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Hairy cell leukemia (HCL) is a rare, chronic, mature B-cell lymphoproliferative disorder accounting for 2% of all leukemias. In this paper, we would like to present our experience in the management of HCL in a financially limited setting where other diagnostic tests and chemotherapy are unavailable. The case report aims to emphasize the recognition of the distinctive morphology of hairy cells in the peripheral blood in the consideration of the initial diagnosis. A 60-year-old Filipino male was incidentally found to have anemia, thrombocytopenia and an absolute neutrophilic count below 1,000 in a pre-operative clearance for elective herniorrhaphy. Blood smear revealed atypical lymphocytes with hair like cytoplasmic projections. CT-scan of the abdomen showed splenomegaly and prominent paraaortic nodes. Flow cytometry of the bone marrow aspirate was consistent with an involvement of a Mature B cell neoplasm markers CD19, CD20, CD22 and surface immunoglobulin lambda and hairy cell leukemia markers CD11c, CD103 and CD25. He responded to six-weekly sessions of Cladribine with remission of the bone marrow and hematologic parameters. HCL is a rare type of a mature B cell neoplasm characterized by pancytopenia, splenomegaly, bone marrow fibrosis and the presence of atypical lymphoid cells with hairy projections in blood, bone marrow and spleen. Immunophenotyping express CD11c, CD103, CD123, and CD25. BRAF V600E mutation is the disease defining genetic event. Cladribine and Pentostatin are the first line of treatment. Cases of leukemia can be easily overlooked because of the mild derangement in the complete blood count. A meticulous differential review of the atypical lymphocyte, is the first step in the diagnosis of this rare disease.Copyright © 2022, Philippine College of Physicians. All rights reserved.
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Introduction: In 2012, coronary heart disease and stroke are the leading causes of death worldwide, accounting for more than 31% of deaths from all causes. In 2020, PH statistics showed that ischemic heart diseases were the leading causes of death in the Philippines (PH), responsible for 17.3% of the total deaths. Objective(s): To determine the knowledge, perceptions, insights and attitudes on cardiovascular disease (CVD) prevention, personal health-related lifestyle practices, and lifestyle counseling practices of selected female physicians who are practicing or training in the PH through an online survey. Method(s): A descriptive ambispective cross-sectional study where the survey questionnaire of Ameh, et al. (2019) was modified with the authors' permission, was conducted online and answered by consenting female physicians. 484 participants' data were collated and analyzed. Result(s): Majority had accurate responses for the CVD prevention knowledge items (Figures 1 and 2). Among the participants, 36.98% had hypertension, 32% were obese, 28.5% had dyslipidemia, and 17.2% had diabetes mellitus. Sleep of 6-8 hours is practiced by 60.33%, 53.51% eat vegetables and fruits daily, 55.79% prefer fish and seafood, 89.05% do not smoke, 61.2% take coffee or black tea daily, 84.51% have no regular exercise, and 30.79% of those who do only exercise for 10-20 minutes. Moreover, 67.98% add salt, soy or fish sauce to their meals, and 72.73% do not drink enough water daily. In addition, 44.42% do not undergo annual general check-up and 58.06% do not have a personal physician. Limitations due to COVID-19 pandemic, lack of education, and expensive screening tests are perceived to be major barriers to CVD screening. More than 90% of our participants practice health teachings on diabetes mellitus prevention, high blood pressure screening, cholesterol screening and management, nutrition, and weight management. Counseling on regular exercise, smoking, and alcohol abuse are being practiced by 88.02%, 85.74%, and 83.88% of our respondents, respectively. Conclusion(s): There are female physicians who are not aware of the World Health Organization's recommendations on the prevention of CVD, who do not do health teaching and counseling, and who practice unhealthy lifestyle. Changing physicians' knowledge and behavior towards CVD prevention is a great challenge to improve standards of CVD prevention. Improvement and enhancement in education of both physicians and patients, together with more consultation time, financing for CVD prevention, and comprehensive, multidisciplinary preventive cardiology programs supported by government and societies in favor of prevention are some of the best ways to improve management of CVD risk factors and prevention.
