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BackgroundThe workload at rheumatology clinics have been growing relentlessly and an audit on new.referrals helps to identify referral behaviour of primary care doctors and improvement can be done by providing further training.ObjectivesTo audit on new referral cases to rheumatology clinic from 2020-2022 and to identify new cases with misdiagnosis for future training purpose.MethodsThis was a retrospective study. The medical records of all new referral to rheumatology clinic Hospital Sultan Ismail and Hospital Pakar Sultanah Fatimah from 1st January 2020 to 31th November 2022 were reviewed. The referral diagnosis and final diagnosis were identified and analysed.ResultsThere were total of 927 new cases referral throughout the 35 months during Covid-19pandemic. Majority of them were diagnosed to have rheumatoid arthritis (217/927)followed by systemic lupus erythematosus (190/927), psoriatic arthritis (147/927),gout (62/927), osteoarthritis (58/927), systemic sclerosis (25/927), ankylosing spondylitis (25/927), soft tissue rheumatism (24/927), Sjogren syndrome (24/927),mixed connective tissue disease (14/927), vasculitis (11/927), fibromyalgia (10/927),polymyositis (7/927) and miscellaneous (39/927).45 out of the new cases were diagnosed as unlikely rheumatic diseases. There were 29pending cases awaiting final diagnosis.212 of the referrals were identified as misdiagnosis with the highest as nodal osteoarthritis.(55/212) followed by unlikely rheumatic disease (43/212), soft tissue rheumatism (24/212),psoriatic arthritis (20/212), Sjogren syndrome (14/212), gout (8/212), rheumatoid arthritis (7/212), fibromyalgia (6/212), systemic lupus erythematosus (5/212), ankylosing spondylitis (4/212), mixed connective tissue disease (3/212), systemic sclerosis (2/212), polymyositis (2/212) and others (19/212): diffuse idiopathic skeletal hyperostosis, hypermobility syndrome, RS3PE syndrome, idiopathic uveitis, graft versus host disease, juvenile idiopathic arthritis, antiphospholipid syndrome, hypothyroidism, post streptococcal arthritis, prolapsed intervertebral disc, cerebrovascular disease, traumatic sternoclavicular joint subluxation, ledderhose disease, paraspinal muscle spasm and viral myalgia).ConclusionNodal osteoarthritis and soft tissue rheumatism can be great mimicker for inflammatory.arthritis and if wrongly diagnosed will lead to unnecessary anxiety or wrong treatment. More training is needed to improve clinical skills amongst primary care doctors.ReferencesNA.Acknowledgements:NIL.Disclosure of InterestsNone Declared.
ABSTRACT
Background: Numerous immune-mediated diseases fare or new disease onset after SARS-CoV2-vaccination have been reported. There were case reports showed the immune-mediated disease fare post vaccination but study on new disease occurs post Covid-19 vaccination is still lacking. Objectives: To describe two SLE cases that diagnosed post Covid-19 vaccination. Methods: Case report Results: 14 years old girl, post Covid-19 vaccination 1st dose 3 weeks ago presented with 2 day history of giddiness, breathlessness, vomiting and diarrhea prior to admission. She also complained of frothy urine for the past 1 week associated with lower limbs swelling and facial puffiness. Clinical examination noted she had sparse hair, oral ulcers and discoid lupus at the ear concha. She also noted to have periorbital puffiness with pedal edema. Lung auscultation noted bi-basal crepitations. Blood investigation noted ANA positive (1:640, speckled) with low complement 3 (0.1g/L). Her full blood count showed leucopenia (3100 UL) with low lymphocyte count of 810UL. UFEME noted protein of 3 + and red blood cell of 2+ with normal renal profile. Her serum albumin was 22g/L. Chest x ray showed clear lung field with no cardiomegaly. Her 24-hour urine protein showed proteinuria of 2.345g/dl and her renal biopsy showed mesangial proliferative lupus nephritis class iI. She was given intravenous methyl-prednisolone 500mg OD for 3 days and discharged with tapering dose of prednisolone, hydroxychloroquine, calcium supplements, perindopril and frusemide. Another case was a 17 year-old female, post covid-19 vaccination 10 weeks, presented with 3 weeks history of bilateral lower limbs weakness with difficulty in getting up from chair. She also had fever on and off with cough for 1 week. There was no alopecia, oral ulcer, facial rash or photosensitivity. No joints pain. Clinical examination noted presence of proximal myopathy with stable vital signs. Other systemic examinations were unremarkable. Blood investigation noted ANA positive (1: 640, homogenous and speckled) with low complements level (C3 0.19g/L and C4 0.049 g/L).Her creatine kinase was 2367U/L and EMG showed evidence of irritable myopathic process which is consistent with inflammatory myositis. Her TFT was normal. Myositis panel showed anti-Ku and anti-Ro 52 were positive. She was treated as SLE with myositis and intravenous methylprednisolone was given. She discharge well with tapering dose of prednisolone and azathioprine. Her creatine kinase showed improvement with immunosuppression therapy and she was advised on intensive physiotherapy. Conclusion: The onset of these two SLE cases were occurred within the 2 month of post covid-19 vaccination. Whether Covid-19 vaccination direct contribute to the occurrence of SLE remained inconclusive. More studies are required to show its correlation between onset of SLE and Covid-19 vaccination.
