A Dissertation on
PREVALENCE OF PERIPHERAL NEUROPATHY IN RHEUMATOID ARTHRITIS
Dissertation Submitted to
THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY CHENNAI – 600 032
With partial fulfillment of the regulations for the award of the degree of
M.D. GENERAL MEDICINE BRANCH – I
COIMBATORE MEDICAL COLLEGE COIMBATORE
APRIL 2016
Certificates
Declaration
Acknowledgement
ACKNOWLEDGEMENT
At the outset, I would like to express my sincere gratitude to our Dean, Prof. Dr. EDWIN JOE, M.D., for his permission to conduct this study in Coimbatore Medical College.
I’m immensely grateful and indebted to my Prof. Dr. KUMAR NATARAJAN M.D., Professor and Head, Department of Medicine, Coimbatore Medical College.
It gives me immense pleasure to express my sincere and deep gratitude to my guide, Prof. Dr. M. RAVEENDRAN M.D., Professor, Department of General Medicine, Coimbatore Medical College, for his guidance and constant encouragement throughout the study.
It is with deepest sense of gratitude and respect that I would like to thank my co- guide, Prof. Dr. MAHESH M.D., D.M., Professor, Department of Rheumatology, Coimbatore Medical College, for his constant support, guidance, invaluable suggestions and help that he has rendered through out the study.
I would like to acknowledge with gratitude, the help provided by our Unit Chief Dr. Sivakumar M.D., our unit Assistant Professors - Dr.
Usha Padmini M.D, Dr. Balamurugan M.D. and Dr Sembakashree
M.D. I would like to thank them for their valuable suggestions
throughout the study. I’m indebted to them for being a constant source
of inspiration.
I’m gratefully indebted to Dr. Shobana M.D., D.M., Assistant Professor, Department of Neurology, for helping me out with the interpretation of nerve conduction study results, without which I would not have completed my study.
I would also like to thank Mr. Pradeep, Technician, Department of Neurology, in helping me in conducting the nerve conduction studies.
I would also like to thank Dr. Karthikeyan M.D., Assistant Professor, Department of PSM, PSGIMS & R, Coimbatore in helping me with the statistical analysis for the study. I would always like to remember with extreme sense of thankfulness for the cooperation and criticism from my fellow post- graduates, my dear seniors and juniors.
I would like to thank my husband, Dr. Dinoop K.P. for taking out his time for editing my work and his constant support. I would like to take this opportunity to show my gratitude to my father, Mr. Venugopalan K., my mother Ms. Sainumole B., and my brother Anand Venugopal for their never ending support and prayers.
I’m ever grateful to the ALMIGHTY GOD for showering his blessings on me and my family and I pray Almighty God to give me the strength to achieve all my endeavors.
Finally, I whole-heartedly thank all my patients, who formed the
backbone of the study without which this would not have become a
reality.
ABBREVIATIONS
RA – Rheumatoid arthritis CNS – Central nervous system PNS – Peripheral nervous system RF – Rheumatoid factor
ESR – Erthrocyte sedimentation rate CRP – C reactive protein
HLA – Human leucocyte antigen EBV - Epstein Barr virus
HBV – Hepatitis B virus HCV – Hepatitis C virus
ACPA – Anti-citrullinated protein antibody PADI – Peptidyl arginine deaminase TNF – Tumor necrosis factor
CD – Cluster differentiation TLR – Toll like receptor
NOD - Nucleotide binding oligomerisation domain like receptors JAK – Janus kinases
FLS – Fibroblast -like synoviocytes MMP – Matrix mettalloproteinases
TIMP – Tissue inhibitor of metalloproteinase
PIP - Proximal interphalangeal joint
MCP – Meta carpophalangeal joint DIP – Distal interphalangeal joint EAM – extra articular manifestations HIV – Human immunodeficiency virus
HRCT – High resolution computerized tomography ILD – Interstitial lung disease
CCP – Citrullinated cyclic peptide
NSAIDS – Non steroidal anti- inflammatory drugs DMARD – Disease modifying anti-rheumatic drugs G-CSF – Granulocyte colony stimulating factor MRI – Magnetic resonance imaging
MRA – Magnetic resonance angiography NCS – Nerve conduction study
SNAP – Sensory nerve action potential CMAP – Compound muscle action potential CV – Conduction velocity
CTS - Carpal tunnel syndrome HCQ – Hydroxychloroquine MTX – Methotrexate
SSZ - Sulfasalazine
SLE – Systemic lupus erythematosus
SABE – Subacute bacterial endocarditis
ELISA – Enzyme linked immunosorbent assay
ACR – American college of rheumatology
EULAR – The European league against rheumatism WBC – White blood cell
IBD – Inflammatory bowel disease CBC – Complete blood count LFT – Liver function tests RFT – Renal function tests
MTB – Mycobacterium tuberculosis DNA – Deoxy ribonucleic acid GFR – Glomerular filtration rate ULN – Upper limit of normal OPD – Out patient department UL – Upper limb
LL – Lower limb
NCN – Non-compressive neuropathy
CN – Compressive neuropathy
Contents
CONTENTS
CONTENT PAGE NO.
1. INTRODUCTION 1
2. AIMS AND OBJECTIVES 3
3. REVIEW OF LITERATURE 4
4. MATERIALS AND METHODS 45
5. RESULTS 50
6. DISCUSSION 73
7. SUMMARY 77
8. CONCLUSION 79
REFERENCES ANNEXURES
PROFORMA
CONSENT FORM
MASTER CHART
List of figures
LIST OF FIGURES
S. No. Details of the figures Page No.
1 Multistep progression to the development of
rheumatoid arthritis 9
2 Adaptive and innate immune processes within
the joint in rheumatoid arthritis 14
3 Motor nerve conduction study 24
4 Temporal dispersion motor conduction 25
5 Sensory nerve conduction study 26
List of tables
LIST OF TABLES
S. No. Details of the tables Page No.
1 ACR-EULAR CRITERIA (2010) for
classification of Rheumatoid arthritis 34 & 46
2 Mean age of the study population 50
3 Sex distribution of the study population 50
4 Frequency of various patterns of axonal
neuropathy in the study population 51 5 Association of axonal changes with various
patterns of neuropathy 53
6 Association between axonal neuropathy and age, duration of rheumatoid arthritis & erythrocyte
sedimentation rate (ESR).
55
7 Frequency of rheumatoid factor in the study
population 56
8 Association of sex with rheumatoid factor. 56
9 Frequency of axonal neuropathy in relation to
rheumatoid factor 57
10 Frequency of various patterns of axonal
neuropathy in relation to rheumatoid factor 58 11 Association between rheumatoid factor and
patterns of axonal neuropathy among males
60
12 Association between rheumatoid factor and patterns of axonal neuropathy among females
62
13 Association between patterns of axonal neuropathy and age of the patients
64
14 Frequency of various patterns of axonal neuropathy in relation to sex of the patient.
65
15 Association between patterns of axonal neuropathy and duration of rheumatoid arthritis.
67
16 Association between patterns of axonal neuropathy and erythrocyte sedimentation rate
68
17 Association between peripheral neuropathy
symptoms with age and duration of illness 69 18 Association between peripheral neuropathy
symptoms with sex.
70
19 Association between peripheral neuropathy symptoms with rheumatoid factor.
70
20 Frequency and association of neuropathy symptoms with various patterns of axonal
neuropathy
71
Introduction
Aims &
Objectives
Review of
Literature
Materials &
Methods
Results
Discussion
Summary
Conclusion
References
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Annexures
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