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Introduction: Hughes-Stovin syndrome (HSS) is a systemic vasculitis characterized by pulmonary artery aneurysms (PAA) and widespread venous and arterial thrombosis. Fatalities in HSS resulted from unforeseeable fatal suffocating hemoptysis. It is critical to early detect pulmonary involvement to take timely measures against inevitable serious life-threatening complications. Case presentation: A 27 year old Filipino male patient presented to the emergency department with an acute attack of massive hemoptysis. The markers of inflammation were elevated with anemia and a normal coagulation profile. The patient had bilateral lower limb edema with tender calf muscles. Color Doppler ultrasound revealed bilateral deep vein thrombosis. Importantly, an urgent computerized tomography pulmonary angiography (CTPA) revealed bilateral large PAAs which matched the pattern of pseudoaneurysms described by the HSS international study group (HSSISG). There was no history of iridocyclitis, recurrent oral or genital ulcers. Accordingly, the patient was diagnosed with HSS. The patient received intravenous pulse methylprednisolone (1 g/3 days), then oral prednisone (1 mg/kg/d/3 months), and monthly pulse cyclophosphamide (1 g) for three months. The patient remained symptom-free, yet on the third pulse of cyclophosphamide;he patient contracted corona virus disease-2019 (COVID-19) infection and died three weeks later from a fatal episode of massive hemoptysis. The case was discussed and the recent literature was reviewed relative to fatal hemoptysis associated with pulmonary artery pseudoaneurysms (PAPs) pattern in HSS Conclusion(s): HSS presenting with massive hemoptysis could be lifethreatening and the PAPs are considered a double edged sword. Detailed description of such rare cases is warranted for optimum future management.Copyright © 2023
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Introduction: Coronavirus disease 2019 (COVID-19) pandemic is ongoing and new variants of severe acute respiratory syndrome coronavirus type 2 (SARS-CoV- 2) are emerging. There is an urgent need for COVID-19 vaccines to control disease outbreaks by herd immunity. Vaccines can trigger immunity as many vaccine-related immunological adverse events have been described. Case Presentation: A case of a 32 years old Filipino female with no known co-morbidity who presented with rashes on bilateral lower extremities one day after receiving her second dose of CoronaVac-Sinovac vaccine. These were non-pruritic nor painful, which appeared to be initially well-defined round erythematous macules, papules, and plaques, mostly raised. It was associated with colicky abdominal pain and inflammatory arthritis affecting the both knees and ankles. She has no vices but known to have allergy with seafood. There were multiple well defined erythematous round to irregularly shaped purpuric macules, papules and plaques, non-blanching, flat and raised, on arms near the antecubital fossa, abdomen and lower extremities. She underwent skin biopsy and direct immunofluorescence showed interface dermatitis with leukocytoclastic vasculitis and IgA +1 vessel wall, and fibrinogen +2 vessel wall, respectively. There was microscopic hematuria and proteinuria. The Urine protein creatinine ratio was normal at 0.193 gm/gm. She was managed as a case of IgA vasculitis and was given moderate dose of steroid (0.5mg per kilogram per day prednisone equivalent) and omeprazole. She was discharged improved with resolution of rashes evident during follow up at the out-patient consultation. Conclusion(s): We report a case of an adult Filipina developing IgA vasculitis following CoronaVac COVID-19 vaccination. She responded well following initiation of steroid therapy. Autoimmune phenomenon following immunization is possible through different mechanisms. These include molecular mimicry, a hyper-stimulated inflammatory state, and autoimmune syndromes induced by adjuvants. While no strategies have been found to prevent autoimmunity following vaccination, it should be emphasized that vaccine recipients should seek medical care for any untoward events following receipt of any immunization.
