Raiyyan Tahsan

Raiyyan Tahsan
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TC(1036).(05).Orthopedics Case No 114:- Bursitis

Bursitis — বাংলা ক্লিনিক্যাল নোট

নোট: নিচের ডোজগুলো adult, non-pregnant patient ধরে দেওয়া। CKD, PUD/GI bleed, anticoagulant use, uncontrolled HTN/CVD, DM, pregnancy/lactation, allergy—এসব থাকলে ডোজ/ড্রাগ বদলাতে হবে। Septic bursitis সন্দেহ হলে steroid injection দেওয়া যাবে না; আগে aspiration/culture, তারপর antibiotic.

1) Definition — Bursitis কী?

Bursitis হলো bursa নামক synovial membrane–lined ছোট fluid-filled sac-এর acute বা chronic inflammation। Bursa tendon–bone বা skin–bone-এর friction কমায়। Inflammation হলে bursa-তে fluid জমে localized pain, swelling, tenderness হয়।

2) Causes / Etiology — কারণগুলো

A. Mechanical / Trauma-related

  • Repeated pressure / microtrauma: হাঁটু গেড়ে কাজ, কনুই টেবিলে ভর দেওয়া, repetitive sports movement।
  • Direct trauma: পড়ে গিয়ে elbow/knee-তে আঘাত → hemorrhagic bursitis।
  • Overuse injury: shoulder, hip, knee, heel-এর repeated friction।

B. Inflammatory / Crystal disease

  • Gout / pseudogout: monosodium urate বা CPPD crystal bursa-তে inflammation করে।
  • Rheumatoid arthritis / psoriatic arthritis / spondyloarthritis: systemic inflammatory disease-এর অংশ হিসেবে bursitis হতে পারে।

C. Infective / Septic bursitis

  • সাধারণত skin break, abrasion, puncture wound, cellulitis থেকে bacteria bursa-তে ঢোকে।
  • Septic olecranon/prepatellar bursitis-এ Staphylococcus aureus প্রায় 80–85% দায়ী; Streptococcus pyogenes-ও হতে পারে।

D. Risk factors

  • Diabetes mellitus, CKD, immunosuppression, alcoholism
  • Chronic hemodialysis
  • Skin wound/cellulitis
  • Repeated kneeling/leaning occupation: plumber, carpet layer, housemaid, student elbow, athlete ইত্যাদি।

3) Symptoms / Clinical features — লক্ষণগুলো

Common symptoms

  • Localized swelling: কনুই, হাঁটু, shoulder, hip, heel—যেখানে bursa আছে সেখানে ফুলে যায়।
  • Pain: movement বা pressure দিলে ব্যথা বাড়ে।
  • Tenderness: bursa-এর উপর চাপ দিলে ব্যথা।
  • Warmth/redness: inflammatory বা septic হলে বেশি দেখা যায়।
  • Movement limitation: active movement painful; তবে isolated bursitis-এ passive ROM অনেক সময় preserved থাকে।

Septic bursitis suspect করার লক্ষণ

  • Fever বা systemic toxicity
  • Marked redness, warmth, severe tenderness
  • Overlying skin wound, scratch, pus/drainage
  • Diabetes/immunosuppression
  • Rapidly increasing swelling/pain
    AAFP অনুযায়ী fever থাকলে superficial bursitis-কে septic until proven otherwise হিসেবে ভাবা উচিত, যদিও fever না থাকলেও septic bursitis বাদ যায় না।

4) Clinically Diagnosis — কীভাবে clinically ধরবেন?

History

  • Recent trauma?
  • Repeated pressure/kneeling/leaning?
  • Fever, wound, cellulitis?
  • Gout/RA history?
  • Anticoagulant use?
  • Occupation/sports exposure?

Examination

  • Inspection: localized bursal swelling, erythema, wound/drainage।
  • Palpation: fluctuation, warmth, tenderness।
  • ROM: bursitis-এ joint movement painful হতে পারে, কিন্তু septic arthritis-এর মতো passive ROM usually severely restricted নয়।
  • Compare opposite side: warmth difference, swelling difference।
  • Regional lymph node: septic হলে lymphadenopathy থাকতে পারে।

5) Specific Investigations — কোন test কখন করবেন?

