BACKGROUND: Amenorrhea may occur in patients with lupus treated with cyclophosphamide. This is commonly attributed to primary ovarian failure leading to infertility -- a possible complication of cyclophosphamide. Urogenital tuberculosis (TB) can be a rare cause of amenorrhea and infertility in lupus patients.
OBJECTIVE: To present a case of endometrial TB causing amenorrhea and abnormal uterine bleeding in a patient with lupus nephritis treated with cyclophosphamide.
CASE: A 32-year-old Filipino female, who was diagnosed with lupus nephritis, was managed with high dose steroid and intravenous (IV) cyclophosphamide. Lupus nephritis improved with treatment, but she subsequently developed amenorrhea and vaginal spotting for two months. Symptoms were initially attributed to premature ovarian failure due to cyclophosphamide.Gynecologic examination showed thickened endometrium with normal ovaries and uterus on ultrasound. Dilatation and curettage was performed. Histopathology of endometrial curetting revealed chronic granulomatous endometritis with Langhans giant cells. Endometrial TB was diagnosed, and anti-Koch's therapy was started. The patient showed a favourable response, with resumption of normal menstruation after only the first month of treatment.
CONCLUSION: This paper emphasizes the importance of considering a wide range of differential diagnosis for gynecologic symptoms in patients with lupus. Tuberculosis should be considered in areas of high endemicity

Human ; Female ; Adult ; Primary Ovarian Insufficiency ; Lupus Nephritis ; Endometritis ; Amenorrhea ; Giant Cells, Langhans ; Cyclophosphamide ; Menopause, Premature ; Tuberculosis, Urogenital ; Infertility ; Uterine Hemorrhage

SYNOPSIS: Cardiac tamponade among systemic lupus erythematosus (SLE) patients is an unusual event. The pericardial effusion may be a consequence of uremia, infections in the pericardium, or the lupus pericarditis itself. We present four atypical cases of cardiac tamponade from pericarditis of connective tissue disease (CTD), all of which were treated with drainage and immunosuppressants. Due to the rarity of this combination, management was a challenge.
CLINICAL PRESENTATION: Four females each sought consult for dyspnea associated with typical manifestations of connective tissue disease such as arthritis, characteristic rashes, serositis, typical laboratory features, and a positive ANA and/or anti-dsDNA. The first three cases fulfilled the criteria for SLE, while the fourth fulfilled the criteria for SLE-dermatomyositis overlap syndrome. Echocardiography was done due to suspicion of pericardial involvement and revealed massive pericardial effusion in tamponade physiology in all cases.
DIAGNOSIS: Cardiac tamponade from serositis due to connective tissue disease [SLE (case 1 to 3) or SLE-dermatomyositis overlap (case 4). Other common etiologies of tamponade such as bacterial, tuberculous, malignant, and uremic pericardial effusion were ruled out by clinical and laboratory tools, including Gram stain and culture, cytology, PCR, and biochemical testing. The pericardial fluid of the first case tested positive for lupus erythematosus (LE) cells, indicative of lupus serositis.
TREATMENT AND OUTCOME: All patients underwent pericardial drainage via tube pericardiostomy. They received high dose glucocorticoids after infectious etiologies for the pericardial effusion were ruled out. The fourth case with the overlap syndrome, however, required more immunosuppressants using azathioprine and methotrexate. Resolution of pericardial effusion was noted with this approach. Three of four were discharged improved, however, the third case suffered from worsening nephritis and pulmonary hemorrhage leading to her demise.
SIGNIFICANCE AND RECOMMENDATIONS: Four cases of cardiac tamponade as a manifestation of connective tissue disease were presented. Literature underlines the rarity of this condition anytime during the course of SLE. Despite this, SLE should be considered as one of the differential diagnosis of cardiac tamponade, especially in patients who manifest with multi-systemic findings. Likewise, massive pericardial effusion should be considered in patients with a connective tissue disease presenting with subtle evidence of pericardial involvement. It requires timely identification and treatment with high dose steroids, after other causes such as infections have been excluded. Immediate drainage through pericardiocentesis or pericardiostomy in combination with immunosuppressants may be life-saving.

Human ; Female ; Adult ; Adolescent ; Pericardiocentesis ; Pericardial Effusion ; Azathioprine ; Cardiac Tamponade ; Methotrexate ; Glucocorticoids ; Serositis ; Dermatomyositis ; Immunosuppressive Agents ; Pericardial Fluid ; Neutrophils ; Lupus Erythematosus, Systemic ;

Digital gangrene is an uncommon initial manifestation of systemic lupus erythematosus (SLE) and rarely in late-onset disease. This case presents a 50-year-old woman who developed digital gangrene and was subsequently diagnosed with SLE. Early treatment with immunosuppression and anticoagulation halted the progression of the digital ischemia. This case highlights that late-onset SLE, often described as having a more benign and insidious course, can also present with catastrophic limb-threatening manifestations.
Late-onset ; lupus

