CASE PRESENTATION

NAME :- Sharda Devi AGE/SEX :- 45 yrs./ female D.O.A :- 17-03-08 ADDRESS :- L-1/5, Police colony, Andrews ganj, N.D OCCUPATION :- Housewife

PRESENTING COMPLAINTS
1. Pain and swelling in all joints of body since 18-20 yrs.

2. Increased frequency of micturition since 3-4 months.

HISTORY OF PRESENTING COMPLAINTS

Patient was apparently well 20 yrs. Back when she started complaining of pain and swelling in left knee joint and then to right knee joint and then gradually spread to all joints of body. ONSET :- gradual. LOCATION:- both knee jts., both ankle jts.,both shoulder jts.,both elbow jts., both wrist jts., bilateral interphalangeal jts. SENSATION:- Stiffness MODALITIES:- < movement, cold weather, morning > hot fomentation

TREATMENT HISTORY
Taken allopathic treatment from safdarjung hospital for 3 weeks, also taken ayrvedic and homoeopathic treatment with transient relief. 2. Increased frequency of micturition since 3-4 months. ONSET :- gradual FREQUENCY:- every 5-10 min during daytime,3-4 times during night. CHARACTER:- yellow, no burning, no other associated complaint. Sometimes there is uncontrollable urge leading to involuntary passage of urine. MODALITIES:- < morning, > N.S

PAST HISTORY No history of any major illness, operations or accidents. X-Ray exposure :- exposed Vaccinations:- done

FAMILY HISTORY
MOTHER:- Hypertensive FATHER :- expired (PUO?) 2 brothers and 1 sister :- all alive and apparently well.

PERSONAL HISTORY
DEVELOPMENTAL LANDMARKS:- On time. DIET:- Non-veg. HABITS/ADDICTIONS:- N.S OCCUPATION:- Housewife EDUCATION:- Till 12th class. ENVIRONMENT AT HOME:- Congenial.

GYNAE AND OBS.HISTORY

Menarche:- 15yrs of age. Cycle:- irregular, 6-7 mnths gap, since 1 yr. Duration :- 3-4 days. Character:- red, no associated complaints. obs. history :- G3P2L2A1 Son- 19 yrs., daughter- 14yrs. Both FTNVDs. Complaint of joint pains started after 1st delivery.

PHYSICAL GENERALS
THERMAL REACTION :- ambithermal APPETITE :- normal, 3meals/day THIRST :- normal, takes a large quantity at a time. DESIRES :- N.S AVERSIONS :- sweets (1+) URINE :- every 5-10 min. during daytime, N3-4 STOOL :- D2-3N0-1, satisfactory SLEEP :- 7-8 hrs., refreshing DREAMS :- N.S PERSPIRATION :- more on face, non-offensive, non-staining.

MENTAL GENERALS
ANGER (1+) IRRITABILITY(1+) MEMORY- intact FEARS:- N.S LOQUACIOUS

INVESTIGATIONS DONE
ROUTINE HAEMOGRAM Hb.:- 6.2gm%, TLC :- 9,800/cumm, DLC:- P68L29E2M1 BSF :- 89mg/dl URINE EXAMINATION:ROUTINE:- colour-pale yellow, reaction-acidic, sugar-nil protein- trace Microscopic- RBCs-nil, WBCs- 10-12/Hpf, epithelial cells-4-6/Hpf bacteria (++++) STOOL EXAMINATION :- NAD USG (whole abdomen) :- NAD

X-Ray chest :- lungs show prominent reticular markings. BOTH KNEE JOINTS :- advanced osteoarthritis, bones are osteoporotic. BOTH HANDS :- subluxation at intercarpal joints, diminished joint space, osteoporosis. BOTH ANKLE JOINTS:- osteoporosis with diminished joint space. IMPRESSION:- Rheumatoid arthritis with superimposed osteoarthritis.

RUBRICS FOR REPERTORISATION (KENT S REPERTORY)

1. Extremities, pain, joints (pg. 1047) 2. Extremities, pain, joints, cold weather (pg.1047) 3. Extremities, pain, joints, motion (pg. 1048) 4. Extremities, pain, joints, warmth, amel. (pg. 1048) 5. Extremities, stiffness, joints (pg. 1191) 6. Extremities, swelling, joints (pg. 1196) 7. Bladder, urging, constant (pg. 653) 8. Bladder, urination, frequent (pg. 657) 9. Bladder, urination, frequent, morning(pg.657) 10. Stomach, aversion, sweets (pg. 482) 11. Mind, irritability (pg.57) 12. Mind, loquacious (pg. 63)

REPERTORIAL RESULT
SULPHUR CAUSTICUM NUX-VOM ARS.ALB PHOS. LYCOPODIUM BELLADONA CALC-CARB RHUS TOX 22/9 19/9 19/9 17/9 16/9 18/8 17/8 17/8 17/7

PRESCRIPTION TILL DATE

Formica Rufa 30 / 5 doses. Causticum 0/1/ 9 doses. Apis 30 / 16 doses. Guaicum 30 on 25-03-08.