Typical mild aseptic bursitis

  • Investigation অনেক সময় লাগে না; clinical diagnosis যথেষ্ট।

If trauma/fracture/calcification suspect

  • X-ray: fracture, foreign body, calcification, Haglund deformity, OA দেখতে।

If swelling deep / cellulitis vs bursitis unclear

  • Ultrasonography: bursal fluid, cellulitis থেকে bursitis আলাদা করা, aspiration guidance।

Septic bursitis suspect হলে

  • Bursal aspiration — must if suspected septic bursitis
    • Gram stain
    • Culture & sensitivity
    • Cell count with differential
    • Crystal analysis
    • Glucose
      Aspiration ideally antibiotic শুরুর আগে করা উচিত, কারণ antibiotic দিলে culture yield কমে যায়।

Blood tests

  • CBC with differential
  • ESR, CRP
  • RBS/HbA1c if diabetes suspected
  • Blood culture if fever/systemic toxicity/immunocompromised
  • Serum uric acid: gout support করে, কিন্তু acute flare-এ normal হতে পারে—crystal analysis বেশি specific।

MRI

  • Deep bursa involvement, osteomyelitis, septic arthritis, abscess, or unclear diagnosis হলে। AAFP বলছে ultrasound/cell count/markers/MRI infection vs noninfection differentiate করতে সাহায্য করে।

6) Differential Diagnosis

  • Septic arthritis
  • Cellulitis
  • Abscess
  • Gout / pseudogout arthritis
  • Hemarthrosis
  • Tendinitis / tenosynovitis
  • Ligament injury
  • Fracture
  • Osteoarthritis flare
  • Rheumatoid arthritis flare
  • Morel-Lavallée lesion

7) Complications — রোগের জটিলতা

  • Chronic recurrent swelling: বারবার fluid জমে daily activity সমস্যা করে।
  • Septic bursitis: infection bursa-তে pus তৈরি করে।
  • Cellulitis: surrounding skin infection ছড়িয়ে যেতে পারে।
  • Septic arthritis: infection joint cavity-তে ছড়ালে joint damage হতে পারে।
  • Osteomyelitis: adjacent bone infection হতে পারে।
  • Sinus/fistula formation: chronic infected bursa থেকে discharge tract হতে পারে।
  • Reduced ROM / stiffness: pain ও chronic inflammation-এর কারণে function কমে।
  • Iatrogenic infection: unnecessary aspiration/injection করলে infection introduce হতে পারে; তাই aseptic microtraumatic bursitis-এ routine aspiration recommend করা হয় না।

8) Treatment / Management — Core approach

A. Non-pharmacological management

Acute non-septic bursitis

  • Rest / relative activity modification
  • Ice pack: 15–20 min, দিনে 3–4 বার, প্রথম 48–72 ঘণ্টা
  • Compression bandage if superficial swelling
  • Elevation
  • Protective padding: elbow pad/knee pad
  • Pain কমলে gradual ROM exercise
  • Repetitive pressure বন্ধ করা
    MSD ও AAFP দুটোই nonseptic bursitis-এ rest/activity modification, NSAID/analgesic, physiotherapy/ROM-এর কথা বলে।

Septic bursitis

  • Aspiration + culture
  • Empirical antibiotic covering S. aureus and Streptococcus
  • Severe/systemic/immunocompromised হলে hospital admission + IV antibiotic
  • Non-response/recurrent/pus collection হলে drainage/bursectomy।

9) Pharmacological Drugs — Bangladesh practice-focused list

Important prescription principle

বাংলাদেশে doctors সাধারণত bursitis-এর ধরন অনুযায়ী prescribe করেন:

