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Differing diagnosis #280436
05/24/18 06:13 PM
05/24/18 06:13 PM
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achala Offline OP
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hello,
thank you in advance for reading.
Could you please direct me if possible to the approximately relevant for me threads?
I am caucasian male 37 yo. Developed first Iridociclities (minor flare) on my honeymoon in Nov 2017, 'treated'with yellox.
Second episode of Iridocilities (this time diagnosed as such) in April 2018 was much harder and Ophtamologist could not open pupil with Tobradex/Tropicamida for about a week, therefore I ended up on Medrol for 1 month. She made a connection to autoimmune diseases, as I had accompanying cervical/occipital pains and here we go I was tested for HLA B27 - positive. CRP - 20, VSH -20, fibrinogen - 572 before Medrol. CRP - 11, VSH 15, fibrinogen - 412 after Medrol.
Visit at rheumatologist and AS diagnosis, although MRI of sacroiliac joint completely clean. MRI of the cervical spine I have performed before the pain started in FEB 2018 also completely clean. After I finished Medrol (1 month) for the uveitis, he put me on Arcoxia 60mg, which took away approx 40% of the cervical pain away. Therefore we moved to 90 mg, which alltogether removed about 60% to 70% of the pain/stiffness of the neck.
I decided to try another rheumatologist for a 2nd opinion. Conclusion: because SIJ has no symptoms + cervical pain does not show the typical AS signs (pain is all the time no matter night or day) she thinks its a mechanical strain, perhaps discopathy of cervical spine and no AS. + she said Uveitis and send me back to Ophtamologist. CRP - 31, VSH 30.
Ophtamologist did some proper yelling at me that the cause is AS and I should be treating AS, etc. She made a check up and concluded its another Uveitis flare just beginning to form (23.05.2018). So I am back on Tobradex/Tropicamida until next monday if no improvement we are back on Medrol. The issue is that Medrol does not help for the cervical pain at all, and I cannot sleep due to pain.
I am in some kind of a vicious circle with 3 episodes of Uveitis in 8 months. Medrol working on Uveitis but not on cervical pain, and Arcoxia the opposite.
I tried acupuncture - made no sense in my case
I swim a lot and do kinetoteraphy + yoga. I try these things not to put me down, so i keep active, but the eye is a problem.
Where shall I go next.
Input appreciated.

Last edited by achala; 05/24/18 06:26 PM.

diagnosed with AS April 2018, starting with cervical pain/stiffness; Aug 2018 enthesitis/bursitis left Achilles
diagnosed with iridociclitis Nov 2017 (4 flares so far) - bilteral, DES
Eosinophilic Gastritis
No signs of inflammations on MRI`s for axial. Visible inflammation/erosion of Achilles/calcaneus + bursitis
Naproxen (occasionally), Sulfasalazine 3000 mg per day
Supplements: vit A&D, reishi mushrooms, fish oil/probiotic/ Mediterranean NSD
plenty of swimming
Re: Differing diagnosis [Re: achala] #280438
05/24/18 07:25 PM
05/24/18 07:25 PM
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Winston Offline
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I would go back to the first rheumatologist and discuss the second rheumatologist's opinion with him/her. Your symptoms certainly sound like SpA to me (maybe not AS, but in the family). Note that the clean MRIs are not dispositive. It can take years for damage to appear on imaging.

Re: Differing diagnosis [Re: achala] #280439
05/24/18 11:02 PM
05/24/18 11:02 PM
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I think I just found something that fits my symptoms more than my diagnosis of AS. I literally stumbled upon it an hour ago and decided to check out these forms to ask about this condition and saw your post. It sounds like you might fit this as well. It’s called Non-Radiographic Axial Spondyloarthritis.

Basically patients with NRAS present outward symptoms consistent with AS, but they show no signs of AS in their X-rays and MRIs (which is my case as well). I’m currently looking for more info, but can’t find much. Seems like NRAS is a pretty recent thing that medical journals and studies have only just begun looking into. For instance I don’t know if it it is just an early form of AS or something a little bit different than AS. I also can’t find anything on patients who (like me) test postitive for HLA B27 and weather or not being HLA B27 positive has the same correlation with NRAS as it does with AS, however what I have found seems to say that the same medications and treatments for AS also help patients with NRAS.