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Purpose: To report a case of a 66-year- old Filipino male who developed spontaneous knee hemarthrosis following enoxaparin prophylaxis. Method(s): Case report Result: Case: We report a case of a 66-year- old Filipino male who developed spontaneous hemarthrosis of the left knee following enoxaparin use as venous thromboembolism prophylaxis. Pertinent in the medical history was the diagnosis of chronic kidney disease and chronic respiratory failure as sequelae of COVID 19 infection. During the course of admission, the patient developed acute pain and swelling of the left knee. He was bedridden and no prior traumatic events were noted. Coagulation parameters were within normal range. Arthrocentesis revealed viscous hemorrhagic synovial fluid (25 ml) with fluid analysis showing predominance of red blood cells (Red blood cells: 680,000/muL, White blood cells: 7200/muL) with no crystals seen on polarizing microscopy. Microbial culture was negative. Intravenous methylprednisolone was given and enoxaparin was continued. One day post arthrocentesis, there was improvement of pain and joint function. Joint swelling resolved. Patient had no recurrence of joint pain and swelling. Ethical consideration: Informed consent for both written and photographic content was secured and patient confidentiality was observed. Conclusion(s): Our patient is an elderly with chronic kidney disease who recently recovered from COVID 19 infection. He received prophylactic dose of enoxaparin at 40 mg every 24 hours subcutaneously. No other drugs that can affect hemostasis were given. The patient's bleeding parameters were within normal during admission and at the onset of hemarthrosis. We hypothesize that elderly patients with chronic kidney disease receiving low dose enoxaparin may present with spontaneous hemarthrosis even in the absence of trauma. Whether the association between history of recent COVID-19 infection and hemarthrosis is co incidental or causal remains to be elucidated. Prompt aspiration can provide early diagnosis and facilitate proper treatment. (Figure Presented).
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Background: Necrotizing myopathy has been previously described but was not included in the Peter and Bohan criteria until 2004, when immune-mediated necrotizing myopathy (IMNM) was distinguished from polymyositis (PM) based on immunologic and histopathologic differences. IMNM is currently a well-recognized autoimmune myopathy and represents up to 20% of these cases. Case: A 60-year- old female with biopsy-proven PM achieved sustained clinical remission with Rituximab. Her co-morbid conditions include hypertension, diabetes mellitus, and dyslipidemia. The patient noted a recurrence of gradual progressive, proximal muscle weakness and easy fatigability after receiving her first mRNA Covid-19 vaccine. Four months after onset of symptoms, CK Total was 9600 U/L. Rituximab was administered and muscle weakness and total CK levels (1247 U/L) improved within 10 days. She was prescribed rosuvastatin and fenofibrate for dyslipidemia within 7 days of completing the rituximab course. Two weeks later, proximal muscle weakness recurred. She became wheelchair-bound and experienced dysphonia. MMT score was 2/5 in proximal muscles and total CK total increased to 19,935 U/L. The patient received Methylprednisolone 500 mg IV once a day for 3 days. She had a good response with resolution of dysphonia and improvement of MMT to 4/5 on shoulder abduction and hip flexion on the 6th hospital day. She was discharged on oral methylprednisolone at 1 mg/kg/day. Muscle biopsy was consistent with an immune-mediated necrotizing myopathy, revealing necrotic fibers, intracellular macrophages, fatty infiltrates, irregular staining patterns on NADH stain with no evidence of endomysial inflammation, perifascicular atrophy, ragged red fibers, or rimmed vacuoles. Antibodiy against 3-hydoxy- 3- methylglutarylcoenzymeA reductase (HMGCR) result is pending but the other myositis-specific antibodies are negative.(including anti-SRP). Conclusion(s): IMNM is an autoimmune myopathy associated with anti-HMGCR and anti-SRP antibodies that clinically present similarly to polymyositis. The temporal occurrence of worsening muscle weakness with initiation of statin therapy make statin toxic myopathy or immune mediated necrotizing myopathy as diagnostic considerations. This case emphasizes the need to re-evaluate the etiology of new onset muscle weakness in patients with idiopathic inflammatory myopathy and highlights the role of myositis-specific antibodies and muscle biopsy in confirming the diagnosis.