  1. Aseptic painful bursitis: Paracetamol ± topical NSAID ± oral NSAID ± PPI
  2. Persistent deep bursitis: infection exclude করার পর intrabursal steroid ± lidocaine
  3. Septic bursitis: aspiration/culture + anti-staphylococcal antibiotic
  4. Gouty bursitis: NSAID/colchicine for flare; recurrent gout হলে urate-lowering therapy

MedEx-listed brand availability সময়ের সাথে বদলাতে পারে; নিচে clinically relevant commonly used MedEx-listed examples দেওয়া হলো, exhaustive market list নয়।

9.1 Pain control / Non-septic bursitis

1) Generic name: Paracetamol / Acetaminophen

  • Therapeutic category: Analgesic, antipyretic
  • Pharmacological class: Non-opioid analgesic
  • Why used: Pain কমাতে; inflammation কমায় না, তবে NSAID contraindicated হলে safer option।
  • Adult dose: 500–1000 mg PO every 6–8 h PRN; usual max 3 g/day, selected healthy adult-এ 4 g/day পর্যন্ত।
  • Duration: 3–5 days PRN.
  • Bangladesh available brand examples: Napa 500 mg, Ace 500 mg, Reset 500 mg, Fast 500 mg, Pyralgin 500 mg, Renova 500 mg। MedEx Napa 500 mg, Ace 500 mg, Reset 500 mg এবং paracetamol brand list দেখিয়েছে।
  • Side effects: nausea, rash, hepatotoxicity in overdose.
  • Interactions: alcohol, liver disease, enzyme inducer drugs, chronic high-dose use with warfarin.

2) Generic name: Ibuprofen

  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: Non-selective NSAID; COX inhibition → prostaglandin synthesis কমায়। MedEx ibuprofen-কে pain with inflammation, rheumatic pain, muscular pain-এ indicated বলেছে।
  • Why used: Pain + inflammation + swelling কমাতে।
  • Adult dose: 400 mg PO TDS after food.
  • Duration: 3–5 days; severe inflammation হলে clinician review করে extend।
  • Bangladesh available brand examples: Profen 400 mg, Inflam 400 mg, Neurofen 400 mg, Iburex 200/400 mg, Rapofen 400 mg।
  • Side effects: dyspepsia, gastritis/GI bleed, renal impairment, edema, BP increase, bronchospasm in aspirin-sensitive asthma.
  • Interactions: anticoagulant/antiplatelet/SSRI → GI bleed; ACEi/ARB + diuretic → AKI risk; methotrexate/lithium toxicity; avoid late pregnancy, active PUD, severe CKD.

3) Generic name: Naproxen sodium

  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: Non-selective NSAID
  • Why used: Longer-acting NSAID; bursitis/tendinitis pain and swelling কমাতে।
  • Adult dose: 250–500 mg PO BD after food; acute severe pain হলে 500 mg initially then 250 mg 6–8 hourly PRN; max 1000 mg/day.
  • Duration: 5–7 days; septic suspicion থাকলে NSAID দিয়ে infection mask করবেন না।
  • Bangladesh available brand examples: Naproxen 500 mg, Naptodin 500 mg, Napxon-P 250/500 mg, Nasox 500 mg। MedEx naproxen 500 mg tablet-এ bursitis indication ও dosing দেখিয়েছে।
  • Side effects: GI upset/bleed, renal toxicity, edema, BP rise.
  • Interactions: ACE inhibitor, diuretics, aspirin, methotrexate, warfarin, SSRI—MedEx এগুলো interaction হিসেবে উল্লেখ করেছে।

4) Generic name: Etoricoxib

  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: Selective COX-2 inhibitor NSAID
  • Why used: Pain/inflammation control; GI-risk তুলনামূলক কম হলেও CV/BP risk বেশি হতে পারে।
  • Adult dose: 60 mg OD; severe short-course pain/inflammationে 90 mg OD.
  • Duration: 3–5 days; shortest duration, lowest effective dose.
  • Bangladesh available brand examples: Etorix 60/90/120 mg, Oricox 30/60/90/120 mg, Recox 60/90/120 mg, Ribox 60/90/120 mg, Rito 60/90/120 mg, Setorib 60/90 mg, Etocox 90/120 mg। MedEx etoricoxib brand list-এ এসব strength দেখিয়েছে।
  • Side effects: hypertension, edema, dyspepsia, renal impairment, CV thrombotic risk.
  • Interactions: warfarin, ACEi/ARB/diuretic, lithium, methotrexate; alcohol unsafe noted by MedEx for etoricoxib 90 mg।