PROVISIONAL DIAGNOSIS
RHEUMATOID ARTHRITIS

RHEUMATOID ARTHRITIS
Rheumatoid arthritis (RA) is traditionally considered a chronic, inflammatory autoimmune disorder that causes the immune system to attack the joints. It is a disabling and painful inflammatory condition, which can lead to substantial loss of mobility due to pain and joint destruction. RA is a systemic disease, often affecting extra-articular tissues throughout the body including the skin, blood vessels, heart, lungs, and muscles.

SIGNS AND SYMPTOMS

SYNOVITIS Synovitis affecting synovial joints is the most prominent feature in rheumatoid arthritis. Inflammation in the joints manifests itself as a soft, "doughy" swelling, pain, tenderness to palpation and movement, local warmth, and functional impairment. Morning stiffness is often a prominent feature and may last for more than an hour. These signs help distinguish rheumatoid and other inflammatory arthritides from non-inflammatory diseases of the joints such as osteoarthritis (sometimes referred to as the "wear-and-tear" of the joints). In RA, the joints are usually affected in a fairly symmetrical fashion although the initial presentation may be asymmetrical.

Rheumatoid arthritis is a systemic disorder mainly affecting synovial joints. Chemical mediators (Cytokines) released as a result of an abnormal immune reaction triggered by yet undetermined agent/ agents, immune system releases cytokines which gives rise to inflammation of joint synovium (Synovitis). Constitutional symptoms such as fever, malaise, loss of appetite and loss weight are also due to cytokines released in to the blood stream due to an abnormal immune reaction. Vasculitis affecting many other organ systems often gives rise to systemic complications. Most common and disabling clinical feature in Rheumatoid arthritis is chronic, deforming, often symmetrical polyarthritis (affecting multiple joints) due to joint Synovitis triggered by an autoimmune reaction in genetically susceptible individuals .

DEFORMITY
As the pathology progresses the inflammatory activity leads to erosion and destruction of the joint surface, which impairs their range of movement and leads to deformity. The fingers are typically deviated towards the little finger (ulnar deviation) and can assume unnatural shapes. Classical deformities in rheumatoid arthritis are the Boutonniere deformity (Hyperflexion at the proximal interphalangeal joint with hyperextension at the distal interphalangeal joint), swan neck deformity (Hyperextension at the proximal interphalangeal joint, hyperflexion at the distal interphalangeal joint). The thumb may develop a "Z-Thumb" deformity with fixed flexion and subluxation at the metacarpophalangeal joint, and hyperextension at the IP joint.

Hand affected by RA

EXTRA-ARTICULAR (ELSEWHERE)
Patients with RA usually exhibit signs of systemic inflammation, that is, the inflammatory process in the joint leaves its marks on other organs as well (and this may also help distinguish it from osteoarthritis). Examples are a general tiredness and lassitude, sometimes lowgrade fever, and some abnormalities on blood tests such as an elevated erythrocyte sedimentation rate (ESR), and anemia, which is often seen as a consequence of the disease itself (anaemia of chronic disease) although it may also be caused by gastrointestinal bleeding as a side effect of drugs used in treatment, especially NSAIDs used for analgesia.

Extra-articular manifestations (manifestations outside the musculoskeletal system) occur in about 15% of patients with rheumatoid arthritis. Examples are hepatosplenomegaly which may occur with concurrent leukopenia and is then referred to as Felty's syndrome), lymphocytic infiltration affecting the salivary and lacrimal glands (Sjgren's syndrome), pericarditis, pleurisy, alveolitis, scleritis, and subcutaneous nodules.

