BACKGROUND

Spontaneous isolated superior mesenteric artery dissection (SISMAD) is a rare vascular condition where the superior mesenteric artery is affected by dissection without involving other arteries. Its incidence is estimated at 0.06% to 0.08% globally. The possible causes include polyarteritis nodosa (PAN), an autoimmune disease affecting medium-sized arteries. SISMAD can manifest with various clinical presentations, from asymptomatic to acute bowel ischemia, warranting consideration when common causes of acute abdomen are ruled out.

CASE SUMMARY

This is the case of a 44-year-old female Filipino, hypertensive, who complained of abdominal pain, initially managed as intestinal amoebiasis. Abdominal examination showed a soft, non-tender abdomen with no guarding, making the symptoms disproportionate to physical examination. Due to persistence of symptoms despite a full antibiotic course, further workup was done. Computed tomography (CT) scan of the whole abdomen with contrast revealed an isolated dissection of the proximal superior mesenteric artery (SMA) with thrombosis which was confirmed on CT angiography. The diagnosis of PAN was established based on the correlation of clinical presentation, laboratory findings and imaging results. Conservative management was done and to address the thrombosis, anticoagulation with heparin was initiated. The patient was also given methylprednisolone pulse therapy and cyclophosphamide with good response. Resolution of symptoms noted and she was eventually discharged improved.

CONCLUSION

SISMAD and PAN are independently rare conditions. This unique case involved both diseases in a 44-year-old Filipino female, and to date, there have been no reported similar cases worldwide. Early diagnosis of the disease requires a high degree of suspicion and pattern recognition. This is crucial for timely treatment and improved prognosis. Furthermore, close surveillance is important to identify potential relapses even after symptom resolution.

Human ; Female ; Adult: 25-44 Yrs Old ; Polyarteritis Nodosa ; Mesenteric Artery, Superior

Spontaneous isolated superior mesenteric artery dissection (SISMAD) is a rare vascular condition where the superior mesenteric artery is affected by dissection without involving other arteries. Its incidence is estimated at 0.06% to 0.08% globally. Possible causes include trauma, congenital connective tissue disorders, arteriosclerosis, and vasculitis such as polyarteritis nodosa (PAN). SISMAD can manifest with various clinical presentations, from asymptomatic to acute bowel ischemia, warranting consideration when common causes of acute abdomen are ruled out.

This is a case of a 44-year-old female Filipino, who complained of abdominal pain, initially managed as intestinal amoebiasis. Abdominal examination showed a soft, non-tender abdomen with no guarding, making the symptoms disproportionate to physical examination. Due to persistence of symptoms despite full antibiotic course, further work up was done. Computed tomography (CT) scan of the whole abdomen with contrast revealed an isolated dissection of the proximal superior mesenteric artery (SMA) with thrombosis which was confirmed on CT angiography. C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), cytoplasmic antineutrophilic cytoplasmic antibodies (ANCA) and perinuclear ANCA were both negative; antinuclear antibody (ANA), C3 and C4 levels were also unremarkable. The diagnosis of PAN was established based on the correlation of clinical presentation, laboratory findings, and imaging results. She was given methylprednisolone pulse therapy and cyclophosphamide with good response. Anticoagulation with heparin was initiated to address the thrombosis. The patient had complete bowel rest, pain management, intravenous hydration, and parenteral nutrition. Resolution of symptoms noted and was eventually discharged improved.

SISMAD and PAN are independently rare conditions. This unique case involved both diseases in a 44-year-old Filipino female. Early diagnosis of the disease requires a high degree of suspicion and pattern recognition. This is crucial for timely treatment and improved prognosis. Furthermore, close surveillance is important to identify potential relapses even after symptom resolution.