5) Generic name: Diclofenac topical gel

  • Therapeutic category: Topical analgesic/anti-inflammatory
  • Pharmacological class: Topical NSAID
  • Why used: Local superficial bursitis pain/swelling-এ systemic NSAID adverse effect কম রেখে local relief।
  • Dose: Apply thin layer over painful area 3–4 times/day; open wound/skin infection-এর উপর নয়।
  • Duration: 7–14 days.
  • Bangladesh available brand examples: Voligel 1%, Voligel Max 2%, Voltagel 1%, Voltagel DS 2%, Clofenac 1%, Diclofen 1%, Volifen 1%, Erdon gel 1%, Fastfit 1%।
  • Side effects: local burning, rash, photosensitivity; systemic NSAID effects rare but possible with large-area use.
  • Interactions: systemic NSAID-এর সাথে একসাথে high exposure হতে পারে; anticoagulant use-এ caution।

6) Generic name: Diclofenac sodium + Methyl salicylate + Linseed oil + Menthol

  • Therapeutic category: Topical anti-inflammatory preparation
  • Pharmacological class: Topical NSAID + counter-irritant combination
  • Why used: Musculoskeletal pain, sprain, tendinitis, bursitis-এ quick local relief; MedEx এই combination-কে bursitisসহ musculoskeletal pain/swelling-এ indicated বলেছে।
  • Dose: Apply locally 2–4 times/day; broken skin/eye/mucosa এড়িয়ে।
  • Duration: 5–10 days.
  • Bangladesh available brand examples: VOLINAC gel 1%, VOLINAC Max 2%, VOLINI gel 1%。
  • Side effects: skin irritation, burning, allergic dermatitis.
  • Interactions: aspirin/salicylate allergy, anticoagulant use, other topical irritants.

7) Generic name: Esomeprazole / Omeprazole

  • Therapeutic category: Anti-ulcerant / gastroprotection
  • Pharmacological class: Proton pump inhibitor, PPI
  • Why used: NSAID-induced gastritis/GI bleeding risk কমাতে, especially older age, previous PUD, anticoagulant/steroid use।
  • Adult dose: Esomeprazole 20 mg OD or Omeprazole 20 mg OD before breakfast.
  • Duration: NSAID চলাকালীন; usually 5–14 days, high-risk patient-এ longer.
  • Bangladesh available brand examples:
    • Esomeprazole: Nexum 20/40 mg, Pronex 20/40 mg, Exor 40 mg, Progut 40 mg, Nexe 20 mg।
    • Omeprazole: Seclo MUPS 20 mg, Losectil MUPS 20/40 mg, Ometid MUPS 20/40 mg, Cosec-MUPS 20/40 mg।
  • Side effects: headache, diarrhea/constipation, hypomagnesemia/B12 deficiency with long use.
  • Interactions: clopidogrel effect reduce করতে পারে, atazanavir/ketoconazole absorption issue, warfarin monitoring.

