Manual of Rheumatology Dedicated to Education Fifth Edition Indian Rheumatology Association Editor-in-Chief Ved Chaturvedi Editors Molly M Thabah Debashish Danda Rajiva Gupta Vir Singh Negi Vinod Ravindran Durga Prasanna Misra Vivek Vasdev Manual of Rheumatology CBS Publishers & Distributors Pvt Ltd Dedicated to Education 9 789387 085039 ISBN: 978-93-87085-03-9 This manual is aimed to serve as a quick and easy reference book for students, clinicians and rheumatologists. It is authored by clinicians and rheumatologists representing each and every corner of India. Using a simple language, it focuses on the clinical aspects of rheumatological diseases. This edition is thoroughly revised and updated, and has several new contents: The new content includes chapter on basics such as musculoskeletal examination, approach to a patient with suspected connective tissue disease, and joint injections The section on osteoporosis has new chapters on glucocorticoid-induced osteoporosis, and DEXA scan interpretation Keeping up with the advances in diagnosis and treatment aspects in rheumatology, there is a new chapter on ultrasonography in rheumatology, MRI in rheumatology, small molecules, and stem cell transplant in autoimmune rheumatic disease The section on vasculitis has been greatly expanded and many diseases discussed in separate chapters. Keeping up with the trend on early diagnosis, a chapter on pre- rheumatoid arthritis has been introduced Orphan diseases such as relapsing polychondritis and adult onset Still’s disease are also covered in this new edition of the Manual. • • • • • Dr (Lt General ) MD, DM is Professor and Senior Consultant in Rheumatology, Sir Ganga Ram Hospital, New Delhi. After finishing his DM from Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, he was entrusted to modernise Department of Rheumatology, Army Research and Referral Hospital, Delhi. He started medical arthroscopy and made a modern immunology laboratory in 2000. He was first to use biologics for rheumatic diseases in 2002 and is known for his concept of low dose Infliximab as a strategy to prevent tuberculosis and as a cost saving measure during anti-TNF therapy. He established first MSK ultrasound in the country in 2004 and conducted first MSK ultrasound workshop in IRACON, Chennai. He worked hard to start DNB program in rheumatology in the country. He has served Indian Rheumatology Association (IRA) for many years and was elected its President. His oratory and teaching skills are well known amongst the students. He served the Indian Army for four decades and reached the top-most position. He has also served as physician to the President of India and was awarded highest peace time award Param Vishist Sewa Medal (PVSM) by the President of India. Ved Chaturvedi Editor-in-Chief Editor-in-Chief
Transcript
Manual ofRheumatology
Dedicated to Education
FifthEdition
Indian Rheumatology Association
Editor-in-Chief
Ved ChaturvediEditors
Molly M ThabahDebashish Danda
Rajiva GuptaVir Singh Negi
Vinod RavindranDurga Prasanna Misra
Vivek Vasdev
Manual ofRheumatology
CBS Publishers & Distributors Pvt Ltd
De
dic
ate
d to
Ed
uca
tion
9 789387 085039
ISBN: 978-93-87085-03-9
This manual is aimed to serve as a quick and easy reference book for students, clinicians and rheumatologists. It is authored by clinicians and rheumatologists representing each and every corner of India. Using a simple language, it focuses on the clinical aspects of rheumatological diseases.
This edition is thoroughly revised and updated, and has several new contents: The new content includes chapter on basics such as musculoskeletal examination, approach to a patient with suspected connective tissue disease, and joint injectionsThe section on osteoporosis has new chapters on glucocorticoid-induced osteoporosis, and DEXA scan interpretationKeeping up with the advances in diagnosis and treatment aspects in rheumatology, there is a new chapter on ultrasonography in rheumatology, MRI in rheumatology, small molecules, and stem cell transplant in autoimmune rheumatic diseaseThe section on vasculitis has been greatly expanded and many diseases discussed in separate chapters. Keeping up with the trend on early diagnosis, a chapter on pre-rheumatoid arthritis has been introducedOrphan diseases such as relapsing polychondritis and adult onset Still’s disease are also covered in this new edition of the Manual.
