BACKGROUND: Non traumatic osteonecrosis also known as  avascular necrosis (AVN),and tuberculous arthritis (TB    arthritis)most commonly present as chronic monoarticular conditions. Corticosteroid intake is known to predispose individuals to the development of these two conditions.                      
In AVN, corticosteroid remains to be the most common cause that leads to a final  common pathway of disrupting    blood supply to segments of bone causing cell death. In TB arthritis, corticosteroid renders  a patient relatively immunocompromised predisposing to this extrapulmonary infection.                                                                                                                                                         
The incidence of tubercular osteonecrosis in a patient with systemic lupus erythematosus is rare. A review of literature only showed one case report of tubercular osteonecrosis diagnosed by aspiration cytology. Since tuberculosis (TB) is a destructive but curable disease, early diagnosis  and  treatment  are essential.
OBJECTIVE: To present a case of tubercular osteonecrosis in a patient with systemic lupus erythematosus treated with anti-Koch's regimen and iloprost infusion.
CASE: A 27-year old Filipino female who was diagnosed with lupus nephritis and underwent three days  methylprednisolone pulse therapy. Lupus nephritis improved  and  was clinically inactive for two years. She  developed insidious onset of intermittent pain on her left knee, associated with swelling for four months with  subsequent right hip pain of one week duration. MRI of the left knee showed osteonecrosis and arthritis. Radiograph of the right hip showed osteonecrosis. She underwent arthrocentesis of the left knee and the synovial  fluid tested positive for tuberculosis by PCR. We started the patient on quadruple anti-Koch's regimen together with iloprost infusion which afforded clinical improvement. 
CONCLUSION: To our knowledge, this is the first reported case of a lupus patient with concomitant polyarticular osteonecrosis complicated by monoarticular tuberculous arthritis. Medical treatment, while it may be complicated by adverse drug events, is effective in symptomatic treatment, but a multidisciplinary approach is suggested for optimal outcome.

Human ; Female ; Adult ; Adrenal Cortex Hormones ; Arthritis ; Arthrocentesis ; Cell Death ; Early Diagnosis ; Iloprost ; Incidence ; Lupus Erythematosus, Systemic ; Lupus Nephritis ; Methylprednisolone ; Osteonecrosis ; Pain ; Polymerase Chain Reaction ; Tuberculosis, Osteoarticular

OBJECTIVE: The aim of the study is to determine the prevalence of metabolic syndrome (MS) in Filipino patients with gout and know the specific component that is predominant in this population.
METHODS: Patients who are diagnosed with gout based on the American College of Rheumatology (ACR) criteria, at least 20 years old, attending the outpatient rheumatology clinic of a tertiary hospital from March 2012 to December 2012 and  willing  to sign written informed consent were included in  the study. The following information was collected: demographic and disease characteristics, blood pressure, body mass index, waist circumference, triglycerides, HDL, and fasting blood sugar. MS was defined according to the revised NCEP/ATP III criteria using the WHO Asia-Pacific obesity criteria. Results were reported in means and proportion.
RESULTS: Sixty-three patients were included in the study. The mean age of onset and at time of diagnosis of gout were 47.3 years and 52.9 years, respectively. At the time of the study, the average duration of gout was five to 10 years. The male to female ratio was 6:1. The prevalence of MS was 47.6% (30/63) with male to female ratio of 5:1.The prevalence of abdominal obesity was 39.7%, hypertension 36.5%, low HDL 31.7%, high triglycerides 30.2%, and diabetes mellitus 14.3%.
CONCLUSION:The prevalence of MS in this subset of Filipino patients with gout was 47.6%. Its most common component was abdominal obesity found in 39.7% of cases. This is an area of intervention that needs to be addressed in the care of these patients.

