Raynaud Case Study
Details of patient.
Name : Mr. Black
Age : 64
Occupation : Retired Process worker
Signs and Symptoms
Pains in Joints. Mainly ankles and wrists.
General aches and pains in his joints.
-occurring gradually for a few months. Could be due to wear and tear of the tissues in the joints as he is 64 years old.
Ankles and wrists were mainly affected by the pains.
Probably due to overuse of his wrists and ankles over a long period of time as he was a process worker. This pain could also be due to post traumatic Arthritis. The pains are probably not caused by Rheumatoid Arthritis or Osteoarthritis because Rheumatoid Arthritis is more common in women than in men and Osteoarthritis affects men before the age of 55.
Cold and whitened …show more content…
fingertips
Tips of his fingers had become whitened and felt cold.
This could be because of reduced blood supply to the fingers.
He may have been exposed to low temperatures for long periods of time.
Wrinkles in his hands were disappearing.
The wrinkles in his hands were disappearing and the skin on his hand seemed to become tighter.
Could be due to scleroderma, a change in skin condition.
Scleroderma is an autoimmune disease.
Discolouration of fingers followed by increased blackening.
His hand had started to discolour.
Maybe he has focal pattern vitiligo which discolours the skin due to lack of melanin
Could also be Raynaud’s phenomenon.
After the discolouration, his hand had become increasingly blackened.
Gangrene could be a reason for this. Another would be frostbites.
Or even diabetes.
Dryness and soreness of mouth and eyes.
Mr. Black complained of dryness and soreness of the mouth and eyes.
Probably because the moisture producing glands are being attacked. causing the disruption of saliva and tears being produced.
Could be a case of Sjogren’s syndrome.
Dysphagia.
Mr. Black had difficulty swallowing.
Dysphagia can occur due to old age very possible in this case as Mr. Black is 64 years old.
Dysphagia can also occur in people with scleroderma.
Another possibility would be Xerostomia
Patient experiences dry mouth due to lack of saliva in Xerostomia.
Xerostomia is caused by the reduced function of the salivary gland.
Increasingly flatulent, severe diarrhea followed by spells of constipation.
Probably due to digestive imbalance such as indigestion and gas.
Can be caused by having too much of processed food without proper nutrition.
Results of investigations and examinations.
Full blood count.
Mr. Black’s full blood count were within the normal range.
He does not have anemia, where the blood count falls below the normal range
Does not have polycythemia vera, where the blood count is above the normal range.
Does not have leukopenia either.
Erythrocyte Sedimentation Rate.
Although his full blood count is within normal range, his Erythrocyte Sedimentation Rate is 35 mm/hr.
His Erythrocyte Sedimentation Rate is much higher than 20 mm/hr which is the normal rate for men above the age of 55.
An increased Erythrocyte Sedimentation Rate shows that Mr. Black may have an auto immune disease.
Serum Electrophoresis.
Mr. black has a high level of polyclonal hypergammaglobulinaemia .
This indicates high levels of immunoglobulins in his blood.
More than one type of immunoglobulin associated.
Condition is due to an infection and is not malignant.
Test would have shown monoclonal hypergammaglobulinaemia if malignant.
Serum Immunoglobulin levels.
Increased levels of Mr. Black’s immunoglobulin levels.
His IgG was 35 g/l. Normal range of IgG in healthy adults is between 6.2 g/l to 14 g/l.
His IgA level was 8 g/l. Normal range of IgA in healthy adults of IgA is between 0.8 g/l to 3.5g/l
His IgM level was 12 g/l. The normal range of IgM in a healthy adult is 0.45 g/l to 2.5 g/l.
Shows that his body is making more immunoglobulins to fight off infections.
X-Rays.
His X-Ray result show that the ‘Arthritic’ joints
Thickening of the periarticular soft tissues.
Can mean that he has Arthritis
Tissues around the bones are thicker than usual due to infection.
Shows juxta-articular osteoporosis.