•
•
•
•
•
Dr (Lt General ) MD, DM
is Professor and Senior Consultant in Rheumatology, Sir Ganga Ram Hospital, New Delhi. After finishing his DM from Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, he was entrusted to modernise Department of Rheumatology, Army Research and Referral Hospital, Delhi. He started medical arthroscopy and made a modern immunology laboratory in 2000. He was first to use biologics for rheumatic diseases in 2002 and is known for his concept of low dose Infliximab as a strategy to prevent tuberculosis and as a cost saving measure during anti-TNF therapy. He established first MSK ultrasound in the country in 2004 and conducted first MSK ultrasound workshop in IRACON, Chennai. He worked hard to start DNB program in rheumatology in the country. He has served Indian Rheumatology Association (IRA) for many years and was elected its President. His oratory and teaching skills are well known amongst the students. He served the Indian Army for four decades and reached the top-most position. He has also served as physician to the President of India and was awarded highest peace time award Param Vishist Sewa Medal (PVSM) by the President of India.
Ved ChaturvediEditor-in-Chief
Edito
r-in-C
hie
f
Fifth Edition
Manual of
Rheumatology
Editors of Previous Editions
1st and 2nd EditionsEditor-in-chiefPrakash K PispatiAssociate editorsNirupa E. Borges, SS Uppal
First Edition: 1999Second Edition: 2002Third Edition: 2009Fourth Edition: 2014
All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic ormechanical, including photocopying, recording, or any information storage and retrieval system without permission,in writing, from the editors and the publisher.
Published by Satish Kumar Jain and produced by Varun Jain for
• Patna 0-9334159340 • Pune 0-9623451994 • Uttarakhand 0-9716462459
Printed at Magic International Pvt. Ltd., Greater Noida, UP, India
Disclaimer
Science and technology are constantly changing fields.New research and experience broaden the scope ofinformation and knowledge. The editors have tried theirbest in giving information available to them while preparingthe material for this book. Although all efforts have beenmade to ensure optimum accuracy of the material, yet itis quite possible some errors might have been leftuncorrected. The publisher, the printer and the editors willnot be held responsible for any inadvertent errors, omissionsor inaccuracies.
It is a great privilege and pride for me to edit the fifth edition of the Manual of Rheumatology. The goalwas to provide a state-of-the-art Manual which can stimulate the readers. It was a challenge for me to editthis edition as we know scientific writing is a balance of science and art, and in multi-authored bookthere is always possibility in overlap in content between chapters and loss of focus.
The Manual of Rheumatology is the official publication of Indian Rheumatology Association writtenprimarily for rheumatologists, postgraduates, teachers, researchers and also for any professional connectedwith care of diseases related to joints, connective tissues and various other autoimmune problems. I amsure this Manual will also be of use to orthopaedic surgeons, dermatologists and many other specialists.Moreover, there is general unawareness about rheumatic and autoimmune diseases in India, many patientstake other system of medicines and go to quacks in their village with the hope of finding a cure andrelieve of their sufferings. Many practitioners are also generally not confident of handling a patient withrheumatic complaint. I hope the Manual serves as a medium to spread awareness about chronicrheumatological diseases to many physicians practising in remote areas of the country.
The Asia-Pacific region particularly India has recently witnessed growth of teaching institutions offeringformal degree courses and short-term training fellowship in rheumatology. Most of the rheumatologycentres have attracted the best brains of medicine who are enthusiastic and crave to learn the latest. Inkeeping up with growth of rheumatology in India, the fifth edition of the Manual of Rheumatology isupdated and revised with international standard of printing. The new edition has several new chapterslike MRI in rheumatology, musculoskeletal examination, ultrasound in rheumatology, and various newchapters. The new format should make the book easier to read and carry. The diagrams have been greatlyimproved. Multiple tables with each chapter would be useful to the undergraduates and generalpractitioners too. There are 50,000 medical students in India at a given time. Unfortunately, rheumatologyis not well taught in most of the medical colleges due to lack of teachers and I am sure this book wouldhelp the needy students.
