Abu Bakar Siddiq

Persistent enthesitis and spondyloarhtropathy: A case series of 71 Bangladeshi people

BACKGROUND Enthesitis is a prominent feature of spondyloarthropathy (SpA) and persisting enthesitis may be a presenting symptom either alone or in combination with peripheral synovitis and/or inflammatory back pain. OBJECTIVE To describe a series of SpA patients with persistent enthesitis as first manifestation. METHODS This is a cross-sectional study. All SpA patients visiting the rheumatology and rehabilitation clinic, of Chittagong Medical College Hospital, between May 2007 and December 2008, were studied and those with chronic enthesitis as presenting symptom were included. Patients were classified with European Spondyloarthropathy Study Group (ESSG) classification criteria for SpA. Demographic data were collected and routine lab tests performed, including HLA-B-27 testing. In all patients X-ray of spinal segments, sacroiliac joints and pelvis were performed. Collected data were analyzed using SPSS package program (version 12.0) and multivariate analysis was done. RESULTS A total of 71 SpA patients could be included with initial presentation with chronic enthesitis. Of these patients 20 gave a history of disease onset before their 16th birthday and in 51 cases it was after their sixteenth. The mean age at presentation was respectively 12.5 ± 2.5 and 23.3 ± 6.4 years in juvenile and adult cases. Enthesitis was defined by history, clinical examination, and radio-imaging at accessible sites (X-ray pelvis/foot). Enthesitis presenting in the heel was the most common site (n= 51), but it was also seen in other locations in another 20 patients. The mean duration between presenting enthesitis and other features of SpA was 7.7 ± 3.2 and 8.5 ± 2.2 months in juvenile and adult cases respectively. All patients had raised ESR at disease onset and HLA-B27 was found to be positive in 58 cases. Ankylosing spondylitis (AS) was diagnosed in 49 cases and GradeI-II, Grade-III, and Grade-IV sacroiliitis was documented in 31, 5, and 13 patients respectively. CONCLUSION Persistent enthesitis is one of the most common clinical presentation of SpA usually associated with high ESR, HLA-B27 positivity. Definition and classification of enthesitis is important in early diagnosis of this rheumatologic condition.

Piriformis Syndrome in Fibromyalgia: Clinical Diagnosis and Successful Treatment

Piriformis syndrome is an underdiagnosed extraspinal association of sciatica. Patients usually complain of deep seated gluteal pain. In severe cases the clinical features of piriformis syndrome are primarily due to spasm of the piriformis muscle and irritation of the underlying sciatic nerve but this mysterious clinical scenario is also described in lumbar spinal canal stenosis, leg length discrepancy, piriformis myofascial pain syndrome, following vaginal delivery, and anomalous piriformis muscle or sciatic nerve. In this paper, we describe piriformis and fibromyalgia syndrome in a 30-year-old young lady, an often missed diagnosis. We also focus on management of the piriformis syndrome.

Interventional Pain Management in Rheumatological Diseases - A Three Years Physiatric Experience in a Tertiary Medical College Hospital in Bangladesh

Background Interventional pain management (IPM) is a branch of medical science that deals with management of painful medical conditions using specially equipped X-ray machines and anatomical landmarks. Interventional physiatry is a branch of physical medicine and rehabilitation that treats painful conditions through intervention in peripheral joints, the spine, and soft tissues. Methods A cross-sectional study was conducted using three years of hospital records (2006 to 2008) from the Physical Medicine and Rehabilitation Department at Chittagong Medical College Hospital in Bangladesh, with a view toward highlighting current interventional pain practice in a tertiary medical college hospital. Results The maximum amount of intervention was done in degenerative peripheral joint disorders (600, 46.0%), followed by inflammatory joint diseases (300, 23.0%), soft tissue rheumatism (300, 23.0%), and radicular or referred lower back conditions (100, 8.0%). Of the peripheral joints, the knee was the most common site of intervention. Motor stimulation-guided intralesional injection of methylprednisolone into the piriformis muscle was given in 10 cases of piriformis syndrome refractory to both oral medications and therapeutic exercises. Soft tissue rheumatism of unknown etiology was most common in the form of adhesive capsulitis (90, 64.3%), and is discussed separately. Epidural steroid injection was practiced for various causes of lumbar radiculopathy, with the exception of infective discitis. Conclusions All procedures were performed using anatomical landmarks, as there were no facilities for the C-arm/diagnostic ultrasound required for accurate and safe intervention. A dedicated IPM setup should be a requirement in all PMR departments, to provide better pain management and to reduce the burden on other specialties.

Wallet Neuritis – An Example of Peripheral Sensitization

Background: Wallet neuritis is an example of extra-spinal tunnel neuropathy concerning sciatic nerve. Its clinical appearance often gets confused with sciatica of lumbar spine origin. Wallet-induced chronic sciatic nerve constriction produces gluteal and ipsilateral lower extremity pain, tin-gling, and burning sensation. It was Lutz, first describing credit-card wallet sciatica in an Attorney, surfaced on Journal of American Medical Association (JAMA), 1978; however, the condition has not been well-studied in various other occupations. Case Summary: In this write-up, we take the privilege of demonstrating wallet neuritis as an example of peripheral sensitization in three different professionals’ namely specialist doctor, driver, and banker first time in Bangladesh. All the three patients’ demonstrated aggravated gluteal pain with radiation on the homo-lateral lower extremity while remained seated on heavy wallet for a while, fortunately im-proved discontinuing such stuff with. Alongside radical wallectomy, piriformis stretching exercise on the affected side had also been recommended and found worthy in terms of pain relief. Conclusion: long-standing use of rear pocket wallet may compress and sensitize ipsilateral sciatic nerve, generating features resembling lumbago sciatica; thereby, remains a source of patients’ misery and diagnostic illusion for pain physicians as well.

Medial collateral ligament calcification: a rare knee pain entity with literature review:

Medial knee pain can originate from both osseous and non-osseous soft tissue structures including medial collateral ligament (MCL), creating a raft for patients’ sufferings. Previously published works demonstrated MCL calcification as a rare medial knee pain entity. Alongside physical examination, radio-imaging techniques, namely conventional X-ray, CT/MRI scanning, etc. have been reported to be useful in recognizing MCL calcification. The present study demonstrates MCL calcification in a 60-year-old Asian-Bangladeshi woman, using high frequency diagnostic ultrasonogram and is the first reported study in the literature. To have available literature review, PubMed, Cochrane, Embase, and Scopus databases were used.