Human ; Male ; Female ; Middle Aged ; Adult ; Metabolic Syndrome X ; Obesity, Abdominal ; Obesity ; Hdl-triglyceride ; Triglycerides ; Diabetes Mellitus ; Lipoproteins, Hdl ; Hypertension ; Adenosine Triphosphate

BACKGROUND: Chikungunya virus (CHIKV) is a mosquito- borne  alphavirus  of  the  family  Togaviridae  transmitted  to humans by the Aedes spp. mosquitoes, causing Chikungunya   Fever  (CHIKF).
OBJECTIVE: This study aims to describe the course and outcome of musculoskeletal (MSK) manifestations in patients  with  CHIKF  seen  over  a   three-month     period.
DESIGN: This is a prospective descriptive  study.  Seventy  patients  with  fever,  rash,  and  arthritis  seen   at the University of the Philippines-Philippine General Hospital  and  private  arthritis  clinics  were  collected from August - December 2012.  Demographics  and course   of   arthritis   were  described.
RESULTS:  Seventy   patients,   53   (68.6%)   female,   with  a mean age  of  39.2  ±13.50  were  diagnosed  with CHIKF. All cases were from the Metropolitan  Manila area. Of these, 15 (21.4%) had  family  members  affected. Twenty-four patients (34.3%) were either employed or students. The most common presenting symptoms were fever (94.3%), arthritis or athralgia  (98.6%), and rash (87.1%).  The  most  common  joint  areas involved were the ankles  (60.0%),  the  wrists (40.0%) and the small joints of the hand (51.4%). Twenty-seven (47.3%) had symmetric  arthritis.  Thirty- seven   cases   (52.9%)   had   arthralgia   or   arthritis    for at least  six  weeks.  By  the  end  of  the  follow-up  period, only four (5.7%) had persistent musculoskeletal symptoms. Age and  sex  were not  found to  be  factors in  determining  chronicity  of  arthritic  symptoms  (p   =   0.104   and   p=0.58  respectively). Of the seventy patients, 31 (44. 3%) were confirmed  cases  of  CHIKF--  29 had  (+)   CHIKV  IgM   by ELISA,  and  two   had   (+)   CHIKV   PCR.   Twenty-  one (67.7%) had  persistent  arthritis  of  at least  six  weeks. Treatment  consisted  of continuous  NSAIDs  for  at  least  two   weeks   and   some   received   steroids.  In this subgroup, age and sex were not shown to  correlate with chronic arthritis (p=0.47 and p=0.05 respectively).
CONCLUSION: This report on a recent outbreak of CHIKF showed the classic triad of fever, rash,  and  arthritis.  There  was  no  correlation  between  age  and  chronicity of  arthritic  symptoms.  Sex,  likewise,  did  not  appear   to influence chronicity. The disease occurred in family clusters. Patients required continuous treatment with NSAIDs and  some  had  to  be given  steroids.  Most cases   resolved   by   12 weeks.

Human ; Male ; Female ; Middle Aged ; Adult ; Chikungunya Fever ; Chikungunya Virus ; Togaviridae ; Anti-inflammatory Agents, Non-steroidal ; Arthralgia ; Arthritis ; Exanthema ; Enzyme-linked Immunosorbent Assay