Background: Rheumatoid arthritis (RA) is a chronic and progressive disease resulting in disability and poor quality of life. Patients’ knowledge (PxK) of disease can contribute to better disease control, reduced disability, and improved quality of life. Objective: The objective of this study was to determine the disease knowledge and functional disability of a cohort of patients with RA. Methods: We conducted a cross-sectional study among patients with RA at the University of the Philippines - Philippine General Hospital Arthritis Clinic. The subjects were recruited using convenience sampling over three months in 2019. We obtained demographic and disease characteristics, clinic attendance, patient knowledge, and functional status through chart review, a questionnaire, and a disability index. Descriptive statistics, 2-sample T-test, Pearson’s correlation, analysis of variance (ANOVA), and multiple linear regression analysis were used for data analysis. Informed consent was obtained before participation in the study. Results: Eighty percent (57/71) of recruited patients participated in the study. All were female, and the mean age was 51.6 years (±12.9). Most participants completed secondary education, were employed, had an average duration of RA of 8 (±6.8) years, had been consulting at the Arthritis Clinic for an average of 4.8 years (±3.8), and had moderate disease activity (49.1%). Most patients had American College of Rheumatology (ACR) class I or II functional status (50/57, 88%). The usual source of the patients' knowledge about RA was their physician. The mean knowledge score was 5.10 (±0.93) out of a perfect score of 9. Most patients were aware of their disease diagnosis and the non-communicable nature of RA. There was low awareness of the need for self-monitoring for disease flares or treatment adverse events and the extra-articular involvement in RA. The mean functional disability score was 6.65 ± 5.33, and the mean functional disability index (FDI) was 0.83 (±0.66). These correspond to mild functional disability (FD). There was no significant relationship between the total knowledge score and age, duration of disease, number of consultations in the past year, level of education, employment status, perceived level of disease knowledge, or the practice of asking their physician about illness. Perception of overall health status was associated with functional disability (p=0.001). Conclusion Most of the patients in our cohort of RA patients had a mild functional disability and low knowledge scores. The study identified the gaps in our patients’ knowledge of disease and its management. A re-evaluation of existing educational and treatment strategies will be beneficial to enhance disease knowledge and improve health outcomes.
Functional Status ; Arthritis, Rheumatoid

Introduction: Takayasu’s arteritis (TA), a large vessel vasculitis has various initial presenting manifestations; making it difficult to diagnose. Hence, the number of those with the disease in the population is underestimated. The study intends to update local data and to describe different presentations of the disease to enhance awareness for TA. Methods: This is a retrospective study done in a tertiary government hospital. Twenty-two out of twenty three charts of patients diagnosed with TA based on the 1990 ACR criteria were reviewed. Demographic profile, initial clinical manifestations, imaging, treatment and outcomes were collected. Descriptive statistics was applied. Institutional Review Board approval was obtained prior to study initiation. Results: Majority (90.1%) were female; mean age at onset of symptoms and at diagnosis were 30.4 (+12.3)years and 33.2 (+12.0)years respectively. The common reasons for consult were hypertension (26.3%), claudication (21.1%) and abdominal pain (11%). Laboratories showed elevated erythrocyte sedimentation rate (87.5%), leukocytosis (43.8%), anemia (31%) and thrombocytosis (4.5%). Common imaging findings were cardiomegaly (27.3%), aortic regurgitation (27.3%) and carotid stenosis (18.2%). CT angiogram in 90% of cases demonstrated arterial wall narrowing. Other findings were aneurysm (31.8%), contour irregularities (13.6%) and femoral artery occlusion (4.5%). Treatment for active disease were glucocorticoids alone (44%) and combined glucocorticoids and other immunosuppressants (56%). Of the 22 records reviewed, six patients (27%) had stroke. Four (18.2 %) had different surgical procedures; ray amputation of toe for digital ischemia, embolectomy for digital gangrene, balloon angioplasty of the renal artery and renal angioplasty for stenosis. Two (9.1%) who had pregnancies after TA diagnosis had premature deliveries without neonatal complications. No mortality was recorded over the mean follow-up of 49.33 patient-years. Conclusion Clinicians should be aware of the different initial presenting signs and symptoms of TA since development of collateral circulation may mask other symptoms. Thus, thorough history and physical assessment are essential tools in the diagnosis of TA.

Background: Rheumatoid arthritis (RA) patients benefit from aerobic and strengthening exercises. Objective: To compare the effectiveness of a home exercise program against center-based aerobic and strengthening exercises on the grip strength, endurance, function, and fatigue among patients with RA. Methodology In this assessor-blind, randomized trial, 50 RA patients were assigned to either center-based physical therapy (CPT) or home exercise program (HEP) that included aerobic and strengthening exercises performed for four weeks. The grip strength, 6-minute walk test (6MWT), health assessment questionnaire disability index (HAQ-DI), and the multidimensional assessment of fatigue (MAF) index were determined at weeks 0 (baseline), 2 and 4 weeks.
Therapeutics ; Arthritis, Rheumatoid ; Fatigue ; Hand Strength