BACKGROUND AND OBJECTIVES

A mounting evidence links dysregulated immune response to cases of fatal pneumonia seen in COVID-19 infection. We aimed to validate the COVID-19-associated Hyperinflammatory Syndrome (cHIS) score, a novel clinical tool devised to identify those at risk for adverse outcomes, in a local population and investigate the relationship of cHIS score taken at admission and the risk of mortality and the need of mechanical ventilation.

This retrospective cohort study analyzed the sociodemographic, clinical, and laboratory data of 1,881 COVID-19 patients admitted at a tertiary hospital in Davao City, Philippines from January to December 2021. We calculated the cHIS score, composed of six clinical and laboratory criteria from admission, and used multivariate logistic regression to determine the risk of mortality and need of mechanical ventilation.

The cHIS score taken at admission, regardless of cut-off value, was a significant predictor of mortality (OR 0.979 [99% CI 0.894-1.064]) and need of mechanical ventilation (OR 0.586 [99% CI 0.4975-0.6745]). Using the Youden Index, a cut-off cHIS score of 3 or more was a better predictor of mortality (sensitivity, 88.59%; specificity, 71.72%), and a cut-off score of 2 or more was a better predictor of need of mechanical ventilation (sensitivity, 84.02%; specificity, 70.82%) than other cutoff cHIS scores.

Among COVID-19 patients, the cHIS score at admission correlated with the risk of mortality and the need of mechanical ventilation. Cutoff scores of 3 and 2 had the optimal sensitivities and specificities to predict the risk of mortality and the need of mechanical ventilation, respectively.

INTRODUCTION

Neurofibromatosis type 1 (NF1) is an autosomal dominantly inherited condition seen in one of 4000 live births, predisposing to peripheral and central neurofibromas. Spinal tumors are seen in 40% of cases with NF1 and only 2% will develop symptoms, and among those who develop symptoms where 33% showed intradural extramedullary location. Thoracic spinal dumbbell neurofibroma is even rarer, and cases that extend to obliterate the posterior mediastinum even more so, with the case presented being the largest in size documented to date.

A 34-year-old female presented since childhood clinical findings consistent with Neurofibromatosis Type I: generalized cafe-au-lait macules, axillary freckling, cutaneous neurofibromas, two iris Lisch nodules identified via slit lamp examination, and anterolateral bowing of the right tibia, and no known parental history of Neurofibromatosis Type I. Prior to admission, the patient presented with progressive loss of motor strength of the lower extremities, and progressive dyspnea. Work-up revealed a Thoracic Intradural Extramedullary Neurofibroma extending to the Right Posterior Mediastinum measuring 15.3 cm x 12.9 cm x 9.7 cm in the thoracic cavity compressing the right lung and bronchus. An extensive two stage surgery was contemplated involving an initial resection of the Intradural mass, with spine instrumentation for support, and subsequent resection of the mediastinal extension. However, complications from the compressing tumor: complete cord transection syndrome causing spinal autonomic dysfunction, lung and airway compromise causing prolonged intubation and difficulty in weaning from mechanical ventilatory support, extensive thrombus formation in the right jugular vein, and nosocomial infections all created compounding difficulties for the surgical technique and anesthetic plan.

Cornerstone management for dumbbell spinal neurofibromas involves their total removal. The best results are obtained in patients showing minimal neurological deficits during the preoperative period. However, little improvement may be expected from patients who develop complete transection syndrome during the postoperative period. Concurrent medical management to prepare the patients are equally important. The multi-subspecialty approach required in managing these cases entails a good balance between the disability before the surgery, anticipated outcomes, and quality of life of the patients.