Finally, I have tried my best to minimize the errors and overlap in content, and I am sure this editionwill serve as a benchmark so that the Manual will evolve further in future editions. I wish to thank theauthors for their contribution, and I hope that this new edition will be well received by the scientificcommunity in India and abroad.
Dr (Lt General) Ved Chaturvedi MD DM
Editor-in-Chief
Preface to the Fifth Edition
Perhaps nowhere in the world as in India that the arthritic patient is vulnerable to influences and counter-influences of modem medicine, homoeopathy, ayurveda and unani systems of medicine, not to speak ofacupuncture, copper bangles, magnetic therapy and what have you. In an ancient land such as India, arheumatologist is competing with these modalities of alternate medicine all the time. Alternate medicine,if practiced in a scientific way may be justifiable, but under this garb outright quackery is practiced aswell. Steroids are mixed on the sly with ayurvedic and homoeopathic preparations. Branding of jointswith hot iron rods in the hope of curing arthritis still goes on rampantly. Some arthritic patients have lostteeth under the false belief that removal of “septic focus” would cure arthritis. Not surprisingly, evenpractitioners of modem medicine at times prescribe drugs of alternate medicine without necessarilyunderstanding their role. The stark reality of the Indian situation is that there is such little understandingof rheumatic diseases in the minds of average practitioners. This is attributed to the fact that rheumatologyis not taught in medical schools. Perhaps a few orthopaedic surgeons may refer to rheumatic diseasesduring their interaction with students. But is this enough?
There is thus a paramount need for a Manual of Rheumatology intended for practitioners, postgraduatesin medicine and orthopaedics, orthopaedic surgeons who mainly treat rheumatic diseases day in and dayout. Rheumatologists are so few in India that much of the arthritis care is delivered by these practitioners.Hence, this manual is mainly addressed to this target audience.
No doubt, the Indian Rheumatism Association (IRA) conducts CME programmes for practitionersthroughout the country from time to time, but its reach is restricted. The Manual of Rheumatology aimsat bringing recent diagnostic and therapeutic skills available in modem medicine to the practitioner. Forexample, there are few practitioners who realize that there are a hundred different types of arthritis. Themanual aims at building their confidence in at least making a tentative diagnosis on clinical grounds. Itsets out guidelines on laboratory investigations for arthritis, which to order and how to interpret theresults. Radiology of arthritis is well illustrated. The reader should be able to discern between rheumatoidarthritis and seronegative spondyloarthropathies. The practitioner should be able to treat successfully acase of infective arthritis with cure as the outcome. The book emphasizes the wide prevalence of tuberculousarthritis in our country. It brings into focus the new diseases like HIV in arthritis. Complexities ofvasculitis and antiphospholipid syndrome are explained in simple terms. Therapeutic modalities aredescribed in a way that the practitioner should be able to choose a rational NSAID and not be afraid toprescribe DMARDs. Finally, the manual raises the challenge of patient education in the management ofchronic diseases such as arthritis.
This Manual is a dream come true. It is a labour of love of us rheumatologists in India. It was indeed aprivilege to write for this manual and to edit the various chapters and finally publish it within the stipulatedtime, for the new millennium. Initially, the print run is a modest five thousand. We hope that the sponsorsM/s. Pfizer Ltd. will take up the challenge of reaching the practising community at large and multiply theprint run several times. We pray that the manual will be received and read by the practitioners with enthusiasmin the hope of better care and treatment for the arthritic patient to whom the book is dedicated.
