Background: Tuberculous arthritis is a rare extra-pulmonary manifestation of tuberculosis (TB) that can lead to significant disability when left untreated. This study described the clinical profile of patients with TB arthritis admitted in a tertiary hospital in the Philippines. Methods: We reviewed medical records of 65 patients with TB arthritis admitted in the Philippine General Hospital from 2006 to 2019. Results: Majority of patients were male (41, 63.0%) and the mean age upon diagnosis was 46.7 ± 1.7 years (20– 85). Majority (33, 50.8%) had underlying co-morbidities including hypertension (16, 24.6%), type 2 diabetes mellitus (10, 15.4%), and chronic kidney disease (8, 12.3%). A history of previous TB treatment (10, 15.4%), intake of immunosuppressive drugs (7, 10.8%), and trauma on affected joints (13, 20.0%) were also reported. Majority presented with chronic mono-arthritis (50, 76.9%) involving the knees (27, 41.5%) and hips (21, 32.3%) with a mean duration of symptoms of 20.9 ± 3.9 months. The most frequent initial diagnosis upon admission was septic arthritis (21, 32.3%). Confirmed septic arthritis (10, 15.6%), pulmonary TB (9, 14.3%), and disseminated TB (4, 6.3%) were also observed. Majority were diagnosed based on positive acid-fast bacilli (AFB) smear, polymerase chain reaction (PCR) for Mycobacterium tuberculosis, or synovium biopsy (34, 54.0%). Anemia (43, 68.3%) and elevated inflammatory biomarkers (erythrocyte sedimentation rate, ESR [36, 97.3%] and C-reactive protein, CRP [40, 87%]) were also seen in majority of patients. The most common radiographic findings on x-ray were joint space narrowing (42, 84.0%), soft tissue swelling (22, 44.0%), and erosions (21, 42.0%). The mean length of hospital stay was 23.8 ± 2.8 days (2–113). Majority underwent surgical interventions (35, 55.6%) including debridement (28, 80.0%) and arthrotomy (25, 71.4%). All received anti-tuberculosis treatment upon diagnosis. Conclusion Majority of patients with TB arthritis in this study were male, with mean age in the 5th decade of life, presenting with mono-arthritis, anemia, elevated inflammatory markers, and radiologic findings of joint narrowing. All patients received medical treatment while more than half underwent surgery. There should be a high index of suspicion for TB arthritis in a patient from an endemic country presenting with chronic mono arthritis in weight-bearing joints to prevent delay in diagnosis and significant joint destruction and disability
Arthritis ; Tuberculosis

Introduction: Gout is a clinical syndrome resulting from deposition of urate crystals in joints causing inflammation, intense pain and even disability. In 2003 National Nutrition and Health Survey (NNHeS), the overall prevalence of gout was 1.6% and the prevalence of hyperuricemia was 28.4% of the 4498 adults >20 years old. Gout complicating cyanotic congenital heart disease (CCHD) was infrequently recognized in early reports with Somerville referring only nine patients over a period of five years in the registry of two hospitals. Recent studies have shown increased recognition, with Yamamura identifying 16% of the 92 patients with CCHD to have gouty arthritis. There is no local data on the frequency of gout among patients with CCHD Case Presentation: 26-year-old male previously diagnosed with Transposition of Great Arteries presented with a mass on the 5th digit of left hand with pathologic bone destruction on radiograph underwent disarticulation of the same finger. Intraoperative findings revealed chalky substances that led to the referral to rheumatology section. A diagnosis of chronic tophaceous gout was considered after review of history. He had a three year history of intermittent polyarticular arthritis involving the elbows, knees and ankle joints and later developed tophi in the helices of the ears and the DIP joint of the fifth digit of the left hand. There is increasing level of hyperuricemia as the severity of arthritis progressed. He had a polyarticular gout flare post operatively. The gout attack resolved after treatment with colchicine. Allopurinol was initiated after control of gout flare with resulting decrease in uric acid level. Discussion: This case described a young male patient with transposition of great vessels with acute intermittent polyarthritis and tophi formation. The occurrence of gout and the complexity of the congenital heart disease have caused a considerable financial, functional and emotional instability on the patient, his parents and extended family. In patients with cyanotic congenital heart disease, the prevalence of hyperuricemia ranges from 16 to 43%. Several factors identified to be associated with hyperuricemia in CCHD in our case which include hypoxemia, polycythemia and impaired renal function. Nonetheless, management of gout in patient with CCHD is similar to the primary and secondary gout. Conclusion Gouty arthritis should be a differential in a patient with a cyanotic congenital heart disease complaining of joint swelling and tenderness. Early and prompt diagnosis will relieve symptoms and prevent complications that may lead to physical inactivity of patients.
Gout ; Heart Defects, Congenital ; Arthritis

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

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: 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

INTRODUCTION: Traditional studies on psoriatic arthritis have evaluated the response to treatment in terms of the rheumatic condition excluding the dermatologic condition. Treatment of the disease with biologic agents has been demonstrated to be effective in the control of both the arthritis and skin condition.

OBJECTIVE: To systematically review the efficacy of locally available biologic agents (etanercept and infliximab) in the treatment of rheumatic and dermatologic manifestations of psoriatic arthritis.

SEARCH STRATEGY: A MEDLINE search (from 1966 to June 2007) was performed using the following search terms: biologic agents, infliximab, etanercept, psoriasis, psoriatic arthritis and randomized clinical trials. Likewise, the Cochrane Database was also searched for existing studies on psoriatic arthritis. This was supplemented by citation tracking of published bibliographies and conference proceedings.

SELECTION CRITERIA: All randomized clinical trials evaluating the efficacy of etanercept and infliximab in Adult patients with active Psoriatic arthritis were included. Outcome assessments should include evaluation of both arthritic and dermatologic manifestations of the disease. These could be in the form of Psoriatic Arthritis Response Criteria (PsARC), American College of Rheumatology (ACR) Response Criteria (20, 50, and 70) and the Psoriatic Arthritis Severity Index (PASI) 75.

MAIN RESULTS: Nine studies were identified using the search strategy previously outlined. Of these, the four main clinical trials involving 569 patients were included in the quantitative analysis. Studies publishing the results of post hoc analysis were excluded if they did not assess for joint and dermatologic efficacy. Quantitative analysis showed that patients treated with biologic agents were more likely to experience improvement in arthritic complaints compared to placebo [PsARC RR 0.32 favoring treatment 95% CI (0.25-0.40) P
Psoriasis Arthropathica ; Psoriasis, Arthritic