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DR. EHTISHAM
DR. EHTISHAM, Doctor
Category: Medical
Satisfied Customers: 3653
Experience:  MBBS, FCPS
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I need a Rheumatologist for my father's condition, as he

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I need a Rheumatologist for my father's condition, as he suffers from small vessel vasculitis
Assistant: Have you seen a doctor about this yet? What medications are you taking?
Customer: yes, Adalmumab (Humira) IV once every month along with other medications, we did lot of blood tests that came negative to Lupus or cryogolbinemia. the wounds in the feet is been static for 4 months and not healing or improving
Assistant: Is this a time sensitive issue? What type of specimen are they testing?
Customer: they took blood test regarding multiple autoimmune diseases, all came negative, HCV negative,
Assistant: Anything else in your medical history you think the doctor should know?
Customer: he had 2 episodes of DVT, neuritis and was on pregablin and lot of neropathic pain management, then advised us to do gastri sleeve as my father was markedly over wheight, he lost weight from 198 kgs to 150 kgs

Hello! My name is***** to JustAnswer. I'm a Consultant Rheumatologist and I am reviewing your question now, and will post back with your reply momentarily.

Sorry to hear about your father

What exactly is your question?

Regards

Customer: replied 1 month ago.
I am a senior house officer in plastic surgery so I can explain to you the case better, 5 years ago he got DVT, then another episode 3 years ago. His only medical problem was his over weight (198kgs) working as desk job,
then 2 years ago he started to have firing pain into his feet bilaterally and accumulate on the lateral malluas, then when he got small wounds in his feet that took vvvv long time to heal.

What investigations were carried out for his problem?

Regards

Customer: replied 1 month ago.
Doctors gave us pregabalin and cymbalta and then the pain wont subsides

What investigations were carried out for his problem?

Regards

Customer: replied 1 month ago.
the doctor advised us to do bariartic surgery to decrease his weight it decrease the load on his back as they suspected this pain from the back stretching on the nerves, we did gastric Sleeve and he lost around 45 kgs.
HCV negative, Tubercline test negative, ADNA negative, Anti beta 2glycoprotein IgG and IgM Negative, Complement C3 and C4 wihin normal range,Lipid prfile HDL low and LDLhigh, Homocysteine Serum high 18.08,
Customer: replied 1 month ago.
Anti cardiolipin IgM and IgG negative, Cryglobulin negative
Customer: replied 1 month ago.
Detective of Lupus Anticoagulant:
dRVV Scree ratio citrate plasma is 3.89, dRVV normalized ration 1.71, dRVV Confirm ration 2.28

What about the results of nerve conduction study and skin biopsy?

Regards

Customer: replied 1 month ago.
he got now try gangrene on the tip of the distal phalanx of the right hand
and lot of ulcers in both feet,
we did CT angio and shows no focus emboli and suspected Autoimmune disease, Doctors here are giving us humira IV once every month
we took 4 doses, the wounds are not improving, the finger is dry and we wish to terminalize it, he is also taking Xeralto
Customer: replied 1 month ago.
the skin biopsy were not able to do it coz all the wounds were chronic and when we when to the pathologist he told us he has to take the biopsy from a fresh wound

Is he on Humira and Xeralto since the start or something else has been given as well?

What about his kidney function?

Regards

Customer: replied 1 month ago.
the nerve conduction study is within normal range but MRI report done 1 year ago shows some myositis
Abnormal high signal change in anterior and posterior compartment muscles of right leg - ? Inflammtory cause - myositis.
Diffuse subcutaneous edema in right leg.
Customer: replied 1 month ago.
Kidney fiunctions within normal range, he was on warfarin for 5 years, then when he got this episode of blue patch in his finger tip in less than a week the finger turned blue then white then black, he was admitted for Pain management and then a small dot of necrotic patch appeared on the tip of the index finger of the OTHER hand, we got scared and rushed Rhematologist who started us on Humira that time and then the left finger was fine but off course we couldn't save the right index finger

So he never received steroids or cyclophosphamide at any stage?

Regards

Customer: replied 1 month ago.
I think he received small dose of oral steroids but not cyclophosphamide

And he didn,t feel any better since being on Humira?

Regards

Customer: replied 1 month ago.
the wound improved about by 50%, the pain on the left finger and coldness subsided, but now its been 3 months the wounds in both feet the same and he gets a lot of pain in the area just proximal to the gangrene tip of the finger, he cannot sleep and we are considering to do terminilization as this is the main problem now the pain, he is constantly on non steroidals for pain and I am so worried about his kidney funtions but also I am scarred to stop the Xeralto to proceed with the amputation

Thanks for the information

Let me explain it all one by one

First of all it seems his problem does not fit into any specific category of vasculitis

It seems like an undifferentiated vasculitis

Now in my opinion he needs to be on steroids in a high dose and as Humira is not working well for him so I would suggest a switch to Cyclophosphamide or Rituximab

For pain relief he should be on Opioids for a short period of time as pain of vasculitis is generally a severe one

I would look for any fresh lesion for biopsy or even biopsy from the edge of that gangrene to be more certain about evidence of vasculitis

Please feel free to ask if you have any other question

I am available to assist till you are satisfied

If you have received the answer to your satisfaction please leave a 5-stars feedback rating

Regards

DR. EHTISHAM and other Medical Specialists are ready to help you
Customer: replied 1 month ago.
the doctors here suspected small vessel vasculitis, another doctor suggested to take myofortic and cellcept but we prefered to be on Humira. unfortunety in Egypt it is vv hard to get opiods I gave him codamol anyways I can not thank you enough for your help. his next dose of Humira next week I will let you know regarding any further details.
Customer: replied 29 days ago.
Doctor please Can I ask you more questions regarding my father's condition mentioned above,

Hi

You have to send another question directly referring my name for further discussion

Regards

Customer: replied 29 days ago.
Sure

Regards