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Background: Autoimmune Syndrome Induced by Adjuvants, or ASIA, suggests certain environmental exposures, including vaccination can cause hyperstimulation of the innate and adaptive immune system leading to production of autoantibodies in a genetically predisposed individual. A diagnosis of exclusion, proposed diagnostic criteria suggested ASIA if specified major and minor criteria are fulfilled. Suspicion for ASIA was raised in our patient due to identified exposure accompanied by typical manifestations not explained by another cause. Case: A 71-year- old Filipino female with controlled hypertension and diabetes, came in due to progressive right eye pain, supraorbital headache, ptosis and limitation of extra-ocular movements for 3 weeks. No blurring of vision, color vision changes, or visual field cuts. She didn't have other systemic features but received 2 doses of inactivated COVID-19 vaccine 1 month (1st) and 1 day (2nd) prior to the symptom onset. The left eye was unremarkable. ESR was elevated (109) with normal CRP. ANA was 1:80 with a speckled pattern. The complements were normal and lupus confirmatory panel was negative. CSF studies showed slightly elevated protein and glucose with no pleiocytosis, IgG level was normal with negative oligoclonal panel and cultures. EMG-NCV showed acute partial incomplete bilateral facial neuropathy. Cranial MRI/MRA showed chronic lacunar infarct in the right corona radiata. The MRI of the orbits showed right optic nerve enhancement with hyperintense nerve sheath compatible with optic neuritis. She underwent pulse IV steroid therapy (Methylprednisolone 1 g) for 3 days and was maintained on oral steroid 1 mg/kg/day. There was minimal improvement of symptoms for which she received intravenous immunoglobulin for 5 days. Her symptoms gradually improved upon discharge. Conclusion(s): Identification of the possible autoimmunity from adjuvants is not to discourage vaccination but rather raise awareness of the need for further studies to screen who might be at risk and to prepare or even develop alternatives, such as vaccines with a different type of adjuvant.
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Background: Telemedicine became the emergent means of providing and continuing medical care due to the COVID 19 pandemic. This study aims to evaluate the knowledge, perception, and satisfaction with the use of telemedicine among patients with rheumatic diseases. An understanding of our patients' experiences can be utilized to provide access to care, improve gaps in delivery of care, and improve healthcare disparities. Method(s): Filipino patients with rheumatic disease who had telehealth visits between June 2020 and August 2021 in St Luke's Medical Center Outpatient Department participated in an online survey. Information on demographics, diagnosis, knowledge and experience on telemedicine, and perspectives on benefits and limitations of telemedicine were collected. Result(s): There were 70 respondents: 52.9% with SLE, 25.7% with RA, 10% with osteoarthritis, 5.7% with psoriatic arthritis, 2.9% with scleroderma. Results showed that 64.3% are familiar with the use of video conference platforms. Facebook messenger was the most used (85.7%). Half of respondents have used telemedicine on their own, while 33% required assistance. The remaining respondents have not used telemedicine due to lack of experience or awareness on how to proceed with consults. The reasons for using telemedicine were restrictions of the pandemic (82.9%), limited access to clinics (31.4%), and disability (1.4%). Most remain satisfied with telemedicine (75.7%), 50% of patients stated that telemedicine was comparable to an in-clinic visit, and 85.7% (N = 60) would recommend its use. Conclusion(s): Filipinos with rheumatic disease are knowledgeable on online platforms and telemedicine, however, it is important to note the digital divide. Patients need assistance and improved awareness on accessing remote care. Providing continuity of healthcare can lead to less complications and better outcomes despite pandemic restrictions. There is an overall favorable satisfaction for care. Half the respondents remain satisfied with telemedicine. Rheumatologists need further studies on benefits and outcomes on providing remote healthcare.
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Objectives: Several case series have been identified describing adult patients with a secondary Multisystem Inflammatory Syndrome (MIS) after a recent COVID-19 infection, presenting with features similar to Kawasaki Disease (KD). This paper aims to describe the first case of Kawasaki-like presentation in an adult Filipino with COVID-19 infection. Method(s): A case of Kawasaki-like presentation in an adult Filipino with COVID-19 infection was reviewed in a tertiary hospital. Result(s): This is a case of a 38-year- old Filipino woman who presented with fever, malaise, dry cough, sore throat, diarrhea and rashes. On examination, she had classic features of KD: non-exudative conjunctivitis, cracked lips, edema of the hands and feet, palmar erythema, diffuse rash, and cervical lymphadenopathy. Laboratory results showed anemia, leukocytosis with neutrophilia, hyponatremia, hypokalemia, transaminitis, hypoalbuminemia, and elevated inflammatory markers. COVID-19 PCR test was negative but serologic studies showed positivity for IgM and IgG, suggesting a recent infection. Treatment included methylprednisolone pulse therapy, intravenous immunoglobulin (IVIG) and anticoagulation, which resulted in rapid clinical improvement. Conclusion(s): As the knowledge of COVID-19 and its associated clinical features continually evolves, it is imperative to be aware of the possibility of KD as a delayed post-viral multisystem inflammatory response in adults that may warrant prompt treatment.
