OBJECTIVE: This study was undertaken to determine whether there is a significant association between aortic arch calcification (AAC) on digital chest radiography (DCXR) and cerebrovascular disease (CVD) by computed tomography of the brain plain (BCT). It also aimed to determine if DCXR may be used to predict stroke.
RESEARCH DESIGN: Retrospective Cross Sectional Chart Review Design
METHODOLOGY: All the 483 patients who underwent DCXR and BCTs at the Doctors Hospital, Inc. from January 2010 to December 2012 were included in the study. Demographic data and risk factors for atherosclerosis and CVD were obtained and analyzed. The DCXR were graded by three radiologists and its association with CVD on BCT using the Chi Square Test of Independence was done. Krusskall Wallis Test was employed. Cochrane Inter rater validity between the three readers was tested. Odds ratio, sensitivity and specificity of DCXR to diagnose CVD on BCT were then determined.
RESULTS: Of the 483 patients included in the study, 52.8% were females with an average age of 65.86±14.46 years old. Patients of the older age group had a higher AAC grade (3) and had more infarcts on BCT. Although risk factors for AAC on DCXR and CVD on BCT were hypertension, dyslipidemia and renal disease, these were not statistically significant. Cross sectional analysis of variables showed that patients with an AAC grade of 1 was highly associated with infarcts and an AAC grade of 2 was associated with hemorrhagic stroke (p=0.0200). A statistically significant inter rater agreement was noted among the three radiologists that read the DCXR.
CONCLUSION: The AAC grade (1) on DCXR is significantly associated with infarcts on BCT scan with a high specificity and strong positive predictive value. Larger studies may be necessary to determine the association of the other AAC grades (2 and 3) with the types of stroke.

Human ; Male ; Female ; Aged ; Aorta, Thoracic ; Radiographic Image Enhancement ; Tomography, X-ray Computed ; Radiography, Thoracic ; Atherosclerosis ; Cerebrovascular Disorders ; Stroke ; Hypertension ; Dyslipidemias ; Brain ; Radiologists

INTRODUCTION: Diabetes mellitus is rapidly increasing worldwide but the greatest increase is expected in developing countries including the Philippines. It is of public health concern to monitor countrywide prevalence of diabetes as it leads to significant cardiovascular-related mortality as well as significant complications such end stage renal disease, blindness, lower leg amputations and blindness.
METHODOLOGY: This is a national survey to estimate the prevalence of diabetes and pre-diabetes using the criteria of the World Health Organization through a stratified multi-stage sampling design representing each of the 17 regions in the country.
RESULTS AND DISCUSSION: The national prevalence of diabetes in the year 2008 was 7.2% (6.5-7.9); impaired glucose tolerance 7.0% (6.1-7.8) and impaired fasting glucose was 2.2% (2.2-3.1). There was a greater prevalence of individuals with diabetes in the urban areas at 8.5% (7.5-9.5) compared to the rural areas at 5.7% (4.6-6.8). Diabetes is slightly more preponderant among females at 7.4% (6.4-8.3) compared to males at 7.0% (6.1-8.0).
CONCLUSION: The prevalence of diabetes mellitus in the Philippines is rising with the prevalence in 2008 at 7.2%. The prevalence of pre-diabetes exceeds that of diabetes mellitus at approximately 10.2%.

Human ; Male ; Female ; Aged ; Middle Aged ; Adult ; Glucose Intolerance ; Fasting ; Prediabetic State ; Diabetes Mellitus ; Amputation ; Kidney Failure, Chronic ; Blindness ; Glucose

OBJECTIVE: Renal allograft recipients are at higher risk of developing tuberculosis (TB) as compared to the general population. The infection also carries with it a significant morbidity and mortality. However, data is limited regarding its incidence and risk factor analysis in our setting. This study determined the incidence, characteristics and risk factors of post-transplant TB in National Kidney and Transplant Institute (NKTI).
METHODS: This is a retrospective study involving chart review of 1,621 renal allograft recipients from 2003-2009. We recorded demographic information, transplant characteristics, median time to diagnosis of TB and forms of TB.
RESULTS: The incidence of TB in renal allograft recipients is 2.6%. Median time to diagnosis of TB after transplant is 21 months (one to 105 months). Risk factors identified in this study were previous history of TB (OR 4.15, 95% CI 1.4-12.2), one episode of rejection (OR 2.33, 95% CI 1.2-4.6) and subsequent use of methylprednisolone as antirejection therapy (OR 2.36, 95% CI 1.3-4.4). Patients given a tacrolimus based regimen (OR 0.5, 95% CI 0.24-1.03) and those without episode of rejection (OR 0.43, 95% CI 0.22-0.84) had less tendency to develop post-transplant TB. There were no sufficient evidence to prove association between onset of TB and use of isoniazid prophylaxis, use of induction immunosuppression and type of immunosuppression. Eighty one percent (81%) had pulmonary and 19% had extrapulmonary forms of TB.
CONCLUSION: Incidence of TB among renal allograft recipients is lower as compared to other high TB burden countries but is still higher as compared to the general Filipino population. The study identified multiple risk factors for post-transplant TB. Prevention of these diseases and identification of patients at risk are as important as early diagnosis and treatment of post-transplant TB.

