as stress and genetics may predispose someone toward the disease. Although there isn’t a cure, medications, lifestyle changes and other therapies offer relief.

Who might get fibromyalgia?

Anyone can get fibromyalgia, including children. Women are twice as likely as men to have fibromyalgia. Symptoms often appear during middle age. Up to 20% of patients who suffer from other chronic disorders such as rheumatoid arthritis, lupus and sarcoidosis can also have fibromyalgia.

What causes fibromyalgia?

Medical experts don’t know why some people develop fibromyalgia. It sometimes runs in families. Certain conditions or events may bring on symptoms, such as:

• Stressors such as: being born premature, traumatic life events such as abuse, accidents.
• Medical conditions such as viral infections or other illnesses.
• Anxiety, depression, other mood disorders, PTSD.
• Poor sleep.
• Lack of exercise.
• What are the symptoms of fibromyalgia?
• Widespread muscle pain and joint pain along with fatigue and poor sleep are the defining symptoms of fibromyalgia. The disease affects people differently. You may also experience:
• Anxiety or depression.
• Digestive problems, including diarrhea or constipation.
• Face or jaw pain (temporomandibular disorders).
• Headaches or migraines.
• Memory problems.
• Tingling or numbness in hands or feet.

What triggers a fibromyalgia attack?

• Certain things can bring on fibromyalgia symptoms (a flare-up) especially those that increase the level of stress. These include:
• Changes in daily routines.
• Dietary changes or a poor diet.
• Hormone fluctuations.
• Lack of sleep.
• Stressors such as work-related, illness, emotional stress.
• Treatment changes.
• Change in sleep patterns (for example, shift work).
• Weather or temperature changes.

How is fibromyalgia diagnosed?

There isn’t a test that definitively diagnoses fibromyalgia. The diagnosis of fibromyalgia is clinical based on your symptoms and physical exam. Basic blood tests are recommended to exclude other causes of fatigue such as anemia or thyroid disease. The diagnosis relies on your family and medical history combined with your symptoms.

People with fibromyalgia tend to be deeply sensitive to pain that wouldn’t bother most people. Your provider may assess the number of tender points, or areas, on your body that are highly sensitive to touch. For a diagnosis, widespread pain should be present for three months along with fatigue and other symptoms such as memory and concentration difficulties, poor sleep, symptoms of depression and irritability syndrome.

How is fibromyalgia managed or treated?

There isn’t a cure for fibromyalgia. These medications and lifestyle changes can improve symptoms

• Cognitive behavioral therapy.
• Antidepressants.
• Improved sleep habits.
• Prescription and over-the-counter pain medicines.
• Stress management techniques.
• Strength training and exercise.

What are the complications of fibromyalgia?

Fibromyalgia isn’t life-threatening. Still, it can be challenging to live with chronic pain and fatigue. If fibromyalgia isn’t treated your work and daily activities are more difficult to do.

How can I prevent fibromyalgia?

Because experts don’t know what causes fibromyalgia, you can’t really take steps to prevent it. Still, it’s always a good idea to:

• Minimize stress.
• Eat a nutritious diet.
• Get enough sleep.
• Maintain a healthy weight.
• Manage arthritis, depression or other conditions.
• Stay active and exercise regularly.