9.2 Injection therapy — only after infection excluded

8) Generic name: Triamcinolone acetonide injection

  • Therapeutic category: Corticosteroid anti-inflammatory
  • Pharmacological class: Depot glucocorticoid; MedEx অনুযায়ী IM/IA use-এর anti-inflammatory corticosteroid।
  • Why used: Persistent deep aseptic bursitis—subacromial, trochanteric, pes anserine—যখন rest/NSAID/physio যথেষ্ট নয়। MSD deep bursae-তে depot glucocorticoid 0.5–1 mL, যেমন triamcinolone 40 mg/mL, উল্লেখ করেছে।
  • Dose: 10–40 mg intrabursal/intra-articular equivalent, single injection; site অনুযায়ী specialist decision.
  • Duration: Single dose; repeated frequent injection avoid.
  • Bangladesh available brand examples: Cenolon 40 mg/ml, Trialon 40 mg/ml, Trimcort 40 mg/ml, Intracort 40 mg/ml, Triacin 40 mg/ml, Triamon 40 mg/ml, Emicort 40 mg/ml, Cynocort 40 mg/ml।
  • Side effects: post-injection flare, skin atrophy/depigmentation, hyperglycemia, infection risk, tendon weakening.
  • Interactions/cautions: diabetes, active infection, anticoagulant use, repeated steroid exposure, live vaccine/immunosuppression.

9) Generic name: Methylprednisolone acetate injection

  • Therapeutic category: Corticosteroid anti-inflammatory
  • Pharmacological class: Depot glucocorticoid
  • Why used: Persistent aseptic inflammatory bursitis; steroid injection only after septic bursitis excluded.
  • Dose: 20–40 mg intrabursal depending on site; specialist procedure.
  • Duration: Single injection.
  • Bangladesh available brand examples: Depo-Medrol 40 mg/ml or 80 mg/2 ml, Depomed 40 mg/ml or 80 mg/2 ml, Depo-pred 40 mg/ml।
  • Side effects: same as steroid—hyperglycemia, local atrophy, infection, pain flare.
  • Interactions/cautions: NSAID + steroid → GI bleed risk; diabetes, infection, anticoagulation.

10) Generic name: Lidocaine hydrochloride injection

  • Therapeutic category: Local anesthetic
  • Pharmacological class: Amide local anesthetic
  • Why used: Aspiration/injection procedure-এর local anesthesia; কখনও steroid injection-এর সাথে diagnostic pain relief-এর জন্য।
  • Dose: 1–2% local infiltration; max dose patient weight অনুযায়ী।
  • Bangladesh available brand examples: Chemocain 2%, G-Lidocaine 2%, Jasocaine 1%/2%。
  • Side effects: local numbness, dizziness, metallic taste, CNS toxicity, arrhythmia in overdose.
  • Interactions: class I antiarrhythmics, beta-blocker/cimetidine may increase toxicity.

9.3 Septic bursitis antibiotics — aspiration/culture আগে করা উত্তম

AAFP septic superficial bursitis-এ empirical systemic antibiotics covering Staphylococcus aureus and Streptococcus pyogenes recommend করে; culture result অনুযায়ী antibiotic modify করতে বলে। Mild–moderate immunocompetent patient outpatient oral antibiotic পেতে পারে, কিন্তু systemic signs/immunocompromised হলে hospital + IV antibiotic দরকার। Common duration 10–14 days।

11) Generic name: Flucloxacillin

  • Therapeutic category: Antibiotic
  • Pharmacological class: Penicillinase-resistant penicillin / anti-staphylococcal penicillin
  • Why used: MSSA/strep suspected septic bursitis, skin source infection।
  • Adult dose: 500 mg PO QID, preferably before food.
  • Duration: 10–14 days; culture guided.
  • Bangladesh available brand examples: Fluclox 500 mg capsule, G-Flucloxacillin 500 mg capsule/injection, Fucil 125 mg/5 ml suspension।
  • Side effects: GI upset, rash, cholestatic hepatitis, allergy/anaphylaxis.
  • Interactions: warfarin INR change, methotrexate toxicity risk; penicillin allergy contraindication.

12) Generic name: Cephalexin

  • Therapeutic category: Antibiotic
  • Pharmacological class: 1st-generation cephalosporin
  • Why used: MSSA + Streptococcus coverage in mild septic bursitis/cellulitis pattern।
  • Adult dose: 500 mg PO QID.
  • Duration: 10–14 days.
  • Bangladesh available brand examples: Acelex 250/500 mg, Cefalex 500 mg, Cephalen 250/500 mg, Navalexin 500 mg, Neorex 250 mg।
  • Side effects: diarrhea, rash, candidiasis, rare C. difficile.
  • Interactions: warfarin INR rise, probenecid increases level; severe beta-lactam allergy caution.