Which means that the bone next to the joint is thinner.
Urine Examination.
Urine examination showed that Mr. Black had proteinuria
Indicates proteins in urine.
Proteinuria may indicate that he has holes in his nephrons as proteins can pass through them.
Skin Biopsy Analysis.
Shows a thinning of the epidermis with immunoglobulin deposition at the dermal – epidermal border.
A reason for the thinning of the epidermis is age.
Can also be because the connective tissue is being attacked.
Immunoglobulins are trying to fight off the attack but are accumulating instead.
Arteriolar Fibrosis was seen.
Arterioles were scarred due to injury
Probably causing reduced blood supply to extremities.
Autoantibody Screen.
Autoantibody screen showed that Mr. Black is positive for autoantibodies in his blood.
Probably means that Mr. Black has an auto immune disease.
Anti-nucleolar pattern of staining on immunofluorescence was seen.
This pattern is commonly seen in patients with the auto immune disease scleroderma.
Anti Salivary Duct antibody was also present.
The salivary duct is being attacked.
Thus preventing saliva from being secreted.
Phenomenon is seen in about 40% to 60% of patients with Sjogren’s syndrome.
Further Investigations.
Capillaroscopy.
Non – invasive, quick and easy
Capillaroscopy would show abnormal nail folding of the capillary loops together with the nailbed.
Test for Anti – RNA Polymerase III, Anti – topoisomerase I and anti centromere antibodies.
One or more of these antibodies would be present in a person with scleroderma.
Test for Autoantibodies to fibrillin I
Higher than normal levels would mean patient has scleroderma. Autoantibody not found in any other autoimmune disease.
d) Potential Therapies for treatment.
1) The treatment options that are currently available for the management and treatment of localized scleroderma, including:
Psoralen photochemotherapy (PUVA) Topical photodynamic therapy Drug therapy
The medications that are prescribed for the management and treatment of systemic sclerosis, including:
Immunosuppressive agents Antifibrotic agents Anti-infammatory agents Vasodilator agents
Angiotensin-converting enzyme (ACE) inhibitors
Medicines used to treat scleroderma include:
Corticosteroids Drugs that suppress the immune system such as methotrexate and Cytoxan Nonsteroidal anti-inflammatory drugs (NSAIDs)
Other treatments for specific symptoms may include:
Medicines for heartburn or swallowing problems Blood pressure medications (such as ACE inhibitors) for high blood pressure or kidney problems Light therapy to relieve skin thickening Medicines to improve breathing (bosentan) Medications to treat Raynaud 's phenomenon
Treatment usually also involves physical therapy.
Some medications keep blood vessels open (prostacyclins, endothelin receptor antagonists, ACE inhibitors, phosphodiesterase 5 inhibitors, and others) and are used to treat Raynaud 's phenomenon, heart and kidney problems, and pulmonary hypertension.
Other drugs reduce inflammation and block damaging immune factors. These treatments, which include cyclophosphamide, penicillamine, and bone marrow transplantation, may be helpful for improving skin thickness and reducing scarring, even in the lungs.
Doctors use other treatments for specific complications, such as proton pump inhibitors and pro-kinetic agents for gastrointestinal problems, or light treatments for skin thickening.
References. http://www.sclero.org/medical/about-sd/a-to-z.html#sd http://www.patient.co.uk/health/Scleroderma-Systemic-Sclerosis.htm
http://www.sclero.org/
http://umm.edu/health/medical/reports/articles/scleroderma http://www.sclero.org/medical/diagnosis/difficult/a-to-z.html#biopsies http://www.sclero.org/medical/diagnosis/tests/a-to-z.html#general http://rheumatology.oxfordjournals.org/content/45/suppl_4/iv43.full http://www.scleroderma-info.com/2009/landingp2.php?gid=RH010&?a=a&assoc=Google&keyword=scleroderma http://health.nytimes.com/health/guides/disease/scleroderma/ http://health.nytimes.com/health/guides/disease/scleroderma/treatment.html
Name : Mr. Black
Age : 64
Occupation : Retired Process worker
Signs and Symptoms
Pains in Joints. Mainly ankles and wrists.
