Dr. Naval Mendiratta
Rheumatology
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hi doctor,
I have extreme swelling and pain in both my lower legs and feet. I also have severe pain in both hands, on all fingers, both wrists, both forearms, both elbows as well as both knees. It is extremely painful for me to stand and walk. I had a CMP (comprehensive metabolic panel) and CBC done, which showed a hemoglobin of 10.4 and a sedimentation rate of 21. I have had a positive ANA, high C3, C4, and high CRP. I also had protein testing that showed high alpha 1 and 2 and high beta 1 and 2. My IgG was also high. Uric acid was 5.1. I have a strong family history of thyroid disease, PMR (polymyalgia rheumatica), CMT, and Wegener's vasculitis. I am currently being treated for blood clots in both lungs reflux, Barrett's disease, and anxiety. I take tablets of Prilosec 20 mg, Xarelto 20 mg, and Celexa 20 mg each once daily, and 50 mg of Tramadol twice daily. My rheumatologist told me there is nothing more he can do for me and he considered my test results to be normal. Can you please tell me what could be wrong with me? Thank you.
Hello,
Welcome to icliniq.com. I have gone through your history and the blood reports (attachments removed to protect patient identity) along with the photographs you have posted. Well, there is gross swelling in both your legs. But, the albumin levels are not so low to explain the edema. Even the urine routine is normal. But never the less, it could be something else that we are missing here. I would like to understand more when you say you are being treated for blood clots. Was it a pulmonary embolism? Or was it something else? I could not find the results of anti-cardiolipin antibody or lupus anticoagulant and beta 2 glycoprotein 1. These are essential for us to know why the clotting did happen. Since you are already on tablet Rivaroxaban, it can be used to treat the condition but we need to look at the cause. I was wondering if they had run the ultrasound of your legs. Also, 24-hour urine protein to see the amount of leakage. Because we need something to get to the bottom of the leg swelling. Lastly, I would like to know a few more details. Did you ever have a history of oral ulcers or hair fall or hearing loss or recurrent sinusitis or dry eyes or dry mouth? Do let me know these queries. I would try to help you out further here.
Thank you.
Investigations to be done
Probable diagnosis
Treatment plan
Patient's Query
Hi doctor,
I was diagnosed with multiple large pulmonary embolisms five months back. Ultrasound was done that day on both legs and was negative. 24-hour urine output was normal. I was in the hospital for a week. I have ringing in my ears, recurrent sinusitis, dry eyes, and dry mouth. I shed a lot of hair, but no thinning or bald spots. I am attaching my laboratory work from the rheumatologist that I had two months ago for your reference. Kindly guide.
Hello,
Welcome back to icliniq.com.
I have gone through your reports (attachment removed to protect patient identity). They have tested you for vasculitis (inflammation of blood vessels) and ENA (extractable nuclear antibodies) profile which is negative. However, your symptoms and the large pulmonary embolism (blood clot in the lung) do fit in with systemic lupus erythematosus (SLE) with possible antiphospholipid syndrome. Since your ultrasound was negative for any deep vein thrombosis (DVT) along with the swelling of legs you are experiencing, it looks more of a capillary leak syndrome which is a part of any connective tissue disease. I strongly feel we should evaluate your antiphospholipid antibodies along with the thrombophilia profile, so these events do not happen further. I would recommend you discuss with your rheumatologist starting low-dose steroids along with Hydroxychloroquine. You will benefit from it more than tablets Tramadol and other drugs.
Thank you.
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