Introduction: Systemic lupus erythematosus (SLE) and systemic sclerosis (SSc) are complex autoimmune conditions that can co-exist with 6.8% prevalence based on cohort studies. This case report details the clinical journey of a 45-year-old female with an SLE-SSc overlap syndrome particularly presenting with autoamputation of digits, which is a rare and debilitating complication of SSc, with a scarcity of published reports as of writing. Case Description: This patient was diagnosed with SLE nearly a decade ago, presenting with alopecia, joint pains, malar rash, and a positive antinuclear antibody test. Initial treatment with prednisone and hydroxychloroquine showed improvement, but hydroxychloroquine was discontinued due to adverse effects. Subsequently, she developed skin tightness, deformities in her digits, and progressive vision loss, consistent with SSc, but she did not seek timely medical attention. During the COVID-19 pandemic, her symptoms worsened, leading to hand weakness, digit shortening, and loss of fingernails. She was eventually diagnosed with SSc by a rheumatologist. The patient commenced treatment with prednisone (10 mg daily) and mycophenolate mofetil (500 mg thrice daily). Six months into treatment, she showed significant improvement in skin pliability and hand functionality, with regrowth of fingernails. The patient demonstrated excellent adherence to the treatment regimen and regular follow-up visits, resulting in continued improvement in her condition. Conclusion SLE-SSc overlap syndromes pose diagnostic challenges due to shared clinical features. This case underscores the need for early recognition and tailored treatment strategies, as evidenced by the patient’s positive response to combined immunosuppressive therapy. Addressing these complexities requires ongoing research and interdisciplinary collaboration to optimize patient outcomes.
Human ; Female ; Middle Aged: 45-64 Yrs Old ; Scleroderma, Systemic ; Lupus Erythematosus, Systemic

Introduction: Graves orbitopathy (GO) is an autoimmune disease affecting the orbits and the periorbital tissues with an annual incidence of 16 per 100,000 population in women and 2.9 in men. While GO occurs in the spectrum of hyperthyroidism or Graves disease, 7.9% of these patients have a normal thyroid function and only a few are negative for thyroid antibodies. When left untreated, GO may become debilitating and threaten vision. Case Description: A 64-year-old male presented with gross bilateral proptosis and chemosis, which developed over a period of 10 years. Palpitations, hand tremors, heat intolerance, weight loss, and insomnia were notably absent, and the thyroid gland was normal. The bilateral proptosis was left unattended for 10 years until extreme lagophthalmos and chemosis with corneal and mucosal exposure leading to dryness, foreign body sensation, excruciating eye pain, and blurred vision resulted. Thyroid-stimulating hormone (TSH), T3, and T4, were normal. TSH-receptor antibody (TRAb) and thyroid peroxidase antibody were negative. The computed tomography scan with contrast of the orbits showed bilateral proptosis and extraocular muscle enlargement typical for thyroid eye disease. The patient was diagnosed with TRAb- negative euthyroid GO with a European Group on Graves’ Orbitopathy (EUGOGO) clinical score of 7/7, indicating a severe, active disease. Screening prior to administration of GO immunosuppressive therapy revealed chronic hepatitis B infection. The patient was started with tenofovir for 2 weeks before treatment for GO. The patient was given intravenous methylprednisolone with cumulative dose of 4.5 g for 12 weeks, with daily mycophenolate sodium 0.72 g for 12 weeks. Upon completing the 12-week treatment regimen and undergoing an adjunctive lateral canthotomy and partial tarsorrhaphy, the GO signs and symptoms dramatically resolved, and visual acuity markedly improved. Conclusion This case report presents an unusual condition of a euthyroid, TRAb-negative Graves orbitopathy. It provides insights on the diagnosis and treatment of patients with such atypical presentation. Despite the chronicity and severity of this patient’s GO, excellent results were achieved with appropriate and guideline-directed treatment.
Human ; Male ; Middle Aged: 45-64 Yrs Old ; Graves Ophthalmopathy ; Exophthalmos ; Mycophenolic Acid

Background and Objectives: A mounting evidence links dysregulated immune response to cases of fatal pneumonia seen in COVID-19 infection. We aimed to validate the COVID-19-associated Hyperinflammatory Syndrome (cHIS) score, a novel clinical tool devised to identify those at risk for adverse outcomes, in a local population and investigate the relationship of cHIS score taken at admission and the risk of mortality and the need of mechanical ventilation Methods: This retrospective cohort study analyzed the sociodemographic, clinical, and laboratory data of 1,881 COVID-19 patients admitted at a tertiary hospital in Davao City, Philippines from January to December 2021. We calculated the cHIS score, composed of six clinical and laboratory criteria from admission, and used multivariate logistic regression to determine the risk of mortality and need of mechanical ventilation. Results: The cHIS score taken at admission, regardless of cut-off value, was a significant predictor of mortality (OR 0.979 [99% CI 0.894-1.064]) and need of mechanical ventilation (OR 0.586 [99% CI 0.4975-0.6745]). Using the Youden Index, a cut-off cHIS score of 3 or more was a better predictor of mortality (sensitivity, 88.59%; specificity, 71.72%), and a cut-off score of 2 or more was a better predictor of need of mechanical ventilation (sensitivity, 84.02%; specificity, 70.82%) than other cut-off cHIS scores. Conclusion Among COVID-19 patients, the cHIS score at admission correlated with the risk of mortality and the need of mechanical ventilation. Cutoff scores of 3 and 2 had the optimal sensitivities and specificities to predict the risk of mortality and the need of mechanical ventilation, respectively.
COVID-19 ; Inflammation ; Mortality ; Respiration, Artificial ; Cytokine Release Syndrome