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Background/Purpose: Concomitant systemic lupus erythematosus (SLE) and human immunodeficiency virus (HIV) infection cases are rare worldwide. It is established that SLE patients have an increased risk of opportunistic infection due to immune dysregulation, as well as in HIV. Method(s): A case of a 25-year- old Filipino man with systemic lupus erythematosus admitted due to a 1-week intermittent fever associated with headache, loss of appetite, and generalized body weakness was reviewed in a tertiary hospital in the Philippines. Result(s): An initial diagnosis was made from the clinical presentation of Raynaud's phenomenon, an elevated antinuclear antibody (1:320;nuclear, speckled), 2+ proteinuria, thrombocytopenia, and nail fold capillaroscopy findings consistent with mixed connective tissue disease. Patient was started on hydroxychloroquine and prednisone. He was admitted as a case of Streptococcus bacteremia with COVID-19 pneumonia after initial diagnosis, presenting as fever, and thrombocytopenia as low as 23.000/mul. Patient presented with a scaly erythematous annular lesion at his left wrist since December 2021 where a skin punch biopsy showed findings consistent with dermatophytosis. Direct immunofluorescence staining showed deposition of granular IgM (+3), C3 (+1), Fibrinogen (+3), and C1q (+1) in the basement membrane zone consistent with Lupus Erythematosus. Additional findings were oral thrush, dermatophytosis, and Pneumocystis pneumonia. Patient was started on antibiotics, remdesivir, and antifungal medications. Being severely immunocompromised, work up for HIV was initiated. Rapid HIV screening was positive, CD4 count revealed 7 (3.14%), and subsequent confirmatory western blot was positive. Additional treatment included hydroxychloroquine, methylprednisolone pulse therapy, and platelet concentrate transfusion. He was referred for CD4 monitoring, and ARV treatment enrollment, however, the patient expired a month after his discharge. Conclusion(s): This case is thereby reported to document a rare case of systemic lupus erythematosus (SLE) male patient with concomitant HIV, SARS-CoV- 2, and opportunistic infections secondary to AIDS. Diagnosis becomes challenging in patients with autoimmune diseases and multiple infectious diseases as clinical presentations tend to overlap and may show similar manifestations. In this setting, skin biopsy utilizing direct immunofluorescence can help establish an accurate diagnosis especially when clinical features and histopathology are overlapping.
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Background: Systemic lupus erythematosus (SLE), a multisystem autoimmune disease more common in females, is associated with autoantibodies against different autoantigens forming immune complexes. Inadequate removal of these complexes from the host triggers inflammatory response which causes tissue damage. Some antiviral vaccines have been associated with the onset of SLE. Few cases of SLE occurring after SARS-CoV- 2 vaccines have been reported. Herein, we describe a case of new-onset SLE associated with COVID-19 vaccine. Case Summary: A previously well 36-year- old male with unremarkable family history of autoimmune disease started to develop muscle and joint pains, hair thinning, and ecchymoses 2 months after receiving second dose of inactivated SARS-CoV- 2 vaccine. He was subsequently admitted after consultation due to thrombocytopenia (platelet count of 58). He was given high dose steroid with tapering dose during the entire 14 days admission with significant increase of platelet count after 72 hours of repeat complete blood count. He went consult at rheumatology clinic a month after due to persistent joint and muscle pains, and progression of hair fall with associated facial rash, oral ulcers, easy fatigability and weight loss. Physical exam disclosed an ambulatory well-built male with normal vital signs, alopecia, malar rash, oral ulcers, joint tenderness and no objective muscle weakness. Complete blood counts and Anti-smith were within normal. Urinalysis, Antinuclear antibody (ANA), Anti-SSA, Anti-SSB, complement factor 3 (C3), and Anti-dsDNA were positive. He was managed with tapering prednisone and hydroxychloroquine with significant improvement at time of this report. Conclusion(s): Development of autoimmune reaction following COVID-19 vaccine has been described extensively;however, evidence of autoimmunity following vaccination seems to be lacking at present. Pathomechanisms include defective elimination and/or control of self-reactive lymphocytes resulting in over-stimulation of the immune system leading to clinical manifestations strikingly similar to the infection itself. Management approach to these autoimmune reactions address the immune hyper-stimulation with immunosuppressive or immuno-modulating agents including steroids and hydroxychloroquine.