CUTANEOUS MANIFESTATIONS
The rheumatoid nodule is the cutaneous (strictly speaking subcutaneous) feature most characteristic of rheumatoid arthritis. The mature lesion is defined by an area of central necrosis surrounded by palisading macrophages and fibroblasts and a cuff of cellular connective tissue and chronic inflammatory cells. The typical rheumatoid nodule may be a few millimetres to a few centimetres in diameter and is usually found over bony prominences, such as the olecranon, the calcaneal tuberosity, the metacarpophalangeal joints, or other areas that sustain repeated mechanical stress. Nodules are associated with a positive RF titer and severe erosive arthritis. They can rarely occur throughout the body in internal organs.

Several forms of vasculitis are also cutaneous manifestations associated with rheumatoid arthritis. A benign form occurs as microinfarcts around the nailfolds. More severe forms include livedo reticularis, which is a network (reticulum) of erythematous to purplish discoloration of the skin due to the presence of an obliterative cutaneous capillaropathy. (This rash is also otherwise associated with the antiphospholipidantibody syndrome, a hypercoagulable state linked to antiphospholipid antibodies and characterized by recurrent vascular thrombosis and second trimester miscarriages.

 Other, rather rare, cutaneous features include: pyoderma gangrenosum, a necrotizing, ulcerative, noninfectious neutrophilic dermatosis. Sweet's syndrome, a neutrophilic dermatosis usually associated with myeloproliferative disorders viral infections drug reactions erythema nodosum lobular panniculitis atrophy of digital skin palmar erythema diffuse thinning (rice paper skin), and skin fragility.

OTHERS
Pulmonary The lungs may become involved as a part of the primary disease process or as a consequence of therapy. Fibrosis may occur spontaneously or as a consequence of therapy (for example methotrexate). Caplan's syndrome describes lung nodules in patients with rheumatoid arthritis and exposure to coal dust. Pleural effusions are also associated with rheumatoid arthritis. Renal Amyloidosis can occur. Cardiovascular Possible complications that may arise include: pericarditis, endocarditis, left ventricular failure, valvulitis and fibrosis. The risk of cardiovascular, specifically myocardial infarction (heart attack) or congestive heart failure are greater in individuals with RA. Over 1/3 of deaths of people with RA are directly attributable to cardiovascular death.

Ocular Keratoconjunctivitis sicca (dry eyes), scleritis, episcleritis and scleromalacia. Gastrointestinal and Hematological Felty syndrome, anemia Neurological Peripheral neuropathy and mononeuritis multiplex may occur. The most common problem is carpal tunnel syndrome due to compression of the median nerve by swelling around the wrist.

Atlanto-axial subluxation can occur, owing to erosion of the odontoid process and or/transverse ligaments in the cervical spine's connection to the skull. Such an erosion (>3mm) can give rise to vertebrae slipping over one another and compressing the spinal cord. At first the patient experiences clumsiness but without due care this can progress to quadriplegia. Vasculitis in rheumatoid arthritis is common. It is typically presents as vasculitic nailfold infarcts. Osteoporosis classically occurs in RA around inflamed joints. It is postulated to be partially caused by inflammatory cytokines. The incidence of lymphoma is increased in RA as it is in most autoimmune conditions.

DIAGNOSIS
Diagnostic criteria
The American College of Rheumatology has defined (1987) the following criteria for the classification of rheumatoid arthritis: Morning stiffness of >1 hour most mornings for at least 6 weeks. Arthritis and soft-tissue swelling of >3 of 14 joints/joint groups, present for at least 6 weeks Arthritis of hand joints, present for at least 6 weeks Symmetric arthritis, present for at least 6 weeks Subcutaneous nodules in specific places Rheumatoid factor at a level above the 95th percentile Radiological changes suggestive of joint erosion At least four criteria have to be met for classification as RA.

BLOOD TESTS
When RA is being clinically suspected, immunological studies are required, such as rheumatoid factor (RF, a specific antibody). negative RF does not rule out RA; rather, the arthritis is called seronegative. During the first year of illness, rheumatoid factor is frequently negative. 80% of patients eventually convert to seropositive status. RF is also seen in other illnesses, like Sjgren's syndrome, and in approximately 10% of the healthy population, therefore the test is not very specific.

 Because of this low specificity, a new serological test has been developed in recent years, which tests for the presence of so called anti-citrullinated protein antibodies (ACPA). Like RF, this test can detect approximately 80% of all RA patients, but is rarely positive in non-RA patients, giving it a specificity of around 98%. In addition, ACP antibodies can be often detected in early stages of the disease, or even before disease onset. Currently, the most common test for ACP antibodies is the anti-CCP (cyclic citrullinated peptide) test.