You might want to bring this up with a Rheumatologist, though I don’t know if it would be better to go back to the one of the doctors you’ve already seen, or seek out a third opinion, perhaps with someone who has experience with patients with AS and patients with NRAS.

https://www.ncbi.nlm.nih.gov/pubmed/26897981
http://www.rheumatologynetwork.com/...l-spondyloarthritis-treatment-guidelines

Last edited by Tim_K; 05/24/18 11:03 PM.
Re: Differing diagnosis [Re: achala] #280440
05/24/18 11:17 PM
05/24/18 11:17 PM
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SouthernMoss Offline
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Tim, there are two different ways of classifying spondyloarthritis. AS in the old classification is radiographic axial spondyloarthritis in the new classification. This link explains the two systems of classification.
https://www.spondylitis.org/Types-of-Spondylitis


Ginny - 57 year old female
Dx with USpA in March 2013; changed to AS in July 2015
Iritis and Scleritis
unicompartmental knee replacements: right-June 2014, left-Aug 2018
MTX, Humira, Cyclobenzaprine, plus Celebrex as needed
Supplements: Folic Acid, Vitamin A, Vitamin D, Calcium, Fish Oil, Culturelle probiotic, Melatonin (as needed)
Re: Differing diagnosis [Re: SouthernMoss] #280441
05/25/18 02:00 AM
05/25/18 02:00 AM
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Originally Posted by SouthernMoss
Tim, there are two different ways of classifying spondyloarthritis. AS in the old classification is radiographic axial spondyloarthritis in the new classification. This link explains the two systems of classification.
https://www.spondylitis.org/Types-of-Spondylitis


Thanks for pointing that out, a lot of the articles I was finding used Axial Spondyloarthitis and Ankylosing Spondylitis in the same sentence as if they were two different conditions.

Still I find it’s interesting that there is a decent enough population of people with a form of AS that does not show on imaging that a Non-Radiographic form of the disease seems to have recently gained some acceptance in the medical community.

Re: Differing diagnosis [Re: achala] #280442
05/25/18 03:11 AM
05/25/18 03:11 AM
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in the past a clinical diagnosis of AS required a specified amount of radiographic damage to the sacroiliac joints. But many of us don't have the required SI joint damage and were diagnosed with undifferentiated spondyloarthritis. Now some rheumatologists will give you a diagnosis of AS without the required SI joint damage, but others won't.

The newer method of classification removes the specific SI joint requirement and simply recognizes radiographic damage wherever it may be. And there is more understanding that doctors shouldn't have to wait for radiographic damage to be present before prescribing biologic treatment.


Ginny - 57 year old female
Dx with USpA in March 2013; changed to AS in July 2015
Iritis and Scleritis
unicompartmental knee replacements: right-June 2014, left-Aug 2018
MTX, Humira, Cyclobenzaprine, plus Celebrex as needed
Supplements: Folic Acid, Vitamin A, Vitamin D, Calcium, Fish Oil, Culturelle probiotic, Melatonin (as needed)
Re: Differing diagnosis [Re: achala] #280443
05/25/18 05:14 AM
05/25/18 05:14 AM
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Tacitus Offline
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Hello, achala:


Ophthalmologist is good one, points out obvious PRE-AS or early AS. It sounds obvious also, but every presentation of AS is different. Treat the AS properly and avoid AAU/iritis in the future and even avoid the eventual permanent skeletal deformity and fusion.

HEALTH,
John


Nota Bene: I am not a medical doctor, and my views do not represent the opinions of the SAA
AS Resources
My Long, Boring AS Story
Professor Alan Ebringer Diet and AS

Re: Differing diagnosis [Re: achala] #280444
05/25/18 07:47 AM
05/25/18 07:47 AM
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achala Offline OP
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in some of the papers posted on this site I read NSAIDs are more efficacious in preventing ossification than TNF blockers in early NRAS.
Does anyone know if NSAIDs like Arcoxia or else could also keep Uveitis at bay? How long does it take for the NSAIDs full benefits to kick in?
I suppose trying TNF blockers for NRAS in an early stage is an ultimate solution, after all other options failed?
many thanks in advance.

Last edited by achala; 05/25/18 08:41 AM.

diagnosed with AS April 2018, starting with cervical pain/stiffness; Aug 2018 enthesitis/bursitis left Achilles
diagnosed with iridociclitis Nov 2017 (4 flares so far) - bilteral, DES
Eosinophilic Gastritis
No signs of inflammations on MRI`s for axial. Visible inflammation/erosion of Achilles/calcaneus + bursitis
Naproxen (occasionally), Sulfasalazine 3000 mg per day
Supplements: vit A&D, reishi mushrooms, fish oil/probiotic/ Mediterranean NSD
plenty of swimming
Re: Differing diagnosis [Re: achala] #280448
05/26/18 04:39 AM
05/26/18 04:39 AM
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SouthernMoss Offline
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Everything I've read says biologics do more to prevent disease progression than NSAIDs.