General aches and pains in his joints.
-occurring gradually for a few months. Could be due to wear and tear of the tissues in the joints as he is 64 years old.
Ankles and wrists were mainly affected by the pains.
Probably due to overuse of his wrists and ankles over a long period of time as he was a process worker. This pain could also be due to post traumatic Arthritis. The pains are probably not caused by Rheumatoid Arthritis or Osteoarthritis because Rheumatoid Arthritis is more common in women than in men and Osteoarthritis affects men before the age of 55.
Cold and whitened …show more content…
fingertips
Tips of his fingers had become whitened and felt cold.
This could be because of reduced blood supply to the fingers.
He may have been exposed to low temperatures for long periods of time.
Wrinkles in his hands were disappearing.
The wrinkles in his hands were disappearing and the skin on his hand seemed to become tighter.
Could be due to scleroderma, a change in skin condition.
Scleroderma is an autoimmune disease.
Discolouration of fingers followed by increased blackening.
His hand had started to discolour.
Maybe he has focal pattern vitiligo which discolours the skin due to lack of melanin
Could also be Raynaud’s phenomenon.
After the discolouration, his hand had become increasingly blackened.
Gangrene could be a reason for this. Another would be frostbites.
Or even diabetes.
Dryness and soreness of mouth and eyes.
Mr. Black complained of dryness and soreness of the mouth and eyes.
Probably because the moisture producing glands are being attacked. causing the disruption of saliva and tears being produced.
Could be a case of Sjogren’s syndrome.
Dysphagia.
Mr. Black had difficulty swallowing.
Dysphagia can occur due to old age very possible in this case as Mr. Black is 64 years old.
Dysphagia can also occur in people with scleroderma.
Another possibility would be Xerostomia
Patient experiences dry mouth due to lack of saliva in Xerostomia.
Xerostomia is caused by the reduced function of the salivary gland.
Increasingly flatulent, severe diarrhea followed by spells of constipation.
Probably due to digestive imbalance such as indigestion and gas.
Can be caused by having too much of processed food without proper nutrition.
Results of investigations and examinations.
Full blood count.
Mr. Black’s full blood count were within the normal range.
He does not have anemia, where the blood count falls below the normal range
Does not have polycythemia vera, where the blood count is above the normal range.
Does not have leukopenia either.
Erythrocyte Sedimentation Rate.
Although his full blood count is within normal range, his Erythrocyte Sedimentation Rate is 35 mm/hr.
His Erythrocyte Sedimentation Rate is much higher than 20 mm/hr which is the normal rate for men above the age of 55.
An increased Erythrocyte Sedimentation Rate shows that Mr. Black may have an auto immune disease.
Serum Electrophoresis.
Mr. black has a high level of polyclonal hypergammaglobulinaemia .
This indicates high levels of immunoglobulins in his blood.
More than one type of immunoglobulin associated.
Condition is due to an infection and is not malignant.
Test would have shown monoclonal hypergammaglobulinaemia if malignant.
Serum Immunoglobulin levels.
Increased levels of Mr. Black’s immunoglobulin levels.
His IgG was 35 g/l. Normal range of IgG in healthy adults is between 6.2 g/l to 14 g/l.
His IgA level was 8 g/l. Normal range of IgA in healthy adults of IgA is between 0.8 g/l to 3.5g/l
His IgM level was 12 g/l. The normal range of IgM in a healthy adult is 0.45 g/l to 2.5 g/l.
Shows that his body is making more immunoglobulins to fight off infections.
X-Rays.
His X-Ray result show that the ‘Arthritic’ joints
Thickening of the periarticular soft tissues.
Can mean that he has Arthritis
Tissues around the bones are thicker than usual due to infection.
Shows juxta-articular osteoporosis.
Which means that the bone next to the joint is thinner.
