Miscellaneous disorders

Dupuytren contracture

It is a proliferative disorder causing thickening and contracture of the palmar fascia. Seen more commonly in 50 plus year old males of Northern European descent. It is inherited as an autosomal dominant disease. Risk factors include alcohol, smoking, trauma, anti-epileptic medications and diabetes mellitus. Cytokine mediated proliferation of myofibroblasts and excessive deposition of types III and I collagen is seen. It presents over years as painful lumps, nodules and cords in the palm, eventually leading to contractures involving one or more fingers. Some patients may develop thickened tissue on the feet (Ledderhose disease) or penis (Peyronie’s disease). Treatment includes physical therapy, corticosteroid injection into painful nodules, injection of Cl.histolyticum collagenase and fasciectomy.

Rhabdomyolysis

It is a disorder characterized by skeletal muscle damage leading to release of excessive quantities of intracellular myoglobin into the circulation. The myoglobin then settles in the renal tubules leading to acute renal failure. Renal injury also happens due to vasoconstriction and free radical damage. Common causes of rhabdomyolysis include severe trauma like crush injuries, lightning strikes, burns, heat stroke, viral infections like Influenza, HIV, EBV, bacterial infections like Legionella, falciparum malaria, McArdle disease, carnitine deficiency, electrolyte imbalances, reduced ATP, drugs like statins, fibrates, alcohol and snake venom. Symptoms include muscle cramping, myalgia, dark urine and fatigue. Complications include hyperkalemia, hypo and hypercalcemia, hyperuricemia, compartment syndrome, DIC, arrhythmias and renal failure. Plasma creatine kinase is elevated, myoglobin is present in urine and urine dipstick test is positive for blood. Management includes hydration, correction of electrolyte imbalances and treatment of complications and underlying conditions. Alkalinization of urine with sodium bicarbonate helps prevent renal failure.

Fibromyalgia

Fibromyalgia is a chronic musculoskeletal pain syndrome. It is not inflammatory or autoimmune in nature, but is associated with abnormal central pain processing in the brain. It is more common in women. Symptoms include multifocal pain and tenderness, fatigue , brain fog, joint stiffness, headache and poor sleep. It is often associated with irritable bowel syndrome. Fibromyalgia is a clinical diagnosis of exclusion, as lab work including ESR is normal. Management includes pain medications, steroids, duloxetine and tricyclic antidepressants.

Polymyalgia rheumatica

Polymyalgia rheumatica is an inflammatory disorder (vasculitis) seen in women over the age of 50 years and characterized by muscle pain and stiffness in the shoulder, hip and neck area. It is often associated with giant cell or temporal arteritis. The pain and stiffness are usually worse upon waking in the morning or after resting, and usually last an hour or more. Joint pain and swelling may be present. Weight loss and flu-like symptoms may be seen. ESR and CRP are elevated while creatine kinase is normal. The cytokine IL 6 is high. Treatment is with corticosteroids, IL 6 inhibitors like sarilumab and tocilizumab, methotrexate, TNF alpha inhibitors like infliximab and analgesics.