13) Generic name: Amoxicillin + Clavulanic acid

  • Therapeutic category: Antibiotic
  • Pharmacological class: Aminopenicillin + beta-lactamase inhibitor
  • Why used: Septic bursitis with surrounding cellulitis, bite/dirty wound, polymicrobial concern; pure MRSA coverage নয়।
  • Adult dose: 625 mg PO TDS or 1 g PO BD depending formulation/severity.
  • Duration: 7–14 days; culture/source guided.
  • Bangladesh available brand examples: Avloclav 500+125 mg, Clacido 875+125 mg, Bioclavid 250+125 mg; IV Avloclav 1 g+200 mg/20 ml, 500+100 mg/10 ml।
  • Side effects: diarrhea, rash, cholestatic hepatitis, candidiasis.
  • Interactions: warfarin INR rise, methotrexate toxicity, allopurinol with amoxicillin rash risk.

14) Generic name: Clindamycin

  • Therapeutic category: Antibiotic
  • Pharmacological class: Lincosamide antibiotic
  • Why used: Penicillin allergy, community MRSA concern, staph/strep soft tissue infection coverage.
  • Adult dose: 300–450 mg PO TDS/QID.
  • Duration: 10–14 days.
  • Bangladesh available brand examples: Clindacin 150/300 mg capsule and injection, Clinex 150/300 mg, Clindamet 150/300 mg, Clindax injection, Dalatic 300 mg।
  • Side effects: diarrhea, C. difficile colitis, rash, hepatotoxicity.
  • Interactions: neuromuscular blockers; erythromycin antagonism possible.

15) Generic name: Co-trimoxazole / Sulphamethoxazole + Trimethoprim

  • Therapeutic category: Antibiotic
  • Pharmacological class: Folate synthesis inhibitor combination
  • Why used: MRSA-suspected septic bursitis alternative; streptococcal coverage variable, so cellulitis-heavy caseে clinician combination/alternative ভাবেন।
  • Adult dose: DS 800/160 mg PO BD.
  • Duration: 10–14 days.
  • Bangladesh available brand examples: Cotrimox DS 800+160 mg, Avlotrin DS 800+160 mg, Biotrim DS 800+160 mg, Alcot 800+160 mg।
  • Side effects: rash/SJS, hyperkalemia, marrow suppression, renal dysfunction, photosensitivity.
  • Interactions: warfarin marked INR rise, ACEi/ARB/spironolactone → hyperkalemia, methotrexate, phenytoin, sulfonylurea.

16) Generic name: Doxycycline

  • Therapeutic category: Antibiotic
  • Pharmacological class: Tetracycline
  • Why used: MRSA-suspected alternative; not ideal as sole drug if strong streptococcal cellulitis concern.
  • Adult dose: 100 mg PO BD.
  • Duration: 10–14 days.
  • Bangladesh available brand examples: Doxacil 100 mg, Doxicap 100 mg, Doxin 100 mg, Doxibac 100 mg, Doxysina 100 mg, Doxy-A 100 mg।
  • Side effects: gastritis/esophagitis, photosensitivity, tooth discoloration.
  • Interactions: antacid/iron/calcium reduces absorption; warfarin, isotretinoin; avoid pregnancy and children <8 years.

17) Generic name: Vancomycin IV

  • Therapeutic category: Hospital antibiotic
  • Pharmacological class: Glycopeptide antibiotic
  • Why used: Severe septic bursitis, MRSA high likelihood, systemic toxicity, immunocompromised patient—hospital setting. AAFP MRSA high likelihood হলে IV vancomycin উল্লেখ করে।
  • Adult dose: 15–20 mg/kg IV every 8–12 h, renal function and trough/AUC monitoring অনুযায়ী.
  • Duration: Usually 10–14 days or longer if deep infection/osteomyelitis.
  • Bangladesh available brand examples: Vanmycin 500 mg/vial or 1 g/vial, Covan 1 g/vial, G-Vancomycin 500 mg/1 g, Vancin 500 mg/1 g, Vancomin 500 mg/1 g।
  • Side effects: nephrotoxicity, infusion reaction/red-man syndrome, ototoxicity rare.
  • Interactions: aminoglycoside, amphotericin, loop diuretic, contrast nephropathy risk.