Objectives: As asthma is a chronic inflammatory disease of the airways, anti-inflammatory treatment should be positioned at the forefront of guideline-directed asthma care. However, patients tend to rely on short-acting β2-agonists (SABAs) for rapid-onset symptom relief. The impact of SABA overuse and associated clinical outcomes have been investigated extensively in Europe and North America. Limited data are available from countries in Asia, Africa, Latin America, and the Middle East. The SABA use IN Asthma (SABINA) III program, a large multicountry, observational study, was undertaken to describe the global extent of SABA use and its potential contribution to suboptimal disease control. As part of the SABINA III study, we aimed to characterize SABA prescription collection and asthma-related clinical outcomes among patients in the Philippines. Methods: This nationwide, observational, cross-sectional, SABINA III study included patients (aged ≥12 years) with a documented asthma diagnosis recruited between May 2019 and January 2020 from 10 sites in the Philippines. Demographics, disease characteristics and prescribed asthma treatments, including SABA and inhaled corticosteroids (ICS) in the 12 months preceding study start, were recorded during a single visit, and transcribed onto an electronic case report form (eCRF). Patients were classified by investigator-defined asthma severity, guided by the 2017 Global Initiative for Asthma (GINA) report and practice type, either primary or pulmonary medicine specialist care. Results: Of 245 patients analyzed, 63.3% were classified as having moderate-to-severe asthma (GINA steps 3−5), and most patients (63.3%) were enrolled by pulmonary medicine specialists. Overall, 33.1% (n=81) of patients had experienced ≥1 severe exacerbation in the previous 12 months and 18.4% (n=45) of patients had uncontrolled asthma. With respect to asthma treatments, a total of 6.5% (n=16), 40.4% (n=99), and 2.4% (n=6) of patients were prescribed SABA monotherapy, SABA in addition to maintenance therapy, and ICS, respectively, in the 12 months prior to their study visit. Most patients (n=156 [63.7%]) received prescriptions of fixed-dose combina-tions of ICS and long-acting β2-agonists. SABA over-prescription, defined as ≥3 SABA canister prescriptions per year, was observed in 10.6% (n=21) of patients. Additionally, 25.6% (n=23) of patients classified as having mild asthma were prescribed either nebulized SABA (n=17) or oral SABA (n=6). Nearly one-third of patients (n=75 [30.6%]) had purchased over-the-counter (OTC) SABA, and 46.9% (n=115) were prescribed antibiotics. Conclusions In this SABINA III Philippines study cohort, more than 10% of patients were over-prescribed SABA canisters. Additionally, prescriptions for oral or nebulized SABA, the purchase of non-prescription (OTC) SABA, and the high percentage of prescriptions for antibiotics warrant country-wide improvements in asthma care and management.
Asthma ; Bronchodilator Agents ; Philippines ; Prescriptions

