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Common Myths in Rheumatology- Need to be Banished



There are many myths in public as well as medical fraternity, related to rheumatologic diseases and their treatment. This is detrimental as patients with rheumatologic diseases reach the rheumatologist very late with deformities and other systemic complications.


• The first myth is that these diseases are just bone and joint disease, this needs to be clarified that these are systemic autoimmune diseases. These patients need to be recognized early and given an early and comprehensive treatment with the principle of “treat to target” as there had been a paradigm change in the understanding of pathophysiology of these diseases and their management.


Approach in a patient with Joint Diseases


Broadly the musculoskeletal and rheumatic diseases can be inflammatory and non- inflammatory/ mechanical in etiology.

When the patient comes with pain in joint area, one has to make out if the joint is involved or not. Joint affection is made out by swelling of joint with effusion, accompanied by warmth and redness. There is tenderness in joint throughout all the joint movement. All these signs and symptoms lead us to diagnose arthritis.

The next step is to make out whether it is inflammatory or non inflammatory. Inflammatory joint diseases present as joint pains that are worst in early mornings and are accompanied by prolonged stiffness (> 30 minutes). The pain improves after moving or exercising the joint but after rest the pain worsens. It responds well to NSAIDs and has a fluctuating course.


A common myth is regarding the presence of Rheumatoid factor (RA Factor) in patients with non-specific body pains but no arthritis. If there is no arthritis clinically or even radiologically (as with musculoskeletal ultrasonography), then presence of autoantibodies does not indicate diagnosis of Rheumatoid arthritis and specific treatment is not required. Rheumatoid factor is an autoantibody (IgG, IgM or IgA) directed against our own IgG. Five percent of our population has it normally, without disease. If a patient has nonspecific body aches, then Rheumatoid factor positivity does warrant diagnosis of Rheumatoid arthritis. There are many metabolic causes which can present as nonspecific myalgia or arthralgia for example thyroid diseases, Vitamin D3 deficiency. Fibromyalgia is a common cause of such symptoms. If no cause can be found out then refer the patient to a rheumatologist for further evaluation.


Hyperuricemia does not mean presence of gout. Hyperuricemia is reflection of our calorie intake and associated with metabolic syndrome and is a risk factor for coronary artery disease. Literature says hyperuricemia without any presence of inflammatory joint involvement is not to be treated. When there is inflammatory involvement of joint, tendons or bursae, or there is presence of tophi, then treatment is indicated.


Another myth is that monoarthritis is tubercular arthritis. The commonest cause of monoarthritis is autoimmune. We need to look for present or past features like enthesitis, inflammatory back pain, uveitis, psoriasis etc. Infectious cause is ruled out by synovial fluid examination or synovial biopsy examination. Even one sided sacroiliitis does not always mean tuberculosis. Spondyloarthritis should not be forgotten as this is a common cause and quite frequently missed diagnosis


Drugs used in Rheumatology are supposed to be too toxic, especially Methotrexate. It is pertinent to understand that Methotrexate is used as either Low dose (LD) Methotrexate and High dose (HD) Methotrexate. High dose Methotrexate is a cancer drug and causes bone marrow suppression. LD (low dose) Methotrexate is used for autoimmune diseases which has a different mechanism of action and is an anti-inflammatory and immune-modulating drug. It is one of the safest drug used in medicine.


Retinopathy with Hydoxychloroquin is rare, therefore the drug should not be blamed for any eye problem in a patient taking it.


In the latest studies it has been found that there is no increase in perisurgical infections in patients taking DMARDs. Rather in a well controlled inflammatory state there would be better healing!


To conclude Medical science has really evolved in understanding and safe management of rheumatologic diseases.

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