I received a call yesterday from Mr J, son of an ex-minister of the state that he wanted to consult me and we scheduled a meeting today.
Mr J, a young handsome gentleman (of about my age) came to my office today afternoon with his wife and a small cute baby, 3 yrs old. He had come to consult regarding his wife who had developed varicose veins ('swollen veins and lumps') over her leg. She had developed these about 3 years old, around the same time of her pregnancy.
On examination, I could see some prominent (hardly significant from medical point of view) veins over her left leg around the knee and even fewer around the ankle. They hardly fitted into anything like varicose veins (long sephanous or short sephanous systems). I assured them that these were just prominent veins which are commonly present in some people and are best ignored.
Then she pointed towards a lump present behind her left knee. It was 4 x 4 cms soft compressible non-tender lump present in the popliteal (knee) fossa. To me it looked like a Baker's cyst (swelling of bursa) or a lipoma ( fat swelling) [Bursa: A bursa is a fluid filled sac/pouch that provides a cushion between bones and tendons and/or muscles around a joint. This helps to reduce friction between the bones and allows free movement. Bursae are filled with synovial fluid and are found around most major joints of the body]. I again reassured that if the swelling is asymptomatic and is stable for the last 2.5 years, then nothing has to be done apart from observation.
At this, she drew my attention to similar swellings behind her both ankles and knees. On examination, they all looked liked bursal swellings. Now, I was thinking as what could possibly cause multiple busral swellings Earlier I had thought of referring her to an Orthopaediacian (bone doctor) but now I changed it to Rheumatologist (doctors who deal with autoimmune diseases like Rheumatoid arthrits, SLE etc).
But I was wondering what could perhaps cause multiple bursitis and subsequent bursal swellings ? All detailed history about fever, oral ulcers, hair fall, small joint stiffness, muscle weakness etc ( symtoms of athritis/ Rheumatological diseases) were negative. So could it be pregnancy because the swelling started around that time only (about 3 yrs back). I was as confused as earlier.
I decided to probe further. That's what make clinical medicine so interesting. My teacher used to say "Every patient (even suffering from the same disease) is different and a good clinician should always be alert and smart like Sherlock Holmes to unravel the mystery and identify the culpri. Thats why computers and robots can never replace human brains as far as clinical medicine is concerned. In medicine, 2 plus 2 can 3, 4,5 or even be 7 ".
On further probing, she divulged that she had also suffered from high fever and joint pains 3 years back and she was diagnosed as suffering from Chikungunya. I wondered whether an episode of Chikungunya could be responsible for all this. I knew that Chikungunya causes arthritis but was not sure whether it could cause bursitis and subsequent bursal swellings. I explained this to the patient and opened internet on my mobile. I checked a couple of trusted sites and also came across a paper on Chikungunya in Indian Journal of Dermatology from Dr Alladi Mohan, an old trusted learned physician from AIIMS , in which the disease was described in detail. And yes, Chikungunya can cause bursitis in multiple joints and residual bursal swellings even years after.
The patient and her relatives were reassured once again and no doubt all of them were extremely happy.Mr J was quite impressed and wanted to interact more. And so, we kept on talking. Mr J had done PhD in international economic relations from John Hopkin's University, USA and was quite knowledgeable and intelligent. We talked about everything and anything and to our utter surprise, it turned out that both of us were together in Campus School, Hisar (Haryana, India) during our schooling from 1985-1989. Mr J turned out to be my brother's classfellow, who was one year my senior.
Wow, its a small and wonderful world. !
Mr J, a young handsome gentleman (of about my age) came to my office today afternoon with his wife and a small cute baby, 3 yrs old. He had come to consult regarding his wife who had developed varicose veins ('swollen veins and lumps') over her leg. She had developed these about 3 years old, around the same time of her pregnancy.
On examination, I could see some prominent (hardly significant from medical point of view) veins over her left leg around the knee and even fewer around the ankle. They hardly fitted into anything like varicose veins (long sephanous or short sephanous systems). I assured them that these were just prominent veins which are commonly present in some people and are best ignored.
Then she pointed towards a lump present behind her left knee. It was 4 x 4 cms soft compressible non-tender lump present in the popliteal (knee) fossa. To me it looked like a Baker's cyst (swelling of bursa) or a lipoma ( fat swelling) [Bursa: A bursa is a fluid filled sac/pouch that provides a cushion between bones and tendons and/or muscles around a joint. This helps to reduce friction between the bones and allows free movement. Bursae are filled with synovial fluid and are found around most major joints of the body]. I again reassured that if the swelling is asymptomatic and is stable for the last 2.5 years, then nothing has to be done apart from observation.
At this, she drew my attention to similar swellings behind her both ankles and knees. On examination, they all looked liked bursal swellings. Now, I was thinking as what could possibly cause multiple busral swellings Earlier I had thought of referring her to an Orthopaediacian (bone doctor) but now I changed it to Rheumatologist (doctors who deal with autoimmune diseases like Rheumatoid arthrits, SLE etc).
But I was wondering what could perhaps cause multiple bursitis and subsequent bursal swellings ? All detailed history about fever, oral ulcers, hair fall, small joint stiffness, muscle weakness etc ( symtoms of athritis/ Rheumatological diseases) were negative. So could it be pregnancy because the swelling started around that time only (about 3 yrs back). I was as confused as earlier.
I decided to probe further. That's what make clinical medicine so interesting. My teacher used to say "Every patient (even suffering from the same disease) is different and a good clinician should always be alert and smart like Sherlock Holmes to unravel the mystery and identify the culpri. Thats why computers and robots can never replace human brains as far as clinical medicine is concerned. In medicine, 2 plus 2 can 3, 4,5 or even be 7 ".
On further probing, she divulged that she had also suffered from high fever and joint pains 3 years back and she was diagnosed as suffering from Chikungunya. I wondered whether an episode of Chikungunya could be responsible for all this. I knew that Chikungunya causes arthritis but was not sure whether it could cause bursitis and subsequent bursal swellings. I explained this to the patient and opened internet on my mobile. I checked a couple of trusted sites and also came across a paper on Chikungunya in Indian Journal of Dermatology from Dr Alladi Mohan, an old trusted learned physician from AIIMS , in which the disease was described in detail. And yes, Chikungunya can cause bursitis in multiple joints and residual bursal swellings even years after.
The patient and her relatives were reassured once again and no doubt all of them were extremely happy.Mr J was quite impressed and wanted to interact more. And so, we kept on talking. Mr J had done PhD in international economic relations from John Hopkin's University, USA and was quite knowledgeable and intelligent. We talked about everything and anything and to our utter surprise, it turned out that both of us were together in Campus School, Hisar (Haryana, India) during our schooling from 1985-1989. Mr J turned out to be my brother's classfellow, who was one year my senior.
Wow, its a small and wonderful world. !
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