<s>[INST] Hello doctor,I had a cesarean 4.5 years back, after which I developed a sinus tract in the left lower abdominal wall (which was stated to be tubercular (though there was no discharge). Took ATT twice but when repeated USG was conducted, it stated the problem as panniculitis. An MRI revealed adhesions and b/l sacroiliitis. Saaz 500 mg and Pregabalin was given, but not availed much relief. I had a history of bronchial asthma for the past eight years and somewhere I felt Saaz did not suit me and increases my asthma problem. What should I do? If I do not take Saaz it increases my back problem a lot and overall tiredness and if I take I feel breathless.Got a recent ultrasound done. Can you please check and see if TB is still persisting or is it panniculitis? Completely tired of this diagnostic dilemma. Please help. I will be grateful. I am attaching all my reports of the past five years. I have bronchial asthma since last eight years. Viral keratitis in right eye post eye lasik surgery. LSCS four years back. Herpes zoster right arm three years back. I have dry eyes for which I am taking Systane Ultra, Flomax ointment and sometimes Cycloiimune 0.5 drops. For asthma, Budamate inhaler and Alerfix total. Please guide. [/INST] Hi. I will try to help you as much as possible. A few questions first: 1. Was there any tissue biopsy done for the abdomen wall or the panniculitis lesion? If yes, please share its details. 2. Did you have symptoms of low backache and early morning stiffness, and pain in any other joints? 3. Did you have any family history of arthritis? 4. Do you take anti-inflammatory medicines in addition to Saaz for pain? Now coming to your queries: USG and MRI reports (attachment removed to protect patient identity) are suggestive of abdomen wall panniculitis, which is a chronic inflammatory condition and is mostly caused by some autoimmune process. In your case, the associated sacroiliitis may point towards the presence of spondyloarthropathy. Tuberculosis is unlikely, as it would have resolved after ATT. Bronchial asthma diagnosis needs to be worked up in order to rule out other autoimmune associations like ILD. I would like to suggest the following, if not already done: 1. HLA B27, RF, and anti-CCP. 2. ANA by immunofluorescence. 3. ENA profile. 4. ANCA (MPO and PR3 by ELISA). 5. ESR (WG) and CRP. 6. Pulmonary function tests, and X-ray chest. 7. Tissue biopsy from the abdomen and its histopathology examination. If you are finding it difficult to tolerate Saaz (Sulfasalazine), then, other drugs like Methotrexate (MTX) may be tried, but only after ruling out the possibility of ILD. MTX would also be helpful in panniculitis. for more severe pain, NSAIDs or low dose Corticosteroids may be added for short term. But it is important to establish a final definitive or most probable diagnosis. </s>