ABSTRACT
Background: According to Statista, 78.5% of the population in Malaysia have completed their vaccination as of 6th january 2022 [1].The acceptance of patients with rheumatic diseases on Covid-19 vaccination is crucial in the long term protection against Covid-19 infection. We conducted a survey to determine the acceptance of Covid-19 vaccination amongst patients with underlying rheumatic disease. Objectives: To fnd out the reasons of vaccination refusal amongst rheumatology patients. Methods: This was an interview survey. All rheumatology patients who were follow up in rheumatology clinic Hospital Sultan Ismail, Malaysia from 26th April 2021 to 25th July 2021 (total 3 months) were interviewed. Demographic and diagnosis of the patients were collected. Results: A total of 952 patients were identified. 83.7% of them were female patients (797/952) and majority of them were Malay (46.4%). This was followed by Chinese (36.1%), Indian (16.3%) and others (1.2%). The mean age group was 48 (range from 13-85). 97.6% of the respondents were categorized as having inactive disease during the interview sessions. 36.6% of the patients were diagnosed to have rheumatoid arthritis and 29.1% of them were having systemic lupus erythematosus. These were followed by psoriatic arthritis (10.9%), mixed connective tissue disease (5.5%), systemic sclerosis (2.9%), gout (2.6%), Sjogren syndrome (1.9%), ankylosing spondylitis (1.6%), myositis (1.5%), vascu-litis (1.3%), osteoarthritis (1.2%), antiphospholipid syndrome (0.9%), non-specific arthralgia (0.8%), juvenile idiopathic arthritis (0.8%), seronegative spondyloarthropathy (0.8%), undifferentiated connective tissue disease (0.7%), adult onset still's disease 0.5%) and others (< 0.5% each for Ig G 4 related disease, soft tissue rheumatism and fibro-myalgia). 87.3% of them were keen or have already received Covid-19 vaccination. 12.7% of them were not keen for the vaccination with various reasons. 48.8% of them were worrying about worsening clinical condition, 12.4% of them were not keen as they concerned about side effects (3 worry about fever, 1 worry about hepatitis, 1 for nausea, 1 for dizziness, 1 for breathlessness, and 7 for non-specific reasons). 10.7% of them were not keen due to pregnancy, 5.79% of them were not keen as worried about allergic reactions, 4.9% of them were worrying about sudden cardiac death, 4% were not keen as on chemotherapy treatment, 3 % of them doubted the efficacy of vaccination, 2.5% were not keen as they worried about heart disease, 2.5% worried about increase risks of infection and others (2 for old age, 2 for thrombotic event, 2 for drug interaction and 1 patient due to hemodialysis). Conclusion: The overall acceptance rate of Covid-19 vaccination amongst patients with rheumatic diseases is very encouraging with the percentage of >85% despite of lacking knowledge about vaccine Covid-19. This result can assist our Ministry of Health to plan for future battle to improve vaccine uptake that hopefully can lead to herd immunity against COVID-19 infection. More counseling sessions are required to clear up the doubts of vaccination and increase the vaccination rate amongst rheumatic patients.
ABSTRACT
Background/Aims According to newspaper Bernama, 6.5% of adolescents in Malaysia aged between 12 and 17 have completed their vaccination and 89.7% of the adult population have completed theirs as of 9th October 2021. The acceptance of patients with rheumatic diseases on Covid-19 vaccination are crucial in the successful long-term protection against COVID-19 infection. We conducted a phone survey to determine the acceptance of COVID-19 vaccination amongst adolescents with underlying rheumatic disease. Methods This was a phone survey. The electronic medical records of all rheumatology patients follow up in rheumatology clinic Hospital Sultan Ismail, Malaysia from 2019 to 2021 were reviewed and patients with the age group between 12 to 21 were identified. Demographic data, diagnosis of the disease and outcome of the survey were collected and analysed. Results Phone survey was done after data extracted from medical records. For those under the age of 18, guardian of the patients was interviewed. A total of 50 patients were identified. Most of the patients were female (46/50) and majority of them were Malay (33/50). This was followed by Chinese (10/50), Indian (4/50) and others (3/50). The mean age group was 18 (range from 13 to 21). 36 of them were having systemic lupus erythematosus (SLE), 5 of them were having juvenile idiopathic arthritis (JIA) ,2 of them were having psoriatic arthritis (PSA) and another 2 of them were having rheumatoid arthritis (RA), followed by RA overlapped SLE, juvenile dermatomyositis, Henoch-Schönlein purpura, SLE overlapped with JIA and mixed connective tissue disease about 1 each respectively. Majority of them patients are keen or already completed COVID-19 vaccination with the acceptance rate of as high as 92% (46/50). Only 8% of them are not keen for vaccination with the only reason of worrying the risk of myocarditis post vaccination (1 SLE patient and 1 PSA patient). Conclusion The overall acceptance rate of COVID-19 vaccination amongst adolescents with rheumatic diseases are very encouraging with the percentage of>90% despite lacking knowledge about vaccination for COVID-19. This result can assist our Ministry of Health in planning for future battles to improve vaccine uptake that hopefully can lead to herd immunity against COVID-19 infection.