9.4 Gouty bursitis / crystal-induced bursitis

18) Generic name: Colchicine

  • Therapeutic category: Anti-gout drug
  • Pharmacological class: Microtubule inhibitor; neutrophil migration/inflammation কমায়। MedEx acute gout flare-এ indication দিয়েছে।
  • Why used: Gouty bursitis/acute gout flare suspected or confirmed হলে।
  • Adult dose: Low-dose regimen: 1 mg initially, then 0.5 mg after 1 hour; এরপর 0.5 mg once/twice daily as needed/tolerated.
  • Duration: Usually 3–5 days or until flare resolves; renal/hepatic impairmentে reduce/avoid.
  • Bangladesh available brand examples: Kolchin 0.5 mg/0.6 mg, Colut 0.6 mg।
  • Side effects: diarrhea, vomiting, abdominal pain, myopathy, bone marrow suppression in toxicity.
  • Interactions: clarithromycin/erythromycin, azole antifungal, verapamil/diltiazem, cyclosporine, statin, renal impairment—toxicity risk।

19) Generic name: Allopurinol

  • Therapeutic category: Urate-lowering therapy
  • Pharmacological class: Xanthine oxidase inhibitor
  • Why used: Acute bursitis pain কমাতে নয়; recurrent gout/tophi/high urate burden থাকলে long-term prevention।
  • Adult dose: Start 100 mg OD; serum urate target অনুযায়ী titrate. MedEx low-dose start 100 mg/day এবং renal impairment-এ caution উল্লেখ করেছে।
  • Duration: Long-term; acute flare-এর সময় নতুন করে শুরু সাধারণত specialist plan ছাড়া নয়।
  • Bangladesh available brand examples: Alurol 100 mg, Duric 100 mg, Esloric 100/300 mg, Goutex 100/300 mg, Purinol 100/300 mg, Ucorex 100 mg।
  • Side effects: rash, GI upset, hepatotoxicity, rare allopurinol hypersensitivity syndrome/SJS-TEN.
  • Interactions: azathioprine/6-MP dose major reduction/avoid; warfarin, ampicillin/amoxicillin rash risk; renal impairment increases toxicity.

10) Bangladesh doctors commonly prescribe — practical list

Non-septic painful bursitis

  • Paracetamol 500 mg — pain relief; NSAID contraindication থাকলে first choice.
  • Ibuprofen 400 mg / Naproxen 500 mg / Etoricoxib 60–90 mg — pain + inflammation + swelling কমাতে।
  • Diclofenac gel 1% — superficial local pain/swelling কমাতে।
  • PPI: Esomeprazole 20 mg or Omeprazole 20 mg — NSAID gastric protection, especially GI-risk patient।

Persistent aseptic deep bursitis

  • Triamcinolone acetonide 40 mg/ml or Methylprednisolone acetate 40 mg/ml — intrabursal steroid; infection excluded হলে।
  • Lidocaine 1–2% — local anesthesia/procedural pain relief।

Septic bursitis

  • Flucloxacillin 500 mg QID or Cephalexin 500 mg QID — MSSA/Strep coverage।
  • Clindamycin 300 mg TDS/QID — penicillin allergy/MRSA concern।
  • Co-trimoxazole DS BD / Doxycycline 100 mg BD — MRSA alternative; case selection দরকার।
  • Vancomycin IV — severe/systemic/MRSA high risk, hospital-based।

Gouty bursitis

  • Colchicine 0.5/0.6 mg — acute gout flare।
  • Allopurinol 100 mg onward — recurrent gout prevention, acute analgesic নয়।

11) Prevention — কীভাবে প্রতিরোধ করবেন?