Prakash K PispatiEditor-in-Chief
Nirupa E BorgesAssociate editor
SS UppalAssociate editor
Preface to the First Edition
Aarthi Priya T MD, DM
Assistant ProfessorDepartment of RheumatologyGovernment Kilpauk Medical College and HospitalChennai
Abhishek Kumar MD, DNB Rheumatology
Senior ResidentDepartment of Rheumatology and Clinical ImmunologyArmy Hospital Research and Referral, New Delhi
Abhra Chandra Chowdury MD, DM
ConsultantMission Hospital, Durgapur, West Bengal
Able Lawrence MD, DM
ProfessorDepartment of Clinical ImmunologySanjay Gandhi Postgraduate Institute of Medical SciencesLucknow
Ajay Wanchu MD, DM
Division of Arthritis and Rheumatic DiseaseOregon Health and Science University, Portland, OR, USA
Ajaz Kariem Khan MD
Director, Centre for Joint Diseases and Pain ManagementSHIFA Medical Centre Srinagar
Alakendu Ghosh MD
Professor and Head, Department of RheumatologyIPGMER & SSKM Hospital, Kolkata
ChiefDivision of Pulmonary, Critical Care and Sleep MedicineProfessor and Head, Department of MedicineSri Venkateswara Institute of Medical Sciences, Tirupati
Aman Sharma MD, FRCP (Lond.)
Additional ProfessorDepartment of Internal MedicinePost Graduate Institute of Medical Education and Research(PGIMER), Chandigarh
Amita Aggarwal MD, DM
ProfessorDepartment of Clinical ImmunologySanjay Gandhi Postgraduate Institute of Medical SciencesLucknow
Anand N Malaviya MD, FRCP (Lond.), FACP, FICP, FAMS
Clinical Immunologist and RheumatologistNiramaya Health Care, Jaipur
Bidyut Kumar Das MD, PhD
ProfessorDepartment of MedicineHead of Clinical Immunology and RheumatologySCB Medical College, Cuttack, Odisha
Bimlesh Dhar Pandey MD, MRCP
Senior Consultant, Department of RheumatologyFortis Hospital, Noida
Binoy J Paul MD, PhD, DNB, FRCP (Edin.)
Professor of Medicine, Chief of RheumatologyKMCT Medical College, Calicut
S Chandrashekara MD, DM
Director, ChanRe Rheumatology and Immunology CenterBengaluru
P Damodaram MD, DM
Consultant Rheumatologist, Tirupati
Debashish Danda MD, DM, FRCP (Lond.), FACR, FAMS
Professor and HeadDepartment of Clinical Immunology and RheumatologyChristian Medical College, Vellore
BG Dharmanand MD, DM
Senior Consultant and Head, Rheumatology, Sakra WorldHospital, Bengaluru
Durga Prasanna Misra MD, DM
Assistant ProfessorDepartment of Clinical ImmunologySanjay Gandhi Postgraduate Institute of Medical SciencesLucknow
Firdaus Fatima MD
Consultant RheumatologistAB Rheumatology Center, Hyderabad
Gautam Dhar Choudhury MD
Professor of Medicine and Unit Chief RheumatologyCommand Hospital, Lucknow
Ghan Shyam Pangtey MD
ProfessorDepartment of Medicine, Lady Hardinge Medical CollegeNew Delhi
Harshini AS MD
Senior ResidentClinical Immunology and Rheumatology, ChristianMedical College, Vellore
Jeet Patel MD
Senior ResidentDepartment of Rheumatology and Clinical ImmunologySir Ganga Ram HospitalNew Delhi
Jyoti Panwar MD (Radiology), FRCR
ProfessorDepartment of RadiodiagnosisChristian Medical College, Vellore
Jyoti Ranjan Parida MD, DM
Associate Professor and HeadDepartment of Immunology and RheumatologyIMS and SUM Hospital, Bhubaneswar
Jyotsna Oak MD
Consultant, Rheumatology and Internal MedicineKokilaben Dhirubhai Ambani Hospital, MumbaiFormer Professor, Department of Medicine and In-ChargeRheumatology, LTMG Hospital & LTM Medical CollegeSion, Mumbai
Kakarla Subbarao MD
Former DirectorNizam’s Institute of Medical Sciences, HyderabadPresident, Krishna Foundation for ResearchKIMS Hospital, Secunderabad
R Kaushik MRCP
Specialist Registrar, RheumatologyPrincess of Wales Hospital, Bridgend, UK
V Krishnamurthy MD, DM
Senior Consultant RheumatologistCEO Chennai Meenakshi Superspeciality HospitalChennai
Krishnan Shanmuganandan MD, DNB
Professor of Medicine and RheumatologyCommand Hospital, Lucknow
Manual of Rheumatologyx
Lalit Duggal MD, FRCP (Glasg.)