Urine Examination.
Urine examination showed that Mr. Black had proteinuria
Indicates proteins in urine.
Proteinuria may indicate that he has holes in his nephrons as proteins can pass through them.
Skin Biopsy Analysis.
Shows a thinning of the epidermis with immunoglobulin deposition at the dermal – epidermal border.
A reason for the thinning of the epidermis is age.
Can also be because the connective tissue is being attacked.
Immunoglobulins are trying to fight off the attack but are accumulating instead.
Arteriolar Fibrosis was seen.
Arterioles were scarred due to injury
Probably causing reduced blood supply to extremities.
Autoantibody Screen.
Autoantibody screen showed that Mr. Black is positive for autoantibodies in his blood.
Probably means that Mr. Black has an auto immune disease.
Anti-nucleolar pattern of staining on immunofluorescence was seen.
This pattern is commonly seen in patients with the auto immune disease scleroderma.
Anti Salivary Duct antibody was also present.
The salivary duct is being attacked.
Thus preventing saliva from being secreted.
Phenomenon is seen in about 40% to 60% of patients with Sjogren’s syndrome.
Further Investigations.
Capillaroscopy.
Non – invasive, quick and easy
Capillaroscopy would show abnormal nail folding of the capillary loops together with the nailbed.
Test for Anti – RNA Polymerase III, Anti – topoisomerase I and anti centromere antibodies.
One or more of these antibodies would be present in a person with scleroderma.
Test for Autoantibodies to fibrillin I
Higher than normal levels would mean patient has scleroderma. Autoantibody not found in any other autoimmune disease.
d) Potential Therapies for treatment.
1) The treatment options that are currently available for the management and treatment of localized scleroderma, including:
Psoralen photochemotherapy (PUVA) Topical photodynamic therapy Drug therapy
The medications that are prescribed for the management and treatment of systemic sclerosis, including:
Immunosuppressive agents Antifibrotic agents Anti-infammatory agents Vasodilator agents
Angiotensin-converting enzyme (ACE) inhibitors
Medicines used to treat scleroderma include:
Corticosteroids Drugs that suppress the immune system such as methotrexate and Cytoxan Nonsteroidal anti-inflammatory drugs (NSAIDs)
Other treatments for specific symptoms may include:
Medicines for heartburn or swallowing problems Blood pressure medications (such as ACE inhibitors) for high blood pressure or kidney problems Light therapy to relieve skin thickening Medicines to improve breathing (bosentan) Medications to treat Raynaud 's phenomenon
Treatment usually also involves physical therapy.
Some medications keep blood vessels open (prostacyclins, endothelin receptor antagonists, ACE inhibitors, phosphodiesterase 5 inhibitors, and others) and are used to treat Raynaud 's phenomenon, heart and kidney problems, and pulmonary hypertension.
Other drugs reduce inflammation and block damaging immune factors. These treatments, which include cyclophosphamide, penicillamine, and bone marrow transplantation, may be helpful for improving skin thickness and reducing scarring, even in the lungs.
Doctors use other treatments for specific complications, such as proton pump inhibitors and pro-kinetic agents for gastrointestinal problems, or light treatments for skin thickening.
References. http://www.sclero.org/medical/about-sd/a-to-z.html#sd http://www.patient.co.uk/health/Scleroderma-Systemic-Sclerosis.htm
http://www.sclero.org/
http://umm.edu/health/medical/reports/articles/scleroderma http://www.sclero.org/medical/diagnosis/difficult/a-to-z.html#biopsies http://www.sclero.org/medical/diagnosis/tests/a-to-z.html#general http://rheumatology.oxfordjournals.org/content/45/suppl_4/iv43.full http://www.scleroderma-info.com/2009/landingp2.php?gid=RH010&?a=a&assoc=Google&keyword=scleroderma http://health.nytimes.com/health/guides/disease/scleroderma/ http://health.nytimes.com/health/guides/disease/scleroderma/treatment.html