Human ; Female ; Adult: 25-44 Yrs Old ; Polyarteritis Nodosa ; Pan

Objectives: Recent studies show that patients with young-onset gout present with visible tophi or nephrolithiasis on diagnosis. In the Philippines, where gout is prevalent, there is no published work on this subset of patients. This study presents the clinical characteristics of a cohort of Filipino patients with gout whose symptoms started at 30 years of age or younger. Methods: The case records of all patients who fulfilled the 1977 American College of Rheumatology (ACR) criteria for gout seen in four adult rheumatology services were reviewed. We selected those whose age of onset of gout was at 30 years or younger. The demographic characteristics, medical history, laboratory parameters, and presenting manifestations were described. Results: Six hundred sixty-nine records of patients with gout were reviewed; 101 (15%) fulfilled the young-onset gout criteria. The mean age of onset was 25±4.40 years (range 14-30), and the mean disease duration before diagnosis was 12.64±11.91 years. All of the patients were male and most were married; 76% were alcoholic beverage drinkers and 38% were smokers. A family history of gout was noted in 47%. Most patients (66%) were already on nonsteroidal anti-inflammatory drugs (NSAIDs), 24% on colchicine, and 14% on urate-lowering therapy before consult at the rheumatology clinic. By history, at onset, the most common pattern of joint involvement was monoarthritis (95%), affecting the ankles (60%), knees (52%), and 1st metatarsophalangeal (MTP) joint (51%). However, on the first rheumatology clinic visit, 34% of arthritis was polyarticular, more than 68% had more than three arthritis attacks per year, and there were tophi in 35%. The mean duration before visible tophi formation was 2.81±6.75 years. Around 21% had nephrolithiasis or a history thereof. The mean serum uric acid (SUA) was 9.18 mg/dL and the mean serum creatinine was 1.5 mg/dL. Thirty-seven percent had estimated glomerular filtration rate (GFR) <60 mL/min. Conclusion Young-onset gout was present in 15% of our patients and gout was familial in 47%. There was a delay in diagnosis of as long as ten years in most of the patients. On presentation at the rheumatology clinic, more than 34% had polyarticular arthritis, 35% had tophi, and 37% had low estimated GFR. This emphasizes the importance of awareness and prompt diagnosis to ensure correct treatment and prevention of complications
Gout

Introduction: Rheumatoid arthritis (RA) is the most common autoimmune inflammatory arthritis of unknown etiology. Cardiovascular disease (CVD) remains a major problem for these patients. This paper aims to describe the presence of cardiovascular risk factors among filipino patients with rheumatoid arthritis seen in the Philippine General Hospital Rheumatology outpatient department. This will also serve as a baseline database for patients with cardiovascular risk factors for future studies on the impact of rheumatoid arthritis on cardiovascular morbidity and mortality. Objective: to describe the presence of cardiovascular risk factors among filipino patients with rheumatoid arthritis seen in the Philippine General Hospital Rheumatology outpatient department included in the Rheumatoid Arthritis Database and Registry (RADAR) Methods: Cases entered in the study were taken from the RADAR. Included patients were those worked up for traditional and non-traditional cardiovascular risk factors. Demographic data, traditional and nontraditional cardiovascular risk factors and management for RA and CVD were extracted. Descriptive statistics were applied. This study is approved by the Institutional Review Board. Results: Ninety eight patients were included in this study. Ninety four percent were female with mean age at diagnosis of 49.95±10.17 (SD) years and mean disease duration of 63.01 months. For traditional cardiovascular risk factors: 18% were smokers; 34% (24/71) were obese; mean BMI was 23.85±4.60 (SD) kg/m2; 39% (38/98) had hypertension of which 87% were on antihypertensive medication; 19% has impaired fasting glucose (IFG) or diabetes and 55% had dyslipidemia but only 53% and 33% were on oral hypoglycemic agents and statins, respectively. For non-traditional CV or diseaserelated risk factors, 20% still had high disease activity and 65% had elevated sedimentation rate (mean 45.58±18.36 (SD) mm/hr) on latest consult. Eighty seven percent were taking methotrexate but only three percent were on biologic agents. Conclusion This study shows the presence of important traditional risk factors such as hypertension, diabetes, dyslipidemia, and obesity in this population. Significantly, more than half the cases have dyslipidemia. In addition, RA disease activity was high to moderate. The combination of traditional and disease related risk factors for cardiovascular disease is ominous and warrants aggressive treatment. In addition, patient education and weight control should be emphasized. It is recommended that this cohort be followed up prospectively.
Arthritis, Rheumatoid ; Heart Disease Risk Factors

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

BACKGROUND AND OBJECTIVES: Gout is an inflammatory arthritis involving the deposition of uric crystals. It has been known to cause renal disease in the form of acute or chronic urate nephropathy, or urolithiases. Numerous studies have been published worldwide, defining proper handling and management of such cases. Despite such recommendations, the renal function of these patients complicates the management. Administration of the properly-adjusted medications and referrals to appropriate services are delayed because of lack of data at the patient's initial visit. This study therefore aims to describe the renal function at index consult of Filipino patients with gout, and identify the factors that correlate with a depressed kidney function in such patients.

METHODS: This study is a retrospective descriptive study involving gout patients seen in four rheumatology clinics. A total of 485 patients were identified. Records of the patients' index consult, were reviewed. Demographic and disease characteristics were noted. Renal function was identified using the Cockroft-Gault equation for estimated glomerular filtration rate. Univariate analysis was done, characteristics of patients with good and poor renal function were compared.

