A Case of Triple Arthritis: Tuberculosis, MRSA and Gout in One Knee.

Aim: To report a case of concurrent tuberculous and bacterial arthritis in chronic tophaceous gout. Presentation of the Case: A 59-year old Filipino male patient consulted for sensorial changes with four-month progressive swelling of the right knee draining non-foul smelling yellowish discharge with chalky material. He eventually had arthrocentesis of right knee. Blood cultures were all negative. Acid fast bacilli were present both in the synovial fluid and endotracheal aspirate. Endotracheal aspirate grew Mycobacterium tuberculosis. Synovial fluid grew methicillin-resistant Staphylococcus aureus (MRSA). He was treated with prednisone, clindamycin, colchicine, febuxostat, tramadol, and anti-tuberculous medications. He failed to undergo surgery. Patient eventually had fatal myocardial infarction. Discussion: To our knowledge, this is the first report of concurrent tuberculous and bacterial (MRSA) arthritis in gout. Conclusion: This case highlights the possible differential diagnoses especially infections among patients with chronic tophaceous gout. Concurrent tuberculosis and bacterial arthritis can complicate the management of these patients. Hence, microbiologic and crystal analysis of synovial fluid is a very important part of the work-up to tailor the early, specific treatment for these patients.

Acquired arteriovenous fistula of the right common iliac artery and left common iliac vein and bilateral lower extremity deep venous thrombosis in a woman presenting as high output heart failure

Acquired intraabdominal arteriovenous fistula (AVF) is a rare disorder where the communication most commonly occurs between the abdominal aorta and inferior vena cava. Ilioiliac AVF has been reported previously, but is exceedingly rare. We present a case of acquired arteriovenous fistula of the right common iliac artery and left common iliac vein with extensive collateralization (ilioiliac AVF) in a 36-year-old female who presented with symptoms of high output congestive heart failure 18 years after sustaining an abdominal gunshot wound.

Drug-induced hypersensitivity syndrome in an ANA-negative, anti-dsDNA-negative systemic lupus erythematosus patient

A 50-year-old female presented with rash and multi-organ toxicity after intake of several antibiotics. This unmasked an elderly-onset, non-drug-induced seronegative systemic lupus erythematosus (SLE)which was confirmed by lupus band test (LBT)and skin biopsy staining. This patient presented with the rare combination of drug-induced hypersensitivity syndrome (DIHS)and SLE.

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.

A case of a 42-year-old Filipino male with bilateral lower extremity swelling

A 42-year-old male was admitted at the University of the Philippines-Philippine General Hospital (UP-PGH) for a 3-month history of non-healing wound in the medial side of his right leg in spite of multiple antibiotics. The wound worsened with multiple ulcerations and draining sinuses. The wound was shown to have suppurative and granulomatous infiltrates that yielded Mycrobacterium tuberculosis. An algorithm in the approach to a chronic or non-healing wound is discussed.

Kidney measurements by sonography on normal Filipino adults influence of age, sex, and habitus

OBJECTIVE: Measurement of kidney size by ultrasonography is an important parameter in the renal evaluation of patients. This study aims to establish the average size of kidneys of healthy adult Filipinos and examine the factors that influence it.DESIGN: Cross-sectional, observational study SETTING: Section of Nephrology, Department of Medicine and Department of Radiology, UP-PGH Medical Center, a tertiary government hospital PARTICIPANTS: 264 healthy Filipino adults underwent kidney ultrasound after preliminary screening by history, physical examination, urinalysis, and serum creatinine RESULTS: Renal sizes and volume were measured by ultrasound in 105 males and 159 females, with ages ranging from 18 to 75 years old. The left kidney was significantly larger than the right for mean length but not for width or thickness. Except for cortical thickness, renal length (L=98 mm, R=96mm vs. L=95mm, R=93mm), width (L=48mm, R=49mmvs. L=46mm,R=46mm), and thickness (L=43mm, R=42 mm vs. L=39 mm, R=39 mm) were significantly larger in males compared to females. While the gender differences persisted when corrected for age and body mass index, this disappeared when corrected for total body area. With advancing age, there was minimal shortening but significant increases in width and thickness (renal shape index) CONCLUSION: Our study provides estimates of the average kidney size for normal adult Filipinos. The average kidney size of Filipinos is smaller than that of Caucasians for length (L=96mm vs. 112 mm, R=94mm vs. 109mm) and for width (L=47mm vs. 58mm, R=48mm vs. 57mm). Males have larger kidneys than females but the gender difference disappeared when corrected for total body area. Height but not weight has a significant influence on kidney size. With advancing age, kidneys tend to increase in width and thickness with no significant decrease in length or volume.

A 52-year-old woman with encephalopathy, fever, and jaundice: A case of disseminated strongyloidiasis

This is a case of a 52 year-old female admitted in the medicine ward of the Philippine General Hospital (PGH) for drowsiness, fever and jaundice. This paper will illustrate an unusual case of encephalopathy, chronic abdominal pain and jaundice due to disseminated strongyloidiasis. Four months prior to admission (PTA), the patient sought consult for on and off right lower quadrant abdominal pain, easy fatigability, generalized body weakness, and vomiting of previously ingested food. Physical examination revealed pallor, right costovertebral angle and right lower quadrant abdominal tenderness. Work-up done showed a urinary tract infection and hookworm. An ultrasound of the kidneys and urinary bladder did not reveal any renal abscess and showed only a hyperechoic mass confirmed to be angiomyolipoma by abdominal CT scan. Bilateral renal cysts were also noted. Treatment for the urinary tract infection and hookworm were prescribed. She was lost to follow up.

A 52-year-old woman with encephalopathy, fever, and jaundice: A case of disseminated strongyloidiasis

This is a case of a 52 year-old female admitted in the medicine ward of the Philippine General Hospital (PGH) for drowsiness, fever and jaundice. This paper will illustrate an unusual case of encephalopathy, chronic abdominal pain and jaundice due to disseminated strongyloidiasis. Four months prior to admission (PTA), the patient sought consult for on and off right lower quadrant abdominal pain, easy fatigability, generalized body weakness, and vomiting of previously ingested food. Physical examination revealed pallor, right costovertebral angle and right lower quadrant abdominal tenderness. Work-up done showed a urinary tract infection and hookworm. An ultrasound of the kidneys and urinary bladder did not reveal any renal abscess and showed only a hyperechoic mass confirmed to be angiomyolipoma by abdominal CT scan. Bilateral renal cysts were also noted. Treatment for the urinary tract infection and hookworm were prescribed. She was lost to follow up.

A case of a 38-year old female with right-sided weakness, hypertension and hypokalemia

This patient is a 38 year old housewife who has been hypertensive and hypokalemic since age 23. She suffered her first stroke at age 32 and a seizure just one week prior to admission. This paper will discuss the clues to the diagnosis of secondary hypertension.