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Background: The coronavirus disease 2019 (COVID-19) pandemic has limited healthcare delivery for patients with chronic diseases, including Systemic Lupus Erythematosus (SLE). This study aims to describe the outcomes of patients with SLE in a national COVID-19 referral center in the Philippines. Method(s): A review of records of all patients with SLE seen in the University of the Philippines-Philippine General Hospital (UP-PGH) from March 2020 to December 2021 was done. Data about patient characteristics, health encounters, and outcomes before and after the first visit during the study period were extracted. Descriptive statistics were employed. Result(s): Our population of 403 patients was predominantly young (mean age 34.53 +/- 11.14 years), female, and unemployed. This consisted of 370 known cases of SLE, 92 were diagnosed in institutions outside UP-PGH, and 33 new patients. Over the 22-month study period, there were 2,093 medical encounters, most of them were teleconsultations (81.70%). During an average gap of 53.6 +/- 26.7 weeks between the last consultation and the first visit within the pandemic study period, 84 patients (22.70%) discontinued at least one of their SLE control medications, 68 (18.38%) patients developed a lupus flare, and 79 (21.35%) were hospitalized for various reasons. On their return to the rheumatology clinic during the pandemic, 37.47% were in lupus flare, 28.29% needed to be hospitalized, and 20 died. However, 86.75% of flares were controlled. During subsequent health encounters, 48 patients had a new flare (43 of these were controlled) and 20 died. The most common reason for hospitalization (n = 160) was lupus disease flare and the most common cause of death (n = 40) was pneumonia. Sixty patients acquired COVID-19 infection from which most recovered and four died. Conclusion(s): Audio teleconsultation was the most common method used by our lupus cohort to interact with their doctors during the pandemic. There was an average of a year-long interruption in medical care for 62.70%. More than a third developed a disease flare and 15% acquired COVID-19 but outcomes were good in more than 85%. Despite the challenges posed by the pandemic, the majority of our lupus cohort who were able to continue their treatment had favorable outcomes.
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Background/Purpose: The coronavirus disease 2019 (COVID-19) pandemic has led to the emergence of a severe associated condition, multisystem inflammatory syndrome in adults (MIS-A). Initially identified in children as MIS-C, literature regarding the clinical manifestations, illness progression, and treatment of MIS-A are limited. Method(s): This study describes a case of MIS-A presenting as fever and seizures. She was initially given steroids and IVIG, and due to recurrence of fever, she was later treated with tocilizumab. Result(s): The patient was a 55-year- old Filipino female presenting to the emergency department with five days of fever, headache, and disorientation. Lumbar tap was done, which showed elevated opening pressure, normal leukocyte count, normal glucose, slightly elevated protein, and no microorganisms. She was admitted and managed as a case of viral encephalitis. On hospital day 6, she had sudden onset of head-jerking and further decrease in sensorium, hence she was transferred to the intensive care unit. Brain MRI was unremarkable, and subsequent immune-mediated encephalitis was considered. The patient underwent methylprednisolone pulse therapy and IVIG infusion, which provided immediate improvement of sensorium and resolution of fever episodes. Her condition stabilized, and she was transferred out of intensive care. She underwent physical and occupational rehabilitation as preparation for discharge. Two weeks after infusion therapy, on hospital day 26, patient had recurrence of fever episodes and persistence of elevated inflammatory markers. The patient had reported a previous COVID-19 infection 10 weeks prior to admission and received a booster dose of Moderna (Spikevax) COVID-19 vaccine three weeks prior. She tested positive for ANA (1:640, nuclear speckled), while the rest of the autoimmune antibody tests were negative. She was diagnosed as MIS-A based on the following: documented fever (>=38 degrees centigrade) for >=24 hours prior to hospitalization;new-onset neurologic signs and symptoms including seizures and encephalopathy in a patient without prior cognitive impairment;elevated CRP, ferritin, IL-6, and ESR;and a positive SARS-CoV- 2 test for recent infection by RT-PCR. Patient was treated with a locally available monoclonal antibody, tocilizumab, which was given on hospital day 43. Following infusion, she had lysis of fever and marked decrease in CRP, ferritin, IL-6, and ESR. Patient was discharged improved and without end-stage organ damage. Conclusion(s): Immunomodulators target hyperinflammation seen in MIS-A. There may be a role for the use of tocilizumab via blockage of IL-6. MIS-A remains a topic for research, particularly its disease characteristics, management, and relation to a dysregulated immune system.