Background: The etiology of pleural effusion remains unclear in nearly 20% of cases. One way to diagnose malignancy is by doing pleural fluid cytology. There are factors that influence the yield of pleural fluid cytology and one of them is appropriate and timely fixation of samples. Currently, there is no local consensus regarding the timing with which the specimen should be fixed. Objective: The study aims to compare the yield of malignancy between early fixation versus usual fixation of pleural fluid samples, meaning there is no set time for fixation to be done. Methodology: The study employed a prospective cross-sectional research design. All patients with pleural effusion who fulfilled the criteria set by the study were included. Two sets of pleural fluid samples were collected amounting to 20cc each. First sample was assigned as Bottle #1 and placed immediately with fixative while the second sample was assigned as Bottle #2. Bottle #2 underwent routine fixation which follows no fixed or standard time of fixation. The time difference between the fixation of two sample groups greatly varied with Bottle #1 fixed immediately right after collection while Bottle#2 depends on the time it will be processed by the laboratory personnel. Both samples were submitted for cell block and cell cytology reading. Results: Characteristics of the 55 patients included in the study showed age group range from 41 to 65 years of age, with 27 male and 28 female patients. Only one third had history of smoking. There were 21.82% who had family history of cancer and with and suspicious mass on chest radiograph. Out of 55 patients, 29 patients had history of previous diagnosis of cancer, 23 had recurrent pleural effusion, and 28 had chest radiograph with suspicious nodules. Based on gross appearance, there were 20 serous and 21 sanguineous pleural fluid noted. Mean cell count was high (1,115.50 ± 741.02) with lymphocytic predominance (82.56 ± 24.46). Elevated protein concentration (5,388.25 ± 8,230.46) and LDH (484.17 ± 248.72) were noted. Glucose (8.78 ± 6.68 mmol/L) was low. There were 21 patients who had high WBC, 24 with high protein and 16 with elevated LDH. There were 3 patients who were positive for AFB and none for KOH. Comparative analysis showed that the pleural fluid samples assigned to the routinely fixed group which were handed to the nurse after thoracentesis, then forwarded to the laboratory through a ward laboratory aide or patient watcherfor fixation with with 95% alcoholby thelaboratory personnel significantly had a longer duration of 406.62 minutes as compared to immediately fixed at 12.27 minutes (P<0.01). For diagnosis of malignancy, significantly more cases were diagnosed in the immediately fixed group with 36.36% cases versus 18.18% (p=0.016). Conclusion Among patients with suspected malignant pleural effusions, early fixation of pleural fluid samples resulted in higher histopathology yields as compared to those fixed after going through the routine fixation.
Pleural Effusion, Malignant

INTRODUCTION: The worldwide prevalence of adverse drug reactions (ADR) to anti-TB medication ranges from 8% to 85%. Major adverse reactions include hepatic, renal, and hematologic disorders of which, Rifampicin-induced thrombocytopenia is one of these rare complications. CASE: A 58-year-old Filipino male developed respiratory and gastrointestinal bleeding with a severe drop in platelet count after several days of anti-tuberculosis (anti-TB) medications. The patient had oral mucosal petechiae, blood-streaked sputum, and epistaxis. The symptoms progressed to the formation of small adherent clots beneath the tongue, gum bleeding, melena, massive epistaxis, and hemoptysis with continued intake of the anti-TB drugs. The patient had anemia, normal WBC and differential count, and thrombocytopenia of 3 x 10^3/uL, a drop from 235 x 10^3/uL five days prior. The bleeding resolved with the discontinuation of the drugs. A slow graded oral challenge to each of the drugs was done to identify the culprit medication. There was a recurrence of bleeding and a decrease in the platelet count after administration of rifampicin. The anti-TB medications were modified not to include rifampicin. The patient was discharged with no signs of bleeding and a normal complete blood count. CONCLUSION TB is a prevalent disease in our country, and its medications can cause adverse drug reactions. Rifampicin-induced thrombocytopenia is a rare and life-threatening condition that physicians must be aware of and able to recognize promptly and treat properly to prevent recurrence of similar cases in the future. The patient should be forewarned not to take rifampicin and any fixed-dose combination drugs containing rifampicin.
Rifampin ; Thrombocytopenia ; Blood Platelets ; Tuberculosis