NSAIDs can control uveitis for some people. www.uveitis.org, founded by world renown uveitis specialist Dr Stephen Foster, has a lot of good information on uveitis. This is a link to a document on that site where Dr Foster explains his approach to uveitis treatment, which includes the use of NSAIDs: http://www.uveitis.org/wp-content/uploads/2017/09/Therapeutic-Algorithm-for-Recurrent-Anterior.pdf


Ginny - 57 year old female
Dx with USpA in March 2013; changed to AS in July 2015
Iritis and Scleritis
unicompartmental knee replacements: right-June 2014, left-Aug 2018
MTX, Humira, Cyclobenzaprine, plus Celebrex as needed
Supplements: Folic Acid, Vitamin A, Vitamin D, Calcium, Fish Oil, Culturelle probiotic, Melatonin (as needed)
Re: Differing diagnosis [Re: achala] #280449
05/26/18 01:47 PM
05/26/18 01:47 PM
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WhiteCell Offline
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NSAID for uveitis can control pain however it can also cause delay in treatments. Steroid drops for better and worse can effectively decrease the inflammation but unfortunately (for me) over time can sponsor glaucoma and other eye problems. Not using them however can lead to nerve damage in the eye. After 40 years of battling eye issues I started Remicade and over time the issues subsided. I have not had a flare in the right eye for many many years. That said I use 1 drop of steroid and 1 drop of pressure relieving drop every day. Talk with your opthamologist about NSAIDS would be my thought.


Starting at 18 yrs old > Reiter's Syndrome. Diagnosed 2001 Ank Spon.
Started Remicade 2002 - 5mg/kg every 7 weeks.

Right Eye Glaucoma- Trabeculectomy/lens replacement 2006.
Right eye DSEK Cornea Transplant 2009.
Right eye Ahmed Shunt 2016.
Right eye DSEK Cornea Transplant 2016.
Supra Ventricular Tachycardia. 2004. Cured by RF ablation 2008.

ICU RN - Seattle, WA

~Grasp The Challenge and Succeed~
Re: Differing diagnosis [Re: achala] #280469
05/28/18 08:00 PM
05/28/18 08:00 PM
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AS, U C, Iritis, migraines. HLA-B27neg. Yoga (instructor) & spin. No meds at this time. Dx 1989. SAA member/donor since 1993. All my posts are personal opinion/feelings and do not represent the SAA. Help find a cure & support others by donating to the SAA.
Re: Differing diagnosis [Re: achala] #280646
06/26/18 06:54 PM
06/26/18 06:54 PM
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achala Offline OP
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I thought I will make a little update on the continuing investigations.
During the past month I ve been continuously on arcoxia 90mg. Somehow lessens the cervical pain.
Stopped swimming as thought the eyes are more prone to flares due to chlor.
Started yoga twice per week + kinetoterapy. Makes me moving but no help as for pain symptoms.
Apart from the cervical pain, creeped up also left Achilles and feel slight pinching in the right.
Went trough colonoscopy after hard episode of diarrhea and discovered red lesions covered in white powder like in terminal ileum. Awaiting biopsy results.
Tried acupuncturA , again no relief.
Reflexoteraphy as my rheumy advised.
Finishing my 3 days apple diet tonight.
But what I am quietly enthusiastic about (first time since 3 months) is the following: I have signed up for some Bowen massage and she is very careful with me knowing my condition. Last Friday after the session I could not turn my head anymore and everything was cracking there while moving. I woke up this morning as usual reddish eye, hell f a neck pain, limping left leg, no mood at all, sleepy as 2 years old, went for another session without hope. Had a little nap there, said thank you, left with no hope. While crossing the street checked right left then right left then again right left, 12 hours later still checking right left, i think I am dreaming. I am scared to go to sleep because I have no pain. Is this possible?


diagnosed with AS April 2018, starting with cervical pain/stiffness; Aug 2018 enthesitis/bursitis left Achilles
diagnosed with iridociclitis Nov 2017 (4 flares so far) - bilteral, DES
Eosinophilic Gastritis
No signs of inflammations on MRI`s for axial. Visible inflammation/erosion of Achilles/calcaneus + bursitis
Naproxen (occasionally), Sulfasalazine 3000 mg per day
Supplements: vit A&D, reishi mushrooms, fish oil/probiotic/ Mediterranean NSD
plenty of swimming
Re: Differing diagnosis [Re: achala] #280720
07/09/18 08:07 AM
07/09/18 08:07 AM
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achala Offline OP
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hello,
I have been waiting for the biopsy results from colonoscopy finally arriving today. However it brought only more confusion for my gastroenterologist.
Initially, she suspected an early Crohn, manifested by occasional red spots covered with white mucus in the small intestine only (no large intestine, duodenum or stomach).