BACKGROUND:  Methylprednisolone  Pulse  Therapy  (MPPT)  is standard of care in the management of severe systemic lupus erythematosus (SLE). This treatment, though,  is considered   a   double-edged   sword   due to its life-threatening adverse  effects.  Renal  disease,  liver disease and high dose of the drug are factors proposed to adversely affect outcomes of patients treated  with  MPPT.   Despite   the   widely   accepted use of MPPT, there are no reports describing the outcomes   from   its   use   among   Filipinos   with SLE.
OBJECTIVE: To determine the in-hospital outcomes of patients with SLE treated with MPPT and to identify  factors   associated   with   adverse  outcomes.
GENERAL STUDY DESIGN:  Retrospective
POPULATION:  Adult  patients  with  SLE  who  were  admitted  in Philippine General  Hospital  and  underwent  MPPT from   January   2008   to   December  2012.
METHODS: Patient demographics,  disease  characteristics  on admission, indications for MPPT and in-hospital outcomes   were  extracted.
ANALYSIS: Chi-square test and Fisher's exact  test  were  used  to  elicit  association  of  population  characteristics  to  outcomes.
RESULTS: Forty-two patients  with  SLE  who  underwent MPPT were included. Majority are females  (98%)  and  most (60%) underwent MPPT within one year of SLE diagnosis.  High   disease   activity   is   seen   at   the time
of MPPT with a mean Mex-SLEDAI score  of  14.69. Infection (83%) is the most common comorbidity.  Anemia, hypoalbuminemia and significant  proteinuria  are the most common  laboratory  abnormalities.  The  top indication for MPPT is nephritis (83.3%). The dose received  by the  majority  (66.7%)   is   one   gram/day for   three   days,   which   is   a   high  dose.
Improvement rate is 76% but the in-hospital complication  rate  is  64%  and  mortality  rate   is   21%. Patients with in-hospital complications have significantly lower absolute lymphocyte count (p=0.013), serum albumin (p=0.04) and greater 24-hour proteinuria (p=0.04) at baseline. High-dose MPPT is significantly associated with in-hospital complications (p=0.04) but not mortality. Nephritis (p= 0.04) and low platelet counts at baseline  (p=0.01)  are  associated with  mortality.
CONCLUSION:  In this  population,  there  is   a   high  rate   of  improvement  of   lupus  disease  activity  when  MPPT   is used but there is a corresponding high rate of in-hospital  complications  and   mortality.   High   dose  of MPPT seems to be associated with increased in-  hospital complication, while nephritis and low platelet count showed a probable association with mortality. Further studies  on  a  larger  cohort  are  needed.  For  now, the findings of this study may be helpful in developing guidelines on the use  of  MPPT  among Filipino   patients   with  SLE.

Human ; Male ; Female ; Adult ; Hypoalbuminemia ; Serum Albumin ; Lupus Erythematosus, Systemic ; Nephritis ; Kidney Diseases ; Proteinuria ; Anemia ; Liver Diseases ; Lymphocyte Count ; Methylprednisolone

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

BACKGROUND: Valid and reliable assessment of pain is essential in the management of rheumatologic conditions. Standardized pain assessment scales have been developed and used in clinical trials, but remain underutilized in clinical practice.

OBJECTIVE: To evaluate the use of the different pain assessment scales: Numeric Rating Scale (NRS), Verbal Descriptive Scale (VDS),Visual Analog Scale (VAS) and Wong Baker Face Scale (FACES) among adult patients with musculoskeletal pain seen in the Rheumatology Out-Patient Clinic in a tertiary government hospital in Manila, Philippines.

METHODS: This is a cross sectional study of adult patients with symptoms of musculoskeletal pain seen in a rheumatology out-patient clinic. The patients answered the different pain assessment scales and ranked them according to ease of use and preference. We checked for correlation of results of the different pain assessment scales using Spearman correlation.     

RESULTS: Ninety-four patients are included in this study. Eighty-one percent are females, with mean age of 52 (±SD 14.12) years old. Majority (73%) have low level of education. Forty-one percent have rheumatoid arthritis, 21% have osteoarthritis and 12% have gout. NRS is preferred and ranked easiest to use by 41.5% of patients. FACES is a close second; preferred by 39.4% and considered easy to use by 36.2% VAS ranks last on over-all preference and ease of use. On subgroup analysis, VDS was preferred by male patients while FACES was preferred by those with low educational status. The pain score obtained using NRS was significantly correlated with VDS, VAS, and FACES (p=<0.005).     

CONCLUSION: The NRS is a validated tool that is easy to use and preferred by patients. The FACES is a good alternative if the patient has difficulty with the NRS. We recommend the use of these pain scales in clinical practice in the Philippines to standardize the assessment and monitoring of pain among patients with rheumatic conditions

Human ; Male ; Female ; Aged ; Middle Aged ; Adult ; Pain Measurement ; Musculoskeletal Pain ; Rheumatology ; Osteoarthritis ; Arthritis, Rheumatoid ; Rheumatic Diseases ; Gout

A 26-year-old female came in with progressive blurring of vision. She had developed memory loss and complained of headache, significant weight loss, and exertional left calf pain after prolonged walking. Pertinent physical findings included light perception on visual acuity examination, and the brachial and radial pulses of both arms were not appreciable. Thoracic and abdominal aortic imaging by computed tomography with contrast revealed narrowing along the thoracic aorta and its branches. Carotid Doppler showed bilaterally thickened walls in the common carotid arteries, with near total occlusion of the left carotid artery. These findings were consistent with bilateral ocular ischemic syndrome in Takayasu arteritis. She was given methylprednisolone 500 mg intravenously daily for 3 days with noted improvement in vision. She was discharged and showed improvement on prednisone 35 mg/day and aspirin 80 mg/day. On follow-up two weeks post-discharge, she reported being able to see silhouettes of persons and objects.

