spondylitic type where sacroiliac and large
joints are involved and (iii) rheumatic like rheumatoid arthritis
which is an additive arthritis and not fleeting, whereas rheumatoid
arthritis in the old is always symmetrical and peripheral
joints are most commonly involved.
The disease may present as a chronic illness,
an acute over a chronic illness or acute excerbations after
remissions. In the acute stage, there is fever, severe pain
with limitation of movements of the joints involved, synovial
thickening, effusion and swelling. This picture subsides with
treatment. Pain is only action oriented during remission.
In late stages, cartilage is totally damaged, defects in circulation
leads on to rarefaction and cyst formation at the ends of
long bones. Synovial thickening extending over articular surfaces
is called panus. Deformities such as the button hole deformity,
swan neck deformity, ulnar deviation of fingers are pathognomonic
of Rheumatoid arthritis. Autoamputation occurs due to (i)
arterial blood deficit and (ii) purely vasomotor disturbances.
Raynaud's phenomenon also occurs in some cases. Systemic extension
may lead to diabetes, hypothyroidism, hypertension and ischemic
Latex fixation test is positive in 42% of
the cases. Rest are seronegative. Seronegativity can occur
in Rheumatoid arthritis itself when all immune complexes get
deposited in joints.. E.S.R. is raised. VDRL is mildly positive.
IgM fraction is increased. Aspiration fluid is cloudy, has
high protein and increased IgM globulin. Polymorpho- nuclear
leucocytosis is reported. The sugar content of fluid is low.
Response to drugs varies from individual
to individual. Trial and error method is to be employed. Aspirin
and analgin do not help. Phenylbutazone and oxyphenbutazone
relieve pain effectively, provided, the drug is accepted by
the patient. Gastric irritability misreported as increased
appetite by the patient leading onto loss of appetite, abdominal
pain, vomiting and haematemesis are the usual adverse effects
of the drugs. Sodium and water retention lead onto puffiness
of the face and oedema. Diuretics have no place in treating
water retention. Reassurance along with a reduced dosage or
stopping the drug is usually effective. These effects are
not dose related.
40% of patients respond well to Indomethacin
which stimulates prostaglandin synthesis. Dose related gastro-intestinal
side effects as vomiting, diarrhoea and abdominal pain limit
the acceptability of the drug. Concurrent administration of
antacids does not relieve these effects. The drug is administered
in doses of 25 mgms to 200 mgms per day. Indomethacin is also
used in the treatment of nephrotic syndrome, polyradiculopathies
and transverse myelitis.
Ibuprofen 200 to 400 mgms per day though
claimed very effective has not been found to relieve pain
much. Ketoprofen is another preparation. Naproxen has a limited
response and is costly too. With Oviran (CIBA) initial relief
of pain is dramatic.
A combination or 25 mgms of Indomethacin
per day and 100 mgms of Butazolidone per day is effective.
Chloroquine 300 mgms per day gives constant relief from pain.
Gold Chloride administered as 50 mgms per
week until a total dose of 2 mgms and 50 mgms once in 3 to
4 weeks for a prolonged period causes remissions.