Challenges in the management of concomitant TB arthritis and AVN in a lupus patient with adverse drug reaction to anti-Koch's medications

BACKGROUND: Non traumatic osteonecrosis also known as  avascular necrosis (AVN),and tuberculous arthritis (TB    arthritis)most commonly present as chronic monoarticular conditions. Corticosteroid intake is known to predispose individuals to the development of these two conditions.                       In AVN, corticosteroid remains to be the most common cause that leads to a final  common pathway of disrupting    blood supply to segments of bone causing cell death. In TB arthritis, corticosteroid renders  a patient relatively immunocompromised predisposing to this extrapulmonary infection.                                                                                                                                                          The incidence of tubercular osteonecrosis in a patient with systemic lupus erythematosus is rare. A review of literature only showed one case report of tubercular osteonecrosis diagnosed by aspiration cytology. Since tuberculosis (TB) is a destructive but curable disease, early diagnosis  and  treatment  are essential.OBJECTIVE: To present a case of tubercular osteonecrosis in a patient with systemic lupus erythematosus treated with anti-Koch's regimen and iloprost infusion.CASE: A 27-year old Filipino female who was diagnosed with lupus nephritis and underwent three days  methylprednisolone pulse therapy. Lupus nephritis improved  and  was clinically inactive for two years. She  developed insidious onset of intermittent pain on her left knee, associated with swelling for four months with  subsequent right hip pain of one week duration. MRI of the left knee showed osteonecrosis and arthritis. Radiograph of the right hip showed osteonecrosis. She underwent arthrocentesis of the left knee and the synovial  fluid tested positive for tuberculosis by PCR. We started the patient on quadruple anti-Koch's regimen together with iloprost infusion which afforded clinical improvement.  CONCLUSION: To our knowledge, this is the first reported case of a lupus patient with concomitant polyarticular osteonecrosis complicated by monoarticular tuberculous arthritis. Medical treatment, while it may be complicated by adverse drug events, is effective in symptomatic treatment, but a multidisciplinary approach is suggested for optimal outcome.

Endometrial tuberculosis causing amenorrhea and abnormal uterine bleeding in a lupus patient treated with cyclophosphamide

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

In-hospital outcomes of methylprednisolone pulse therapy in the treatment of systemic lupus erythematosus

BACKGROUND:  Methylprednisolone  Pulse  Therapy  (MPPT)  is standard of care in the management of severe systemic lupus erythematosus (SLE). This treatment, though,  is considered   a   double-edged   sword   due to its life-threatening adverse  effects.  Renal  disease,  liver disease and high dose of the drug are factors proposed to adversely affect outcomes of patients treated  with  MPPT.   Despite   the   widely   accepted use of MPPT, there are no reports describing the outcomes   from   its   use   among   Filipinos   with SLE.OBJECTIVE: To determine the in-hospital outcomes of patients with SLE treated with MPPT and to identify  factors   associated   with   adverse  outcomes.GENERAL STUDY DESIGN:  RetrospectivePOPULATION:  Adult  patients  with  SLE  who  were  admitted  in Philippine General  Hospital  and  underwent  MPPT from   January   2008   to   December  2012.METHODS: Patient demographics,  disease  characteristics  on admission, indications for MPPT and in-hospital outcomes   were  extracted.ANALYSIS: Chi-square test and Fisher's exact  test  were  used  to  elicit  association  of  population  characteristics  to  outcomes.RESULTS: Forty-two patients  with  SLE  who  underwent MPPT were included. Majority are females  (98%)  and  most (60%) underwent MPPT within one year of SLE diagnosis.  High   disease   activity   is   seen   at   the timeof MPPT with a mean Mex-SLEDAI score  of  14.69. Infection (83%) is the most common comorbidity.  Anemia, hypoalbuminemia and significant  proteinuria  are the most common  laboratory  abnormalities.  The  top indication for MPPT is nephritis (83.3%). The dose received  by the  majority  (66.7%)   is   one   gram/day for   three   days,   which   is   a   high  dose.Improvement rate is 76% but the in-hospital complication  rate  is  64%  and  mortality  rate   is   21%. Patients with in-hospital complications have significantly lower absolute lymphocyte count (p=0.013), serum albumin (p=0.04) and greater 24-hour proteinuria (p=0.04) at baseline. High-dose MPPT is significantly associated with in-hospital complications (p=0.04) but not mortality. Nephritis (p= 0.04) and low platelet counts at baseline  (p=0.01)  are  associated with  mortality.CONCLUSION:  In this  population,  there  is   a   high  rate   of  improvement  of   lupus  disease  activity  when  MPPT   is used but there is a corresponding high rate of in-hospital  complications  and   mortality.   High   dose  of MPPT seems to be associated with increased in-  hospital complication, while nephritis and low platelet count showed a probable association with mortality. Further studies  on  a  larger  cohort  are  needed.  For  now, the findings of this study may be helpful in developing guidelines on the use  of  MPPT  among Filipino   patients   with  SLE.