Also, several other blood tests are usually done to allow for other causes of arthritis, such as lupus erythematosus. The erythrocyte sedimentation rate (ESR), C-reactive protein,full blood count, renal function, liver enzymes and other immunological tests (e.g. antinuclear antibody/ANA) are all performed at this stage. Ferritin can reveal hemochromatosis, which can mimic RA.

PROGNOSIS
The course of the disease varies greatly from patient to patient. Some patients have mild short-term symptoms, but in most the disease is progressive for life. Around 20%-30% will have subcutaneous nodules (known as rheumatoid nodules); this is associated with a poor prognosis. Disability Daily living activities are impaired in most patients. After 5 years of disease, approximately 33% of patients will not be working After 10 years, approximately half will have substantial functional disability.

PROGNOSTIC FACTORS
Poor prognostic factors include persistent synovitis, early erosive disease, extra-articular findings (including subcutaneous rheumatoid nodules), positive serum RF findings, positive serum anti-CCP autoantibodies, carriership of HLA-DR4 "Shared Epitope" alleles, family history of RA, poor functional status, socioeconomic factors, elevated acute phase response (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP]), and increased clinical severity.

What causes rheumatoid arthritis?

The cause of rheumatoid arthritis is unknown. Even though infectious agents such as viruses, bacteria, and fungi have long been suspected. The tendency to develop rheumatoid arthritis may be genetically inherited. It is suspected that certain infections or factors in the environment might trigger the immune system to attack the body's own tissues, resulting in inflammation in various organs of the body such as the lungs or eyes. Environmental factors also seem to play some role in causing rheumatoid arthritis. Recently, scientists have reported that smoking tobacco increases the risk of developing rheumatoid arthritis.

PATHOPHYSIOLOGY
A joint (the place where two bones meet) is surrounded by a capsule that protects and supports it. The joint capsule is lined with a type of tissue called synovium, which produces synovial fluid that lubricates and nourishes joint tissues. In rheumatoid arthritis, the synovium becomes inflamed, causing warmth, redness, swelling, and pain. As the disease progresses, the inflamed synovium invades and damages the cartilage and bone of the joint. Surrounding muscles, ligaments, and tendons become weakened. Rheumatoid arthritis also can cause more generalized bone loss that may lead to osteoporosis (fragile bones that are prone to fracture).

GOALS OF TREATMENT
Relieve pain Reduce inflammation Slow down or stop joint damage Improve a person's sense of well-being and ability to function

CURRENT TREATMENT APPROACHES

Lifestyle Medications Surgery Routine monitoring and ongoing care

MANAGEMENT
Health behavior changes: Rest and exercise: People with rheumatoid arthritis need a good balance between rest and exercise, with more rest when the disease is active and more exercise when it is not. Rest helps to reduce active joint inflammation and pain and to fight fatigue. The length of time for rest will vary from person to person, but in general, shorter rest breaks every now and then are more helpful than long times spent in bed. Exercise is important for maintaining healthy and strong muscles, preserving joint mobility, and maintaining flexibility. Exercise can also help people sleep well, reduce pain, maintain a positive attitude, and lose weight. Exercise programs should take into account the person's physical abilities, limitations, and changing needs.

Joint care: Some people find using a splint for a short time around a painful joint reduces pain and swelling by supporting the joint and letting it rest. Splints are used mostly on wrists and hands, but also on ankles and feet. A doctor or a physical or occupational therapist can help a person choose a splint and make sure it fits properly. Other ways to reduce stress on joints include self-help devices (for example, zipper pullers, long-handled shoe horns); devices to help with getting on and off chairs, toilet seats, and beds; and changes in the ways that a person carries out daily activities.

Stress reduction: People with rheumatoid arthritis face emotional challenges as well as physical ones. The emotions they feel because of the disease-fear, anger, and frustration-combined with any pain and physical limitations can increase their stress level. Stress also may affect the amount of pain a person feels. There are a number of successful techniques for coping with stress. Regular rest periods can help, as can relaxation, distraction, or visualization exercises. Exercise programs, participation in support groups, and good communication with the health care team are other ways to reduce stress.