Human ; Male ; Female ; Middle Aged ; Adult ; Isoniazid ; Tacrolimus ; Methylprednisolone ; Kidney Transplantation ; Tuberculosis ; Immunosuppression ; Transplantation, Homologous

INTRODUCTION: Current guidelines recommend that in patients presenting with clinically palpable nodules or with an ultrasound finding of a thyroid nodule, one has to evaluate its risk for malignancy by proceeding with a fine needle aspiration biopsy (FNAB). The decision to do FNAB would depend on ultrasonographic features of the nodule, which include its size, hypoechogenicity, presence of microcalcifications, increased central vascularity, infiltrative margins, and taller than wide measures on transverse plane. Elastography, a measure of tissue stiffness, is now also being utilized as another feature that has a positive correlation with malignancy. This study hopes to determine which among the abovementioned ultrasonographic features would best correlate with a higher risk for thyroid malignancy among adult patients who had undergone ultrasound guided FNAB.
METHODOLOGY: A prospective study was done in a cohort of all Filipino patients 19 years old and above who underwent ultrasound guided FNAB of the thyroid nodule/s from July to December 2013 at the Radiology Section of The Medical City, Pasig City, Philippines. Specimen obtained from FNAB were then reviewed by a pathologist to determine its cytopathology and categorized based on the Bethesda System of Classification. The cytopathology reports were correlated with the features seen on the patient's thyroid ultrasound to determine which characteristic would be predictive of malignancy.
RESULTS: A total of 100 patients underwent ultrasoundguided FNAB, from which 157 nodules were biopsied. 27 nodules were excluded from the analysis due to non-diagnostic or unsatisfactory (Bethesda Category I) findings on cytopathology. Among the 100 patients, 86% of which were females with the mean age of 41 ± 11.31 in those found to have malignant cytopathologic diagnosis. Of the 130 nodules biopsied, 115 nodules were identified as benign (Bethesda Category II) while 15 were identified to be malignant or suspicious for malignancy (Bethesda Category III-VI). Each of the five sonographic features that were predictive of malignancy was compared between the two outcome groups (benignversus malignant). Among them, only the presence of microcalcifications on ultrasound showed to be significantly correlated with malignancy with an odds ratio of 11.3. Ultrasound evaluation with elastography was only performed on 24 nodules and hence results were inconclusive. A nodule possessing more than two of the ultrasound features that were predictive of malignancy was more likely to be malignant on cytopathology (p value of 0.00).
CONCLUSION: The presence of microcalcifications on thyroid nodules as seen on ultrasound is a significant predictor of malignancy and remains to be consistent locally as with foreign studies. Nodules that were proven to be malignant on cytopathology presented with more of the ultrasound features that are said to be predictive of malignancy.

Human ; Male ; Female ; Middle Aged ; Adult ; Thyroid Nodule ; Biopsy, Fine-needle ; Elasticity Imaging Techniques ; Thyroid Neoplasms ; Ultrasonography ; High-energy Shock Waves ; Calcinosis

INTRODUCTION: Diabetes Mellitus is associated with vascular disease. One of its macrovascular complications is peripheral arterial disease (PAD), which can present as critical limb ischemia (CLI) that can eventually lead to amputation and death.
OBJECTIVE: Determine the long-term outcome of Type 2 diabetic patients with critical limb ischemia in National Kidney and Transplant Institute (NKTI).
METHODS: Computerized search of NKTI Medical Records Section was done using the Docuview. Type 2 diabetic patients with critical limb ischemia of the lower extremities were included in the study. Patients were grouped according to the intervention received (No intervention, Bypass Graft or Peripheral Angioplasty). Endpoints such as amputation and mortality were ascertained on readmissions and on outpatient records. Data processing and analyses were performed using SPSS v20. Kaplan-Meier Survival Analysis was used to examine days to amputation and days to mortality between groups.
RESULTS: Twenty-three (23) patients were included in the study. There was no significant difference on the baseline characteristics of those who received revascularization and those who did not have revascularization. Amputation rate was 31% while mortality rate was 30% for the whole population. Patients who had revascularization seemed to have greater probability of amputation and lesser probability of dying, but these were not statistically significant based on Kaplan - Meier Survival Curves p values of 0.918 and 0.433, respectively.
CONCLUSION: Diabetic patients with CLI still carries a high risk of amputation and mortality even with revascularization but the time to amputation is longer for those who were revascularized.

