Cardiac tamponade as a rare manifestation of systemic lupus erythematosus: A report on four cases in the Philippine General Hospital

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.

Comparison of the different pain assessment scales used in adult patients seen at the Philippine General Hospital rheumatology out-patient clinic

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= 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

A case of a 39-year-old immunocompromised Filipino male with non-healing wound of the right lower leg

This a case of a 39-year-old Filipino male with systemic lupus erythematosus (SLE) diagnosed in 2006, presenting with a 3-month history of non-healing wound on his right lower leg. This paper will discuss the etiologies of a non-healing wound and present an algorithm to guide the approach to diagnosis and management.