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.

The gait, arms, legs and spine (GALS) locomotor screen teaching-learning package: Has it achieved its intended learning outcome?

INTRODUCTION: Clinicians rarely screen their patients for musculoskeletal disorders during routing physical examination. Reasons vary, but inadequate teaching of musculoskeletal medicine is cited as a major factor. To address the above issue, the Section of Rheumatology, Department of Medicine, College of Medicine, and Philippine General Hospital, University of the Philippines Manila recently adopted the Gait, Arms, Legs and Spine Locomotor Screen (GALS) as the central focus of instruction for musculoskeletal conditions. OBJECTIVES: A total of 189 medical interns participated in this descriptive study to determine whether GALS is deemed useful and can be readily applied in the outpatient clinics. METHODS: Data was gathered using a questionnaire, key informant interviews, and chart review. The data was analyzed using measures of central tendency, percentages and qualitative evaluation. RESULTS: Only 26% claimed to routinely perform the musculoskeletal screening examination and only 21% claimed they used the GALS technique. The medical interns emphasized that they were adequately taught to perform the GALS technique but felt that the routine of GALS was time consuming. Emphasis on musculoskeletal screening was done only during clinical rotations in specialties like rheumatology, rehabilitation medicine or orthopedics, but not in other specialties. In addition, only the Section of Rheumatology used the GALS technique. CONCLUSION: The findings of this study suggest that while medical interns feel competent in performing the GALS technique, its application in the clinics leaves much room for emphasis and that there is a need to standardize instruction on musculoskeletal screening.

The gait, arms, legs and spine (GALS) locomotor screen teaching-learning package: Has it achieved its intended learning outcome?

INTRODUCTION: Clinicians rarely screen their patients for musculoskeletal disorders during routing physical examination. Reasons vary, but inadequate teaching of musculoskeletal medicine is cited as a major factor. To address the above issue, the Section of Rheumatology, Department of Medicine, College of Medicine, and Philippine General Hospital, University of the Philippines Manila recently adopted the Gait, Arms, Legs and Spine Locomotor Screen (GALS) as the central focus of instruction for musculoskeletal conditions. OBJECTIVES: A total of 189 medical interns participated in this descriptive study to determine whether GALS is deemed useful and can be readily applied in the outpatient clinics. METHODS: Data was gathered using a questionnaire, key informant interviews, and chart review. The data was analyzed using measures of central tendency, percentages and qualitative evaluation. RESULTS: Only 26% claimed to routinely perform the musculoskeletal screening examination and only 21% claimed they used the GALS technique. The medical interns emphasized that they were adequately taught to perform the GALS technique but felt that the routine of GALS was time consuming. Emphasis on musculoskeletal screening was done only during clinical rotations in specialties like rheumatology, rehabilitation medicine or orthopedics, but not in other specialties. In addition, only the Section of Rheumatology used the GALS technique. CONCLUSION: The findings of this study suggest that while medical interns feel competent in performing the GALS technique, its application in the clinics leaves much room for emphasis and that there is a need to standardize instruction on musculoskeletal screening.