Human ; Male ; Female ; Middle Aged ; Peripheral Arterial Disease ; Kaplan-meier Estimate ; Patient Readmission ; Amputation ; Lower Extremity ; Angioplasty ; Diabetes Mellitus, Type 2

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 ;

BACKGROUND: Churg-Strauss syndrome (CSS), or eosinophilic granulomatosis with polyangiitis, is a rare syndrome that affects small- to medium-sized arteries and veins. Criteria for the diagnosis include: asthma (wheezing, expiratory rhonchi), eosinophilia of more than 10% in peripheral blood, paranasal sinusitis, pulmonary infiltrates (may be transient), histological proof of vasculitis with extravascular eosinophils, and mononeuritis multiplex or polyneuropathy. The worldwide incidence of CSS is approximately 2.5 cases per 100,000 adults per year and its incidence in the United States is one to three cases per 100,000 adults per year.1 In the Philippines, the exact incidence is unknown with very few published case reports about it.
SETTING: University of the Philippines-Philippine General Hospital (UP-PGH), a tertiary training hospital in Manila, Philippines
THE CASE: A 40-year-old Filipino male with a history of adult onset asthma and recurrent sinusitis manifesting with inability to dorsiflex the left ankle (foot drop), various dermatologic lesions, and arthralgia. Complete blood count showed hypereosinophilia. Electromyography revealed asymmetric moderate to severe sensory and motor denervation of limbs compatible with polyneuropathy. Skin biopsy revealed lymphocytic vasculitis. P-ANCA was positive. During his incumbent hospitalization, the skin lesions, arthralgia and neurologic manifestations improved on administration of high dose steroids. Pregabalin was used to control pain secondary to the mononeuritis multiplex.
SIGNIFICANCE: To report a rare case of ChurgStrauss syndrome presenting as foot drop. This case highlights the importance of considering ChurgStrauss syndrome among adult patients presenting with neurologic complaint (inability to dorsiflex the left ankle/foot drop) and various dermatologic lesions.

Human ; Male ; Adult ; Churg-strauss Syndrome ; Respiratory Sounds ; Mephenoxalone ; Antibodies, Antineutrophil Cytoplasmic ; Pregabalin ; Asthma ; Granulomatosis With Polyangiitis ; Pulmonary Eosinophilia ; Mononeuropathies ; Polyneuropathies

INTRODUCTION: Tuberculosis (TB) is a chronic infectious disease, with a growing incidence seen worldwide. Among the tuberculous infections, pulmonary TB remains to be the most common, with extrapulmonary TB seen in only less than 2.0% of this population. Although the latter remains to be rare, it is commonly found in the lymph nodes, gastrointestinal (GI) and genitourinary (GU) tracts, weight- bearing joints, and the meninges. But, however rare extra- pulmonary tuberculosis may be, some patients have reported the occurrence of such in less common sites.
In patients with autoimmune diseases, the diagnosis and management of microbial infections remain complicated because of their immunocompromised nature, and because of the medications they receive. As tuberculosis is a curable disease, early identification and proper treatment should be applied to avoid further patient compromise.
OBJECTIVE: The objective of this paper is to present three cases of patients diagnosed with extrapulmonary tuberculosis at atypical sites namely tuberculous cellulitis, endometrial tuberculosis, and tuberculous dactylitis, accompanying a primary rheumatologic disease.
CASES: Case 1 is a patient with Dermatomyositis who presented with pain and non- traumatic ecchymosis on his right gluteus, later diagnosed as TB cellulitis through a positive AFB smear of the aspirate. Case 2 is a patient with SLE whose amenorrhea was initially attributed to Cyclophosphamide. However, further work up revealed tuberculous bacteria through AFB smear of the curetting, hence was diagnosed with Endometrial TB. Case 3 reports another patient with SLE, who was diagnosed with recurrent TB dactylitis through a positive AFB smear of the biopsy.
CONCLUSION: Despite the high endemicity of the Philippines for tuberculosis, extra- pulmonary TB continues to be underrecognized. Patients with autoimmune conditions are most likely to suffer from such infections due to their immunocompromised state. High suspicion and management remain to be the cornerstone to avoid diagnostic delays, and improve outcome.

Human ; Male ; Female ; Adult ; Dermatomyositis ; Cellulitis ; Ecchymosis ; Amenorrhea ; Weight-bearing ; Tuberculosis, Pulmonary ; Meninges ; Collagen Diseases ; Autoimmune Diseases ; Lymph Nodes ; Bacteria ; Arthritis, Rheumatoid

BACKGROUND

Melioidosis is an infectious disease caused by Burkholderia pseudomallei. It is endemic in the Philippines and is underreported. Of the reported cases, the most common comorbidity is diabetes mellitus. The increasing cases of antibiotic resistance and the relatively high mortality rate highlights the need for increased awareness among clinicians regarding this disease. We aim to report a case of Burkholderia pseudomallei resistant to trimethoprim/sulfamethoxazole (TMP-SMX), used in its eradication following initial intravenous therapy.