A three-month follow up of musculoskeletal manifestions in chikungunya fever

BACKGROUND: Chikungunya virus (CHIKV) is a mosquito- borne  alphavirus  of  the  family  Togaviridae  transmitted  to humans by the Aedes spp. mosquitoes, causing Chikungunya   Fever  (CHIKF).OBJECTIVE: This study aims to describe the course and outcome of musculoskeletal (MSK) manifestations in patients  with  CHIKF  seen  over  a   three-month     period.DESIGN: This is a prospective descriptive  study.  Seventy  patients  with  fever,  rash,  and  arthritis  seen   at the University of the Philippines-Philippine General Hospital  and  private  arthritis  clinics  were  collected from August - December 2012.  Demographics  and course   of   arthritis   were  described.RESULTS:  Seventy   patients,   53   (68.6%)   female,   with  a mean age  of  39.2  ±13.50  were  diagnosed  with CHIKF. All cases were from the Metropolitan  Manila area. Of these, 15 (21.4%) had  family  members  affected. Twenty-four patients (34.3%) were either employed or students. The most common presenting symptoms were fever (94.3%), arthritis or athralgia  (98.6%), and rash (87.1%).  The  most  common  joint  areas involved were the ankles  (60.0%),  the  wrists (40.0%) and the small joints of the hand (51.4%). Twenty-seven (47.3%) had symmetric  arthritis.  Thirty- seven   cases   (52.9%)   had   arthralgia   or   arthritis    for at least  six  weeks.  By  the  end  of  the  follow-up  period, only four (5.7%) had persistent musculoskeletal symptoms. Age and  sex  were not  found to  be  factors in  determining  chronicity  of  arthritic  symptoms  (p   =   0.104   and   p=0.58  respectively). Of the seventy patients, 31 (44. 3%) were confirmed  cases  of  CHIKF--  29 had  (+)   CHIKV  IgM   by ELISA,  and  two   had   (+)   CHIKV   PCR.   Twenty-  one (67.7%) had  persistent  arthritis  of  at least  six  weeks. Treatment  consisted  of continuous  NSAIDs  for  at  least  two   weeks   and   some   received   steroids.  In this subgroup, age and sex were not shown to  correlate with chronic arthritis (p=0.47 and p=0.05 respectively).CONCLUSION: This report on a recent outbreak of CHIKF showed the classic triad of fever, rash,  and  arthritis.  There  was  no  correlation  between  age  and  chronicity of  arthritic  symptoms.  Sex,  likewise,  did  not  appear   to influence chronicity. The disease occurred in family clusters. Patients required continuous treatment with NSAIDs and  some  had  to  be given  steroids.  Most cases   resolved   by   12 weeks.

Prevalence of metabolic syndrome in Filipino patients with gout in a tertiary hospital

OBJECTIVE: The aim of the study is to determine the prevalence of metabolic syndrome (MS) in Filipino patients with gout and know the specific component that is predominant in this population.METHODS: Patients who are diagnosed with gout based on the American College of Rheumatology (ACR) criteria, at least 20 years old, attending the outpatient rheumatology clinic of a tertiary hospital from March 2012 to December 2012 and  willing  to sign written informed consent were included in  the study. The following information was collected: demographic and disease characteristics, blood pressure, body mass index, waist circumference, triglycerides, HDL, and fasting blood sugar. MS was defined according to the revised NCEP/ATP III criteria using the WHO Asia-Pacific obesity criteria. Results were reported in means and proportion.RESULTS: Sixty-three patients were included in the study. The mean age of onset and at time of diagnosis of gout were 47.3 years and 52.9 years, respectively. At the time of the study, the average duration of gout was five to 10 years. The male to female ratio was 6:1. The prevalence of MS was 47.6% (30/63) with male to female ratio of 5:1.The prevalence of abdominal obesity was 39.7%, hypertension 36.5%, low HDL 31.7%, high triglycerides 30.2%, and diabetes mellitus 14.3%. CONCLUSION:The prevalence of MS in this subset of Filipino patients with gout was 47.6%. Its most common component was abdominal obesity found in 39.7% of cases. This is an area of intervention that needs to be addressed in the care of these patients.