The histopathological examination came back with: suspicion of Eosinophilic Gastroenteritis.
Doctor does not understand the results at this point and she has to consult.

From what I read on the internet so far is that Eosinophilic Gastroenteritis is triggered by some food allergens and leads to eosinophilic infiltration of gastrointestinal tract.
More here:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3746377/

Anyone ever heard of this in or without relation to AS?
Do you reckon might be caused by NSAIDS?
thank you

Last edited by achala; 07/09/18 08:08 AM.

diagnosed with AS April 2018, starting with cervical pain/stiffness; Aug 2018 enthesitis/bursitis left Achilles
diagnosed with iridociclitis Nov 2017 (4 flares so far) - bilteral, DES
Eosinophilic Gastritis
No signs of inflammations on MRI`s for axial. Visible inflammation/erosion of Achilles/calcaneus + bursitis
Naproxen (occasionally), Sulfasalazine 3000 mg per day
Supplements: vit A&D, reishi mushrooms, fish oil/probiotic/ Mediterranean NSD
plenty of swimming
Re: Differing diagnosis [Re: achala] #280721
07/09/18 12:03 PM
07/09/18 12:03 PM
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Winston Offline
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I know someone who has eosinophilic esophagitis. In his case, it's being treated as an autoimmune disease, as opposed to a chronic allergic condition. Never heard of it in relation to AS or NSAIDs.

Re: Differing diagnosis [Re: Winston] #280732
07/10/18 11:28 AM
07/10/18 11:28 AM
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achala Offline OP
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Originally Posted by Winston
I know someone who has eosinophilic esophagitis. In his case, it's being treated as an autoimmune disease, as opposed to a chronic allergic condition. Never heard of it in relation to AS or NSAIDs.


perhaps found something here:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1002150/pdf/annrheumd00284-0051.pdf


diagnosed with AS April 2018, starting with cervical pain/stiffness; Aug 2018 enthesitis/bursitis left Achilles
diagnosed with iridociclitis Nov 2017 (4 flares so far) - bilteral, DES
Eosinophilic Gastritis
No signs of inflammations on MRI`s for axial. Visible inflammation/erosion of Achilles/calcaneus + bursitis
Naproxen (occasionally), Sulfasalazine 3000 mg per day
Supplements: vit A&D, reishi mushrooms, fish oil/probiotic/ Mediterranean NSD
plenty of swimming
Re: Differing diagnosis [Re: achala] #281080
08/20/18 07:17 PM
08/20/18 07:17 PM
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achala Offline OP
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hello again,
I am being put on Methylprednisolone again + Tobradex/Tropicamida for another episode of Iritis.
Meantime I dropped Arcoxia and started the following Combo to address also my Eosinophilic gastritis: Budenofalk/Montelukast.

+once in few days I take Vimovo (Celebrex)for cervical pain.

I am also suppose to start Sulfalazine, but had to postpone due to some plans. My main Rheumy said if Sulfalazine wont work we think about biologic.
Meantime, I met another Rheumy who told me Sulfalazine will not work for Achilles enthesis (which i developed in addition quite recently), as current view states enthesis is not a peripheral SpA, but an axial. ?

Question: Sulfalazine can work for Uveitis/Achilles enthesis? Or shall I go another route and try to get Humira for the Uveitis?
Question 2: which biologic would work on all of the stuff I currently posses: Uveitis/cervical pain/Achilles enthesis/Eosinophilic gastritis
Question 3: Am I to naive thinking I can stop AS, by targeting Eosinophilic gastritis alone?

PS. i am also taking some supplements like: msm/shark cartilage/turmeric/vit D/probiotics

Last edited by achala; 08/20/18 07:18 PM.

diagnosed with AS April 2018, starting with cervical pain/stiffness; Aug 2018 enthesitis/bursitis left Achilles
diagnosed with iridociclitis Nov 2017 (4 flares so far) - bilteral, DES
Eosinophilic Gastritis
No signs of inflammations on MRI`s for axial. Visible inflammation/erosion of Achilles/calcaneus + bursitis
Naproxen (occasionally), Sulfasalazine 3000 mg per day
Supplements: vit A&D, reishi mushrooms, fish oil/probiotic/ Mediterranean NSD
plenty of swimming
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