CASE PRESENTATION

A 51-year-old male Filipino with poor health-seeking behavior came with generalized body weakness, weight loss, dysarthria, fever, cough, difficulty breathing, bloatedness, dysuria, joint pains, and bilateral lower extremity hyperpigmented macules for four months. He has diabetes mellitus and hypertension and is a mechanic by trade. Initial workups revealed hemoglobin A1c (HbA1c) of 14.7%, and urinalysis with bacteriuria. Imaging revealed bilateral pneumonia on chest xray, hepatosplenomegaly on whole abdomen ultrasound, and old cerebral infarcts on cranial computed tomography scan (CT scan). Empiric antibiotics for the impression of sepsis from community-acquired pneumonia and urinary tract infection were ertapenem and azithromycin. Upon isolation of Burkholderia pseudomallei from blood cultures, the team shifted to TMP-SMX and ceftazidime for initial therapy of melioidosis. Sensitivity showed resistance to TMP-SMX; hence the team revised the antimicrobials to four weeks of levofloxacin and ceftazidime. After eleven hospital days, the team sent the patient home, clinically improved. The team continued levofloxacin for eradication therapy for three months and the patient responded well.

CONCLUSION

Fever with multi-system involvement in a Filipino patient with diabetes mellitus with significant environmental risk factors, poor glycemic control, splenomegaly, and treatment failure with appropriate empiric antibiotic therapy should raise suspicion for melioidosis. It is paramount that antimicrobial resistance be detected and documented upon isolation of Burkholderia pseudomallei, given the high relapse rates and the need for a prolonged duration of treatment.

Human ; Male ; Middle Aged: 45-64 Yrs Old ; Melioidosis ; Philippines ; Diabetes Mellitus ; Burkholderia Pseudomallei

INTRODUCTION

Splenic Abscess is an ongoing infectious process with pus accumulation specifically at the spleen, this is associated with a high mortality rate with studies showing 16.6% among those diagnosed, with risk factors mainly present are among immunocompromised state. Among the immunocompetent population, an incidence of 0.14-0.70% were documented. 13 The etiology for this may include hematogenous or contiguous spread of infection as a pathophysiology, with bacterial seeding at the site. Detection of this is through ultrasound or CT scan, with a goal of identify a complex or a simple abscess. Therapeutics lie in choosing splenectomy, placing the patient in an immunocompromised state despite being at a young age against the conservative percutaneous drainage on top of the maximized antibiotic use. A recent meta-analysis showed a mortality rate of 12% among patients with splenectomy and a complication rate of 26%, however the percutaneous drainage had a mortality of 8% and a complication rate of 10% 14 This highlights the clinical awareness and decision among patients with splenic abscess.

CASE

Presenting a case of 37-year-old female who came in with left upper quadrant pain. This patient had undergone laparoscopic cholecystectomy 6 months prior to admission with an unremarkable outcome. An onset of left upper quadrant pain was noted 3 months prior to admission and was initially conservatively managed with unrecalled antibiotics. Persistence of this prompted further work up where ultrasound revealed an abscess in the spleen and was then admitted for broad spectrum antibiotics, namely piperacillin-tazobactam and further imaging. CT scan of whole abdomen with contrast was then done which revealed splenomegaly with rim enhancing near fluid attenuating lesions in the mid to inferior pole. The complexity of the abscess prompted the decision for splenectomy, the gold standard for treatment for splenic abscess. Patient had tested negative for HIV.

CONCLUSION

Splenic abscess is a rare condition, usually presenting with fever and left upper quadrant pain, the patient however did not present with fever despite a complex abscess. Splenic abscess is associated with a high mortality rate. A wide array of differentials is considered in patients with left upper quadrant pain and laboratories are directed into investigating the structural cause for left upper quadrant pain as the spleen has many adjacent organs which may present similarly. The decision to choose splenectomy and percutaneous abscess determines survivability of infection as splenectomy places patient in an immunocompromised state, thus early recognition of splenic abscess, and feasibility of percutaneous drainage is vital to the out-hospital outcome for the patient. Among immunocompetent individuals, given the lower mortality and lower complication rates, it may be ideal to combine both medical and minimally invasive procedures and a rise in complication may then warrant splenectomy.

Human ; Bacteria ; Male ; Adult: 25-44 Yrs Old ; Splenectomy ; Minimally Invasive Surgery ; Minimally Invasive Surgical Procedures