Senior Consultant and ChairmanDepartment of Rheumatology and Clinical ImmunologySir Ganga Ram Hospital, New Delhi
Latika Gupta MD, DM
Senior ResidentDepartment of Clinical ImmunologySanjay Gandhi Post Graduate Institute of Medical SciencesLucknow
Liza Rajasekhar MD
ProfessorDepartment of RheumatologyNizam’s Institute of Medical Sciences, Hyderabad
KM Mahendranath MD, FRCP (Lond.)
Senior Consultant RheumatologistSamarapan Health Centre, Bengaluru
Manish Rathi MD, DM
Additional ProfessorDepartment of NephrologyPost Graduate Institute of Medical Education and Research(PGIMER), Chandigarh
Manjit Ahlawat MBBS
Resident in MedicineMedical Division Command Hospital (Air Force)Bangalore
HR Madhuri MD, DM
Consultant RheumatologistCARE Hospital, Hyderabad
Marcia Friedman MD
Division of Arthritis and Rheumatic Disease,Oregon Health and Science University, Portland, OR, USA
Milind Nadkar MD, FICP
ProfessorDepartment of MedicineChief of Rheumatology, Seth GS Medical College and KEMHospital, Mumbai
Molly Mary Thabah MD
Associate ProfessorDepartment of MedicineJawaharlal Institute of Postgraduate Medical Education andResearch (JIPMER), Puducherry
Mohit Goyal MD
Consultant RheumatologistCARE Pain and Arthritis Centre, Udaipur
G Narasimulu MD, FICP, FIACM
Senior Consultant RheumatologistGVN Medical Centre, HyderabadFormer Professor and Head, Department of RheumatologyNizams Institute of Medical Sciences, Hyderabad
Nagma Bansal MD
Senior ResidentDepartment of Rheumatology and Clinical Immunology,Sir Ganga Ram Hospital, New Delhi
Natasha Negalur MD
Senior ResidentDepartment of Rheumatology and Clinical ImmunologyMedanta, The MedicityGurgaon
Neha Arora DNB (Medicine)
Classified RegistrarDepartment of RheumatologyClinical Immunology and AllergiesArtemis HospitalsGurgaon
Nibha Jain MD
Senior ResidentMedicine and RheumatologyVS Hospital, Ahmedabad
Nikhil Gupta MD
Senior Resident, Post doctoral fellowDepartment of Clinical Immunology and RheumatologyChristian Medical College, Vellore
Nutan Kamath MD
ProfessorDepartment of PediatricsKasturba Medical College, Mangalore
PD Rath MD
Associate Director and Head, RheumatologyMax Super Speciality Hospital, New Delhi
Parasar Ghosh MD, DM
ProfessorDepartment of RheumatologyIPGMER and SSKM Hospital, Kolkata
Senior ResidentDepartment of Clinical ImmunologySanjay Gandhi Postgraduate Institute of Medical SciencesLucknow
Sanat Phatak MD
Senior ResidentDepartment of Clinical ImmunologySanjay Gandhi Postgraduate Institute of Medical SciencesLucknow
Sanjeeb Kakati MD
ProfessorDepartment of Medicine, In charge of Rheumatology ClinicAssam Medical College, Dibrugarh, Assam
Sanjiv Kapoor MD, DM
Senior Consultant RheumatologistIndian Spinal Injuries Centre, Vasant Kunj, DelhiSanjivani Rheumatology and Infertility Centre, Delhi
Sapan Pandya MD, DM
Consultant RheumatologistVS Hospital and Vedanta Institute of Medical SciencesAhmedabad
Sarath Chandra Mouli Veeravalli MD, MRCP (UK)
Clinical DirectorDepartment of Rheumatology and Clinical ImmunologyKrishna Institute of Medical Sciences, Hyderabad
Sathish Kumar MD, DCH
Professor of PediatricsChristian Medical College, Vellore
Shankar Naidu MD, DM
Senior ResidentDepartment of Internal MedicinePost Graduate Institute of Medical Education and Research(PGIMER), Chandigarh
Sharath Kumar MD (Ped), DNB Rheumatology
Consultant RheumatologistColumbia Asia Hospital, Bengaluru