Objectives: As asthma is a chronic inflammatory disease of the airways, anti‑inflammatory treatment should be positioned at the forefront of guideline-directed asthma care. However, patients tend to rely on short-acting β2- agonists (SABAs) for rapid-onset symptom relief. The impact of SABA overuse and associated clinical outcomes have been investigated extensively in Europe and North America. Limited data are available from countries in Asia, Africa, Latin America, and the Middle East. The SABA use IN Asthma (SABINA) III program, a large multicountry, observational study, was undertaken to describe the global extent of SABA use and its potential contribution to suboptimal disease control. As part of the SABINA III study, we aimed to characterize SABA prescription collection and asthma-related clinical outcomes among patients in the Philippines. Methods: This nationwide, observational, cross-sectional, SABINA III study included patients (aged ≥12 years) with a documented asthma diagnosis recruited between May 2019 and January 2020 from 10 sites in the Philippines. Demographics, disease characteristics and prescribed asthma treatments, including SABA and inhaled corticosteroids (ICS) in the 12 months preceding study start, were recorded during a single visit, and transcribed onto an electronic case report form (eCRF). Patients were classified by investigator‑defined asthma severity, guided by the 2017 Global Initiative for Asthma (GINA) report and practice type, either primary or pulmonary medicine specialist care. Results: Of 245 patients analyzed, 63.3% were classified as having moderate-to-severe asthma (GINA steps 3−5), and most patients (63.3%) were enrolled by pulmonary medicine specialists. Overall, 33.1% (n=81) of patients had experienced ≥1 severe exacerbation in the previous 12 months and 18.4% (n=45) of patients had uncontrolled asthma. With respect to asthma treatments, a total of 6.5% (n=16), 40.4% (n=99), and 2.4% (n=6) of patients were prescribed SABA monotherapy, SABA in addition to maintenance therapy, and ICS, respectively, in the 12 months prior to their study visit. Most patients (n=156 [63.7%]) received prescriptions of fixed‑dose combinations of ICS and long-acting β2-agonists. SABA over-prescription, defined as ≥3 SABA canister prescriptions per year, was observed in 10.6% (n=21) of patients. Additionally, 25.6% (n=23) of patients classified as having mild asthma were prescribed either nebulized SABA (n=17) or oral SABA (n=6). Nearly one-third of patients (n=75 [30.6%]) had purchased over-the-counter (OTC) SABA, and 46.9% (n=115) were prescribed antibiotics. Conclusions In this SABINA III Philippines study cohort, more than 10% of patients were over-prescribed SABA canisters. Additionally, prescriptions for oral or nebulized SABA, the purchase of non-prescription (OTC) SABA, and the high percentage of prescriptions for antibiotics warrant country-wide improvements in asthma care and management.
Asthma ; Bronchodilator Agents ; Prescriptions

Introduction: Pulmonary arterial aneurysm (PAA) is a rare condition with varying symptomatology. Patients are often referred due to incidental finding of intrathoracic mass on chest radiograph. Common causes include structural cardiac and vascular abnormality, pulmonary hypertension, infection, vasculitis, connective tissue disease, and trauma. Case presentation: A 37-year-old female came in due to shortness of breath associated with easy fatigability, exertional dyspnea, orthopnea, and occasional palpitations. Workup revealed 2D echocardiography findings of atrial septal defect (ASD) with left to right shunt; dilated right atrium and right ventricle; severe pulmonary hypertension; dilated main pulmonary artery. Contrast-enhanced computed tomography (CT) angiography showed PAA in the right main trunk, left and right pulmonary artery with thrombus formation. Cardiac catheterization and hemodynamic study were intended prior to definitive surgical treatment however patient did not opt to proceed. She was managed with warfarin, bisoprolol, digoxin, and trimetazidine. In spite of symptom relief, the patient still needs regular follow-up for reassessment to monitor disease progression. Discussion: Pulmonary arterial aneurysm (PAA) is a rare complication of ASD, a common congenital heart disease. In this case, it presented as a mediastinal mass with nonspecific symptoms diagnosed after routine chest x-ray, verified through echocardiogram. Contrast-enhanced CT angiography ruled out aortic aneurysm and provided additional information of the extent of thrombus formation. However, pulmonary angiography still remains the diagnostic gold standard. Due to the rarity of the disease, optimal treatment of PAA is still uncertain. It is reasonable, however, to treat conservatively for asymptomatic patient with no significant pulmonary hypertension. A more aggressive surgical approach has been advocated for patients with complications. Conclusion It is important to emphasize that PAA can present with non-specific manifestations thus high index of suspicion is critical for the diagnosis. It is also vital for early detection of the aneurysm and correction of the etiology to prevent disease morbidity and mortality.
Thrombosis ; Heart Septal Defects, Atrial