Introduction: Malnutrition is a frequently neglected problem among patients with chronic illnesses. It correlates with decreased functionality and quality of life and increased morbidity and mortality. The prevalence of malnutrition in chronic rheumatologic conditions ranges from 15-24%. There is an unfounded suspicion that malnutrition is common among Filipino patients with rheumatic diseases. The study will bridge this knowledge gap and pave the way for a more holistic approach in the care of rheumatic diseases. The researchers aim too assess the risk of malnutrition among patients of the rheumatology clinic of the Philippine General Hospital. Methods: This is a cross-sectional study. After getting informed consent, we collected data on demographics and disease characteristics and administered the Malnutrition Universal Screening Tool (MUST). We classified patients according to malnutrition risk and managed accordingly. Results: One hundred eighty-two patients are included (86% are female), with mean age of 45 years old (SD=16.65). The majority (54%) has less than collegiate level of education and 76% are below minimum wage earners. Twelve percent are smokers and 16% are alcohol beverage drinkers. Thirty-nine percent have systemic lupus erythematosus (SLE), 17% have rheumatoid arthritis (RA) and 16% have osteoarthritis (OA). The average duration of illness is 75 months. Ten percent are at high risk and 18% are at moderate risk of malnutrition. Six percent of SLE patients have high risk and 24% at moderate risk while 19% and 16% of patients with RA, respectively, have high and moderate risk of malnutrition. Among patients with OA, 6.9 % have high and 3.4% have moderate risk of malnutrition. Conclusion Using the MUST routinely identifies patients at risk of malnutrition. Twenty-eight percent of patients at the rheumatology clinics of the Philippine General Hospital have moderate to high risk of malnutrition. Identifying those at risk of malnutrition allows for timely intervention and optimal care.
Rheumatic Diseases ; Malnutrition ; Philippines

Introduction: Cognitive impairment (CI) in patients with systemic lupus erythematosus (SLE) presents with or without overt signs of central nervous involvement. The prevalence of CI is variable, ranging from 19-80%. It is often overlooked, leading to high healthcare costs and productivity loss. The usual tools for detection are expensive, time-consuming and not locally available. Detection of CI using the Mini Mental State Examination (MMSE) and Montreal Cognitive Assessment Test (MoCA) is more clinically relevant and practical. The objectives of this study are to determine the prevalence of CI in SLE patients using MMSE/MoCA, to determine the degree of impairment in the different cognitive domains, and to characterize patients with CI in terms of disease activity, education, and employment. Methods: This is a cross-sectional study of 62 SLE patients, 19 years or older, at a rheumatology clinic. Demographic and disease characteristics were collected. The validated Filipino versions of the MMSE/MoCA test were administered. Descriptive and non-parametric statistics were applied. Results: Most patients are female (96.77%), below collegiate level of education (58.06%), and unemployed (70.97%). Mean disease duration is 8.92 (SD±7.03) years. Mean age at diagnosis is 28 (SD±10.30) years. Hypertension is the most common co-morbidity. Most have low lupus disease activity or are in remission (80.65%). Most are on prednisone (72.58%), with an average dose of 11.88mg/day (SD±10.66). The prevalence of CI is 38.71% (MMSE-P) and 77.42% (MoCA-P). The presence of CI is not related to educational level, employment, and disease activity. Conclusion Cognitive impairment (CI) is common in this cohort of SLE patients. Disease activity, level of education and employment do not seem to affect its occurrence. The MMSE-P and MoCA-P are rapid tools to assess the presence of CI and should be used in clinical practice to improve the quality of care for patients with lupus.
Lupus Erythematosus, Systemic ; Cognitive Dysfunction ; Mental Status and Dementia Tests ; Philippines