Delayed diagnosis and treatment of rheumatoid arthritis in Sarawak General Hospital

@#Introduction: Rheumatoid arthritis (RA) is an autoimmune systemic inflammatory disorder characterised by symmetrical polyarthritis which leads to damage of joints if untreated. Early diagnosis and treatment of RA to achieve tight control of the disease will improve outcome and prevent disability. Objective: We aimed to examine the delays in the diagnosis of RA in patients presenting to the Rheumatology Unit, Sarawak General Hospital (SGH). Methods: Data on demographics and various delays were collected from the medical records from January 2015 until March 2018. Patient delay is defined as from the time onset of symptom to the first primary care presentation. Primary care delay is defined as from the first primary care presentation to referral to rheumatology. Rheumatology delay is defined as from rheumatology referral to appointment at the rheumatology clinic. Disease modifying anti-rheumatic drugs (DMARDS) delay is defined as from the rheumatology clinic appointment to starting DMARDS. Total delay is from symptom onset to starting DMARDS. Results: There were 84 new patients diagnosed with rheumatoid arthritis, out of which 66 were females (78.6%). The mean age was 54.1±12.0 years. Only 19 patients (22.6%) were treated with DMARDS within 12 weeks of symptom onset. The median time for patient delay was four weeks (Interquartile range (IQR) 2-20 weeks), while the median time primary care delay was 11 weeks (IQR 4-24 weeks). The median time for rheumatology delay was zero weeks (IQR 0- 1 week) and the DMARDS delay was zero week (IQR 0). The median time from symptom onset to DMARDS initiation was 23.5 weeks (IQR 13.25-51 weeks). Conclusion: The delays in the diagnosis of rheumatoid arthritis were mainly from the patient and primary care.

Myxopapillary ependymoma of cauda equina presented with communicating hydrocephalus and papilloedema: A case report

@#We reported a case of cauda equina myxopapillary ependymoma in a patient who presented with atypical history of progressive blurring of vision. Ophthalmology examination revealed relative afferent pupillary defect, binasal hemianopia and papilloedema. This case report serves as a reminder that the intraspinal tumour could be a cause of papilloedema, despite rare, should be considered in a hydrocephalus patient who presented with no intracranial pathology and minimal spinal symptoms.

Discrepancy in blood pressure between the left and right arms - importance of clinical diagnosis and role of radiological imaging

Introduction: Differences in systolic blood pressure reading between arms are common but could signal trouble if the discrepancy is significant. Early detection of aortic dissection could invariably determine patient’s survivability. Hence, a high index of suspicion with prompt diagnostic imaging is vital for accurate diagnosis. Case Presentation: A previously healthy 35-year-old lady was referred from district hospital for hypertensive cardiomyopathy complicated by acute pulmonary oedema. After being admitted to the Intensive Care Unit, the mean arterial pressure on the left arm was noted to be significant higher. On physical examination, both lower limbs were dusky in appearance because of poor perfusion. Investigations: Computed Tomography Angiography showed extensive arch and abdominal aorta dissection extending to the proximal common carotid artery. There was distal abdominal aorta thrombosis with partial left renal infarction. Echocardiogram showed global hypokinesia, presence of intimal flap, aortic regurgitation and mild pericardial effusion. Supine chest X-ray showed apparent cardiomegaly. Treatment: Repair of the ascending aortic dissection and suspension of the aortic valve by the cardiothoracic team on Day 2 of admission. The vascular team did bilateral high above knee amputation on Day 9 of admission. Outcome: Patient passed away on Day 10 of admission. Discussion: With the absence of classical features of aortic dissection, establishing the diagnosis can be challenging and requires both good clinical judgment and prompt radiological imaging, such that early treatment can be initiated. Conclusion: A high index of suspicion and good clinical judgment is needed in cases of significant blood pressure discrepancy between arms.