RESULTS: A total of 485 patients were studied. Most were males with presenting with a monoarticular joint involvement, with attacks occurring more than three times a year. Tophi were present in 28.2% of patients at the initial consult. The most commonly reported comorbidity was hypertension. At index consult, the average serum creatinine and uric acid are 1.7mg/dL and 9.1 mg/dL, respectively. The average creatinine clearance is 65.0±34.1 mL/min, and 51.3% presented with an eGFR of

CONCLUSION: In this cohort of 485 Filipino patients with gout, 51.3% have eGFR

Human ; Male ; Female ; Middle Aged ; Uric Acid ; Creatinine ; Comorbidity ; Glomerular Filtration Rate ; Rheumatology ; Gout ; Urolithiasis ; Kidney Calculi ; Hypertension ; Diabetes Mellitus ; Probability

BACKGROUND: Gouty  arthritis  is  one  of  the  most  common  arthritis  in  adults  in  the  Philippines.  It  is  more  common  in  men,  although  also  seen  in  post-menopausal  women.    Its  characterization  in  the  Filipino  population  will  help  in  earlier  recognition  of  the  disease  and  administration  of 
appropriate  management.

OBJECTIVE: To describe the clinical characteristics of Filipino female  patients  with  gout. 

METHODOLOGY: We reviewed the charts of female patients who were diagnosed with gout using the American College of Rheumatology (ACR) criteria. We collected data on the demographic and disease characteristics of these patients.

RESULTS: In our cohort of 768 patients with gout, 8.82% were females. The mean age of onset was 60.25 years old, and the  mean  age  at  the  initial  consult  was  63.68  years  old.  Only  a  few  patients  had  a  family  history  of  gout  and  of  drinking  alcohol.  Hypertension  was  a  comorbid  condition in 58.21% and there was more than one coexistent illness in 20.89%. The majority presented with a monoarthritis (67.16%). The most commonly involved joints were the ankle (59.7%), knee (41.79%), and the first metatarsophalangeal joint (MTP,
37.3%).    On  the  first  visit  at  the  rheumatology  clinic,  most  patients (47.76%) reported less than three attacks of arthritis per year, and 14.92% had tophi. The mean serum uric acid was 8.53 mg/dL, mean serum creatinine was 1.55mg/L, and the  mean  eGFR  was  42.45  mL/min.

CONCLUSION: In  clinical  practice,  gouty  arthritis  in  Filipino  females  should  not  be  confused  with  other  inflammatory  arthritides because its presentation is classic in the majority of patients. On consult at the rheumatology clinic, at least 15%  of  the  patients  already  had  complicated  disease. Awareness of Filipino physicians of gout in postmenopausal females  must  be  enhanced  for  proper  recognition  and  management  of  this  disease.  

Human ; Male ; Female ; Middle Aged ; Arthritis, Gouty ; Ankle ; Uric Acid ; Creatinine ; Postmenopause ; Rheumatology ; Gout ; Ankle Joint ; Alcohol Drinking ; Metatarsophalangeal Joint ; Hypertension

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

INTRODUCTIONGranulomatous cervicofacial lymphadenitis (GCL) is not uncommon in children. Nontuberculous mycobacteria (NTM) seem to be the predominant cause. We sought to study the clinical and microbiological profile of patients with GCL, and identify features that may impact outcome.

METHODSChildren aged < 16 years who presented to KK Women's and Children's Hospital, Singapore, between January 1998 and December 2006, and who had GCL were identified from laboratory records. Clinical and laboratory data was collected and analysed for risk factors for patients with positive lymph node cultures, and for patients with and without recurrence after treatment.

RESULTSIn all, 60 children were identified, with a median age of 56 (interquartile range [IQR] 34-101) months. Median duration of symptoms before presentation was 5 (IQR 4-8) weeks. The majority presented with single (73.3%) or unilateral (96.7%) lymphadenopathy, located in the submandibular, preauricular/parotid or infra-/post-auricular region (76.7%). Out of 51 patients, 26 (51.0%) had a tuberculin skin test reading of ≥ 10 mm. Out of 52 patients, 10 (19.2%) had positive mycobacterial cultures, which included seven isolates of NTM. Out of 34 cases, tuberculous polymerase chain reaction was positive in 11 (32.4%). With regard to recurrence after initial treatment, age < 5 years at presentation was found to be a predictor for recurrence (p = 0.008), while initial complete excision of affected nodes predicted no recurrence (p = 0.003).

CONCLUSIONIn our study, younger age was noted to be associated with a higher chance of recurrence, while complete excision of the involved node at initial presentation predicted non-recurrence.

Adolescent ; Child ; Child, Preschool ; Female ; Humans ; Infant ; Lymphadenitis ; diagnosis ; epidemiology ; microbiology ; Lymphatic Diseases ; diagnosis ; microbiology ; Male ; Mycobacterium ; Mycobacterium Infections ; diagnosis ; epidemiology ; microbiology ; Recurrence ; Retrospective Studies ; Singapore ; Treatment Outcome ; Tuberculin Test