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RA vs SSLR
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RA vs SSLR

Patient is 48 year old Cambodian female w/ family hx hypertension and autoimmune disorders (multiple drug/food allergies, IgM nephropathy, asthma).

Prior hx:  
1) post-traumatic seizure disorder, well controlled on gabapentin1200 mg daily
2) hypothyroidism, euthyroid  on 100mcg synthroid daily. Onset was after commencing gabapentin, ? secondary to the drug?
3) hypertension, generally well controlled on irbesartan 300mg daily but exacerbates  emotionally stressed

Management of the above has been greatly complicated by allergic reactions to: dilantin, phenobarbital, valproic acid,  ACE inhibitors, atenolol, thiazide diuretics.

Excepting valproic acid, all these reactions occurred 2-4 weeks after exposure with rash, urticaria, photophobia, malaise. s.  Reaction to valproic acid occurred almost 2 years after initiating therapy and was of  Stevens-Johnson type.

1 year ago for  gradual onset on neck and shoulder pain radiating down the arms, and numbness in the hand.  MRI showed nerve root compression at C5-7. EMG showed median nerve compression.  She was treated with physiotherapy and with NSAIDs but latter had to be stopped after allergic reaction. Carpal tunnel release in June 2004 resolved numbness of hand  but  stiffness and pain at wrist and fingers con tinued & progressed to  generalized polyarthralgias, impairing ADLs.

6 months ago, a rheumatologist dx'd RA based on clinical exam & elevated ESR. Placed on ASA and hydrochloroquine with initial e improvement in joint pain but allergic reaction required discontinuation . Switched to methotrexate. Joint pain did not improve and about 3-4 weeks into treatment she had another allergic reaction, this one of Stevens-Johnson type and very severe. Next placed on SSZ;t pain improved  allergic reaction (rash/urticaria) required discontinuation.

A second rheumatologist/immunologist  conducted more comprehensive exam including hand/wrist xrays, ANA, rheumatoid factor, C-reactive protein etc. All tests  negative except for ESR which was elevated. Hand/wrist films showed only mild osteoarthritic changes disproportional to the amount of pain and functional impairment.  He dx'd serum sickness  rather than RA and rx'd prednisolone 30mg/day tapering down to 10mg.

Now 3 months later, prednisolone is 10 mg daily and joint pain continues to severely limit ADLs.   Severity flunctuates but pain never completely absent. She has had 2 mild allergic reactions to drugs  during this period.  Every effort is made to avoid new drug exposures but unfortunately her other medical problems sometimes result in hospital or doctor visits where, despite being provided with the history, new  drugs and/or drugs she is known to be allergic to (e.g. NSAIDs) are given.

Q:

How likely that  arthralgia  due to past  drug reactions? If so, what is  long term prognosis? Suggestions on management?

Could it instead be a adverse effect  gabapentin or irbesartan? If so, what to do given allergy to most alternatives
233190_tn?1278553401
Serum sickness is a clinical diagnosis, and can be considered given your hypersensitivity to prior medications as well as the negative workup thus far (except for the ESR).  There is no specific test for this, except finding and removing the offending medications.  

You are being appropriately treated for this, with corticosteroids.  Finding the agent will result in curing the arthralgias.  Sometimes doctors may add antihistimines to the treatment regimen.  

Regarding the seizure medication, your allergies to many other classes makes it difficult to manage - I am not a neurologist, but I would suggest a referral to discuss other options.

There are several other classes of hypertensive medications (you are currently taking an angiotensin receptor blocker).  Changing to a different one (i.e. Diovan or Avapro) or to a calcium channel blocker can be considered if the irbesartan is causing problems.

You can discuss these options with your personal physician.