  • Repetitive pressure কমান: elbow/knee pad ব্যবহার।
  • দীর্ঘ সময় হাঁটু গেড়ে কাজ করলে frequent break নিন।
  • Sports/occupation technique correct করুন; physiotherapy strengthening/stretching।
  • Tight shoe/heel friction থাকলে footwear modify করুন।
  • Minor wound/abrasion clean করুন; infected skin হলে দ্রুত treatment।
  • Diabetes, gout, RA, CKD ভালোভাবে control করুন।
  • নিজে needle দিয়ে fluid বের করা/ম্যাসাজ/স্টেরয়েড injection করবেন না।
  • Workstation ergonomics: elbow টেবিলে চাপ দিয়ে রাখা avoid।
  • Pain কমে গেলে gradual return to activity; sudden overuse করলে recurrence হয়।

Overview / Summary

Bursitis হলো bursa inflammation, যার প্রধান কারণ repetitive pressure, trauma, gout/RA বা infection। Most aseptic cases rest, ice, compression, padding, topical/oral analgesic-NSAID দিয়ে ভালো হয়। Septic bursitis সন্দেহ হলে bursal aspiration + culture জরুরি এবং empirical anti-staphylococcal antibiotic দরকার। Steroid injection শুধু infection exclude করার পর selected persistent deep bursitis-এ করা উচিত।

Actionable Plan / Steps

  1. Red flag দেখুন: fever, marked redness/warmth, skin wound, pus, diabetic/immunocompromised → septic bursitis ধরে evaluate।
  2. Mild aseptic case: rest + ice + compression + padding + paracetamol/topical NSAID ± short NSAID course।
  3. Investigation: trauma হলে X-ray; unclear/deep হলে US; septic/crystal suspect হলে aspiration with Gram stain, C/S, cell count, crystal, glucose।
  4. Septic case: aspiration/culture before antibiotic if possible; flucloxacillin/cephalexin or alternative based on allergy/MRSA risk; severe হলে hospital + IV therapy।
  5. Recurrence: underlying gout/RA/OA/occupation/footwear/ergonomics address; persistent functional swelling হলে ortho/rheumatology referral।

Reference List — Textbook + Guideline + DOI

Textbooks

  1. Harrison’s Principles of Internal Medicine, 22nd ed. McGraw Hill, 2025 — rheumatology/MSK regional pain and inflammatory arthritis principles; 22nd edition verified on AccessMedicine.
  2. Davidson’s Principles and Practice of Medicine, 24th ed. Elsevier — musculoskeletal medicine, recognition/investigation/management principles; 24th edition verified.
  3. Firestein & Kelley’s Textbook of Rheumatology, 12th ed. Elsevier — rheumatic disease evaluation and regional musculoskeletal pain; 12th edition listing verified.

Guidelines / Clinical reviews

  1. Khodaee M. Common Superficial Bursitis. American Family Physician. 2017;95(4):224–231.
  2. MSD Manual Professional Edition. Bursitis. Reviewed/revised Apr 2026.
  3. NICE CKS. Olecranon bursitis: management — conservative measures including rest, ice, reduced activity.
  4. Stevens DL, et al. IDSA Practice Guidelines for Skin and Soft Tissue Infections, 2014 update. Clinical Infectious Diseases. 2014;59(2):e10–e52. DOI: 10.1093/cid/ciu296.

Peer-reviewed DOI

  1. Steuri R, et al. Conservative interventions for shoulder impingement/subacromial pain. Br J Sports Med. 2017;51:1340–1347. DOI: 10.1136/bjsports-2016-096515.
  2. Sun Y, et al. Steroid injection and NSAIDs for shoulder pain: PRISMA meta-analysis. Medicine. 2015;94(50):e2216. DOI: 10.1097/MD.0000000000002216.
  3. FitzGerald JD, et al. 2020 American College of Rheumatology Guideline for Management of Gout. Arthritis Care & Research. 2020. DOI: 10.1002/acr.24180.

Md.Rafiqul Islam Lipu,Date:-15-06-2026 Tuesday,Time:-03-32-12 Pm

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