V Shantaram MD
Consultant PhysicianFormer Professor and Head, Department of MedicineNizam’s Institute of Medical Sciences, Hyderabad
Manual of Rheumatologyxii
Shefali Khanna Sharma MD
Associate ProfessorDepartment of Internal MedicineRheumatology and Clinical Immunology UnitPost Graduate Institute of Medical Education and Research(PGIMER), Chandigarh
J Shivanand MD
ConsultantSri Deepti Rheumatology Centre, Hyderabad
Shweta Singhai MD
ConsultantDepartment of RheumatologySakra World Hospital, Bengaluru
Shyamashis Das MD, DM
Consultant RheumatologistInstitute of Neurosciences, Kolkata
SJ Gupta FRCP (Glasg.), FRCP (Edin.)
Senior Consultant RheumatologistApollo Indraprastha and Sant Parmanand HospitalsNew Delhi
Siddharth Jain MBBS
Junior ResidentDepartment of Internal MedicineAll India Institute of Medical Sciences, New Delhi
Silas Supragya Nelson MD
Associate Professor, Medicine andIn-charge Rheumatology UnitNSCB Medical College, Jabalpur
Sita Naik MD
Retired Professor of Immunology and DeanSanjay Gandhi Postgraduate Institute of Medical SciencesLucknow
MR Sivakumar MD, DM, PhD, FRCP, FACR, FAAN, FAHA
Program DirectorStroke Interventions and Neurocritical CareGLB Hospitals and Acute Stroke Center, Chennai
Somnath Bhar MBBS, MRCP
Consultant PhysicianGD Hospital and Diabetes Institute, Kolkata
Sonal Mehra MD, DM
Consultant RheumatologistJaypee Hospital, Noida
Subhankar Haldar MD
Assistant ProfessorDepartment of RheumatologyIPGMER and SSKM Hospital, Kolkata
Subramanian Shankar MD, DNB FRCP (Glasg.)
Professor and Senior Advisor (Medicine and ClinicalImmunology)Command Hospital (Air Force), Bengaluru
Sujata Sawhney MD, MRCP (UK)
Senior ConsultantPediatric and Adolescent RheumatologistPediatric Rheumatology Division, Institute of Child HealthSir Ganga Ram Hospital, New Delhi
Sukumar Mukherjee MD, FRCP, FRCPE, FICP
Ex-Professor and HeadDepartment of Medicine, Medical College, KolkataConsultant PhysicianCalcutta Medical Research InstituteGD Hospital and Diabetes InstituteKothari Medical Centre, Kolkata
Sumeet Agrawal MD, DM
HeadDepartment of RheumatologyClinical Immunology and AllergiesArtemis Hospitals, Gurgaon
Sundeep Grover MD, DM
Associate ProfessorDepartment of Medicine, Subharti Institute of MedicalSciences, MeerutArthritis and Immunology Clinic, Meerut
Sundeep Upadhyaya MD, DM
Senior Consultant RheumatologistDepartment of Rheumatology, Indraprastha ApolloHospitals, New DelhiAssociate Professor—AHERF
Professor of Pediatrics andIn-charge Allergy Immunology UnitAdvanced Pediatrics CentrePost Graduate Institute of Medical Education and Research(PGIMER), Chandigarh
Taral Parikh MD, DNB Rheumatology
Consultant RheumatologistColumbia Asia Hospital and GCS Medical CollegeAhmedabad
Uma Kumar MD
Professor and HeadDepartment of RheumatologyAll India Institute of Medical Sciences, New Delhi
Y Uday MD, DM
Associate ProfessorDepartment of Haematology andBMT Army Hospital (Research and Referral), New Delhi
Contributors xiii
URK Rao MD
Consultant RheumatologistDirector, Sri Deepti Rheumatology CentreHyderabad
Varun Dhir MD, DM
Associate ProfessorDepartment of Internal MedicinePost Graduate Institute of Medical Educationand Research (PGIMER), Chandigarh, India
Ved Chaturvedi MD, DM
Professor and Senior Consultant RheumatologistDepartment of Rheumatology and Clinical ImmunologySir Ganga Ram Hospital, New Delhi
Velu Nair MD, FRCP (Lond.)