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Kevin, M.D.
Medical Weblog:
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I have a family history of arthritis and a generalized absence seizure disorder(even though I'm 29, most people grow out of it.)  When I was given Zarontin(a seizure drug) I got drug induced Lupus.  This was confirmed by tests and I also had obvious symptoms.  The Rheumatologist immediately took me off of it even though it was working(as far as seizures go).  After the medicine was out of my system, the symptoms went away.  My neurologist was not aware of this rare side effect.
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63754_tn?1290966980
http://www.valdezlink.com/pages/whatinotice.htm
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Avatar_n_tn
Thank you. A further literature search revealed other case reports of arthralgia due to gabapentin. A reduction in gabapentin dosage was tried and resulted in rapid alleviation of the symptoms, so it is clear that the gabapentin was responsible. As with the experience cited above, the doctor was unaware of this rare side effect although the pharmaceutical company when contacted confirmed it is known to occur in a small minority of patients. (Unfortunately, the reduced dosage gabapentin did not provide adequate seizure control, so we are back to square one, but at least we know why)
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Hi everybody. I'm new here, & though I know I'm not really supposed to "post a question", I'm so excited to have found a spot where one can do that, that I can't hardly help myself. (I was going to post a quest. for a Dr. but it seems that it costs $15? Was I in the right area? Are all of the folks here paying $15/question!?)
First off, I can identify with so many of the 'signs & symptoms' here, that it's both scarey, & yet a relief to know I'm "not the only one". I have suffered in debiliating CHRONIC pain for 5 years for what was assumed by WAY too many doctors that I had mere TMJ dysfunction, (which is certainly agonizing enough, but I had no idea all the other 'mysterious symptoms' I had could mean anything WITH the jaw/face/neck pain which was chiefly my # 1 Chronic pain complaint - literally, much of the past 5 years I was "flat on my face" in bed or on the couch, unable to work - I mean I didn't even make a good house wife because I couldn't complete ANY task I started! - & hardly able to be a decent wife to my husband or mother to my 5 children. You just have NO idea!)
I had injured my jaw joint in a car accident - flattened condoyle/pocket of arthritis found 4 yrs ago - I was in at age 15, & had all the usual typical TMJ complications chronic TMJ sufferes have, (and many have them continuosly, not just periodic episodes like so many MD's seem to think!) which included extreme jaw dysfunction, neck & shoulder pain, weakness in the arm strength (I have not been able to hardly lift a gallon of milk since I was 17, & I'm 39 now!)blinding pain in the jaw & face, face locking up etc.
Recently, in May '05, I had a dentist send me 5+ hours away to Kansas City MO. to a teaching hospital there to see an oral facial surgeon. Imagine my surprise when what the dentist thought was the problem, turned out to not be it at all, & of all things I had an ORAL FACIAL SURGEON put me on a COMPLETELY different path of what could be wrong - which incidently, I'm still not exactly sure what, but at least I know it's Rhuematologistic/Vascular - and to think I had suffered for so long when much of the symptoms are at least somewhat treatable!
Tell me God doesn't work in mysteroius ways! The Oral Surgeon told me right off the bat as I sat crying in his office feeling yet again back to square 1, (dentist thought I had majoy bone cyst - I had NO cyst!) and told me where my major pain was, ran a major artery alongside the temple, front of the ear, alongside the jaw/chin/side of the neck leading down to the  front of the shoulder into the chest. He strongly suspected several things based on where the pain was/general symptoms - that he said I needed an RA Specialist for. For starters, Temporal Arteritis, (Also known as Cranial arteritis and Giant Cell arteritis) and Lupus, MS, Myofacial Pain, & Trigimenal Nueralgia, to name the few I can recall. Soon as he said where that artery was for Temporal Arteritis, my husband & I looked at eachother like, "Oh my God!" I went home & researched online all these things & right away GCA appears a distinct possbility, especially as I have lost some peripheal vision, gotten thickened corneas & have "high pressure" on my eyes. But I also noticed MS has similar symptoms. What I find confusing is that though my EMS rate WAS considered high, 21/2 times higher than the "high normal" if that means anythings to you all, is that all the literature explains Temporal Arteritis/GCA as a "sudden onset" or "sudden attack", whereas mine came and never LEFT, literally! If I would say I HAD an attack, it would be those times where I literally nearly OD'd myself desoerately trying to get the pain under control. (Sometimes drugs worked, other times literally nothing worked - but the literally nothing worked grew more & more frequent.)
Okay....then I have these other symptoms that DON'T fit from the literature I found on this. My feet bottoms BURN like live wires. My legs burn but less often/less severe as my feet. I can't bear wearing shoes or driving for too long due to both nerve pain and what I believe is actually BONE pain! (The bones in the bottoms of my feet will literally hurt to stand on them)My SHIN bones also hurt really really bad. Since I also have rigidity episodes (minor) here & there, and twitchy sensations (even in my thighs) I thought at first maybe I just THOUGHT my shin bones hurt, maybe it was more muscular. Until I learned over my couch to pick up a stack of folded laundry and my shin brushed against the couch & I about fell to my knees as I screamed in pain, & I realized, no, it's definitely the BONE hurting.
Three years ago, was the first I recall the foot & leg thing. I was rushed to the hospital when literally every nerve in my body all at ONCE grew burning like live wires, I couldn't lift my long hair to put my coat on to go the hospital without screaming, & by the time I got to the hospital, I couldn't stand on my feet from the burning. (They gave me morphine intravieneously & even the needle injection I SCREAMED through & yelled, "My GOD what size is that needle!?" It had literally FELT like a pencil!) Since then, I get scalp burning/tenderness as well as the foot/lerg/thich thing.
These things are not present in any of the GCA literature I've found, nor in the MS, Lupus, etc.  In fact, I really can't find ANYTHING in the literature with all/most of these symptoms lumped together! So I'm really confused. The two I most identify with though are the GCA/some of the MS. (I have episodes of minor bladder incontinence as well - but then I have birthed 5 children!)
Also, vascular tyhings seem to run in my family on one side, & my own 9 year old son suffered with HSP - a temporary rare form of Rhuematoid Arteritis as I understood it - and at 9, I am noticing some jaw claudification in him, as well, which frankly worries me. Can anyone give me a CLUE as what all these things together could mean?
Any Dr's/nurses here?
Thanks. And I'm really sorry for rambling. I just can't BELIEVE I found this place!
PS. I am getting into seeing a new MD this week, & also have an eye appt to check for further vision loss since last year, this week. But I really want to know from you "experienced patients" if all these various symptoms mean anything - together??? What disorder/autoimmune ones(s)?
Thanks all!
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63754_tn?1290966980
Seizure control?

I think sometimes that is part of the lack of oxygen that can happen with the fatigue of autoimmune hemolytic anemia

http://home.gci.net/~blessing/pages/grandemal.htm
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