SURGERY
Joint replacement: This is the most frequently performed surgery for rheumatoid arthritis, and it is done primarily to relieve pain and improve or preserve joint function. Artificial joints are not always permanent and may eventually have to be replaced. This may be an important consideration for young people. Tendon reconstruction: Rheumatoid arthritis can damage and even rupture tendons, the tissues that attach muscle to bone. This surgery, which is used most frequently on the hands, reconstructs the damaged tendon by attaching an intact tendon to it. This procedure can help to restore hand function, especially if the tendon is completely ruptured. Synovectomy: In this surgery, the doctor actually removes the inflamed synovial tissue. Synovectomy by itself is seldom performed now because not all of the tissue can be removed, and it eventually grows back. Synovectomy is done as part of reconstructive surgery, especially tendon reconstruction.

DIFFERENTIAL DIAGNOSIS
1. OSTEOARTHRITIS 2. SEPTIC ARTHRITIS 3. GOUT AND PSEUDOGOUT 4. SYSTEMIC LUPUS ERYTHEMATOSUS 5. PSORIATIC ARTHRITIS

HOMOEOPATHIC THERAPEUTICS
FORMICA RUFA An arthritic medicine. Gout and articular rheumatism; pains worse, motion; better, pressure. Right side most affected. Extremities.--Rheumatic pains; stiff and contracted joints. Muscles feel strained and torn from their attachment. Weakness of lower extremities. Paraplegia. Pain in hips. Rheumatism comes on with suddenness and restlessness. Sweat does not relieve. Relief after midnight and from rubbing.

STELLARIA MEDIA Sharp, shifting, rheumatic pains in all parts very pronounced. Rheumatism; darting pains in almost every part; stiffness of joints; parts sore to touch; worse, motion. Chronic rheumatism. Shifting pains (Puls; Kali sulph). Psoriasis. Enlarged and inflamed gouty finger joints. Pain in shoulders and arms. Synovitis. Bruised feeling. Rheumatic pains in calves of legs. Modalities.--Worse, mornings, warmth, tobacco. Better, evenings, cold air, motion.

BRYONIA ALBA rheumatic pains and swellings; Knees stiff and painful. Hot swelling of feet. Joints red, swollen, hot, with stitches and tearing; worse on least movement. Every spot is painful on pressure. Constant motion of left arm and leg (Helleb). RHUS TOXICODENDRON Rhus affects fibrous tissue markedly-joints, tendons, sheathsaponeurosis, etc, producing pains and stiffness. Rheumatism in the cold season. Hot, painful swelling of joints. Pains tearing in tendons, ligaments, and fasci. Rheumatic pains spread over a large surface at nape of neck, loins, and extremities; better motion (Agaric).

KALMIA LATIFOLIA A rheumatic remedy. Pains shift rapidly. Deltoid rheumatism especially right. Pains from hips to knees and feet. Pains affect a large part of a limb, or several joints, and pass through quickly. Weakness, numbness, pricking, and sense of coldness in limbs. Pains along ulnar nerve, index finger. Joints red, hot, swollen. Tingling and numbness of left arm. Worse, leaning forward (opposite, Kali carb); looking down; motion, open air.

LITHIUM CARBONICUM Chronic rheumatism connected with heart lesions and asthenopia offer a field for this remedy. Rheumatic nodes. Paralytic stiffness all over. Itching about joints. Rheumatic pains throughout shoulder-joint, arm, and fingers and small joints generally. Pain in hollow of foot, extending to knee. Swelling and tenderness of finger and toe joints; better, hot water. Nodular swellings in joints. Ankles pain when walking. Worse, in morning, right side. Better, rising and moving about.

COLCHICUM shifting rheumatism; pains worse at night. Sharp pain down left arm. Tearing in limbs during warm weather, stinging during cold. Pins and needles in hands and wrists, fingertips numb. Pain in front of thigh. Right plantar reflex abolished. Limbs, lame, weak, tingling. Pain worse in evening and warm weather. Joints stiff and feverish. ARNICA MONTANA Rheumatism begins low down and works up (Ledum).

LEDUM PALUSTRE Rheumatism begins in lower limbs and ascends (Kalmia opposite). Ankles swollen. Gouty pains shoot all through the foot and limb, and in joints, but especially small joints. Swollen, hot, pale.

GUAIACUM
Rheumatic pain in shoulders, arms and hands. rowing pains (Phos ac). Pricking in nates. Sciatica and lumbago. Gouty tearing, with contractions. Immovable stiffness. Ankle pain extending up the leg, causing lameness. Joints swollen, painful, and intolerant of pressure; can bear no heat. Stinging pain in limbs. Arthritic lancinations followed by contraction of limbs. A feeling of heat in the affected limbs. Modalities.--Worse, from motion, heat, cold wet weather; pressure, touch, from 6 pm to 4 am. Better, external pressure.