Director General, Medical Services (Army), New Delhi
VR Joshi MD, FRCP (Lond.)
Consultant Physician and RheumatologistDirector Research, PD Hinduja Hospital and MRC, MahimMumbai
Vijay KR Rao MBBS, MRCP (UK), FRCP
Manipal Hospital, Bengaluru
Vijaya Prasanna Parimi MD, DM
Consultant RheumatologistKrishna Institute of Medical Sciences, Hyderabad
Vinod Ravindran MD, MRCP, FRCP (Edin.)
Centre for Rheumatology, CalicutDepartment of Rheumatology, National Hospital, CalicutKerala
Vikas Agarwal MD, DM
ProfessorDepartment of Clinical ImmunologySanjay Gandhi Post Graduate Institute of Medical SciencesLucknow
Vikram Londhey MD
ProfessorDepartment of MedicineTopiwala National Medical College andBYL Nair Charitable Hospital, Mumbai
Vir Singh Negi MD, DM
Professor and HeadDepartment of Clinical ImmunologyJawaharlal Institute of Postgraduate Medical Education andResearch (JIPMER)Puducherry
Vishad Vishwanath MD, DM
Consultant RheumatologistDirector, Institute of Rheumatology and ImmunologicalSciences, Thiruvanathapuram
Vivek Vasdev MD, DNB Rheumatology
Head, Department of Rheumatology and ClinicalImmunologyArmy Hospital Research and ReferralNew Delhi
Yojana Gokhale MD
ProfessorDepartment of Medicine and In-charge of RheumatologyLokmanya Tilak Medical College, Sion, Mumbai
Manual of Rheumatologyxiv
Preface to the Fifth Edition v
Preface to the First Edition vii
Contributors ix
SECTION I: ASSESSMENT OF RHEUMATIC DISEASES
1. Rheumatology Non-stop (A Short Story: History in the Making) 3Prakash Pispati
2. Simple Clinical Clues to Bedside Diagnosis 12Prakash Pispati
3. Epidemiology of Rheumatic Diseases in India 14Arvind Chopra
4. Musculoskeletal System Examination 29Milind Nadkar, Vikram Londhey
5. Approach to Monoarthritis 40SJ Gupta
6. Approach to the Patient with Polyarthritis 49Anand N Malaviya
7. Approach to Regional Pain 64Sharath Kumar, BG Dharmanand
8. Approach to a Patient with Suspected Connective Tissue Disorder 70Anupam Wakhlu, Rasmi Ranjan Sahoo
9. Approach to Vasculitis 78Ramnath Misra
10. Outcome Measures in Rheumatic Diseases 87Sapan Pandya10A. Outcome measures in rheumatoid arthritis 91
Puja Srivastava10B. Outcome measures in systemic lupus erythematosus 95
Taral Parikh10C. Outcome measures in scleroderma 97
Taral Parikh10D. Outcome measures in spondyloarthropathies 101
Anuj Shukla10E. Outcome measures in primary Sjögren’s syndrome 106
Nibha Jain, Sapan Pandya10F. Outcome measures in vasculitides 110
Piyush Joshi10G. Outcome measures in osteoarthritis 114