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Introduction: Guillain-Barre syndrome (GBS) is an acute inflammatory neuropathic illness with striking clinical manifestations and significant morbidity. Rare sporadic cases of GBS have been described following vaccination. This case in particular was temporally related to the Sinovac-CoronaVac (COVID-19) vaccine. A causal link with the vaccine is not proven but is possible and warrants further investigation. Hence, the objective of this study is to describe a case of GBS after COVID-19 vaccination. Method(s): Case report Results: 55-year-old Filipino woman presented with progressive symmetric ascending weakness of bilateral upper and lower extremities which began four weeks after receiving vaccination with the Sinovac-CoronaVac (COVID-19) vaccine. She also described concurrent facial weakness, dysphagia, and paresthesia of both feet. Fortunately, there were no clinical findings of dysautonomia. On neurological examination, she had facial diplegia, quadriparesis with lower extremity predominance, manual muscle testing revealed 4-/5 on bilateral upper limbs and 2/5 on bilateral lower limbs. The deep tendon reflexes were absent generally. The cerebrospinal fluid analysis showed protein-cytological dissociation and the nerve conduction study (NCS) revealed generalized motor axonopathy. Thus, the patient was managed as GBS, specifically the Acute Motor Axonal Polyneuropathy (AMAN) variant. She underwent plasma exchange in 5 sessions over 10 days with significant clinical improvement at a 4-week follow up visit. Conclusion(s): Only a few cases of GBS after COVID-19 vaccination have been reported. Among these, AMAN is uncommonly described. In patients with GBS, several viral and bacterial pathogens have been found in several studies but the factors that induce the immune-mediated destruction of the nerve tissues need more rigorous research. Copyright © 2022
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Although online teaching is not anymore new in the field of education, but it has become the trend in teaching during the advent of the COVID-19 pandemic. Countries also differ on online teaching implementation due to the strength and level of sophistication of their internet connectivity. That is why is, it very interesting to determine how students learn through online teaching in a third world countries such as Philippines. This quantitative study employed a descriptive design utilizing the tertiary students’ Mathematics grade during the full conduct of the online teaching. The data revealed that respondents’ mental ability in higher Mathematics was described as “satisfactory” in which they met the minimum competence with average score. In addition, gender did not also indicate a significant difference as a variable. No significant difference between their gender was also found out in the results. This finding points out that online teaching was still the best alternative mode of delivery in the height of the pandemic. Although it has been known that many Filipino students has no personal computers and laptops, most of these students utilized their cellular phone not only for personal use but for academic as well. Thus, this study recommends that teachers may continue employing online teaching or blended teaching to let the students learn on their own with the aid of technology.
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Introduction: The Fungitell assay is an in vitro diagnostic test for the qualitative detection of (1-3)-beta-D-Glucan (BDG) in serum. It can be particularly useful in early diagnosis of fungal infections that would otherwise take weeks to finalize in culture.Description:This is a case of a 73 year old Filipino female with a history of diffuse large B-cell lymphoma status post RCHOP therapy, currently maintained on Ritixumab, and rheumatoid arthritis treated with Methotrexate who was admitted to the hospital with increasing shortness of breath for several weeks. In the Emergency Department she was hypoxic and required 2 liters of oxygen via nasal cannula and with 92% oxygen saturation. Her vital signs were otherwise normal. She was afebrile and WBC was 9.4. She had a negative respiratory viral PCR which included COVID-19. Infectious work up including sputum culture and urine antigens were also sent. A CT chest was performed and showed bilateral ground glass opacities suspicious for atypical pneumonia.There was concern for drug toxicity from Methotrexate which was subsequently suspended. A bronchoscopy and bronchoalveolar lavage (BAL) was performed to rule out infection prior to starting steroids for suspected pneumonitis. Cell count from the BAL revealed low neutrophils. There was negative growth over the next 48 hours. Steroids were initiated at 1 mg/kg daily and patient was discharged home with close outpatient follow up scheduled. A fungitell (serum beta D glucan) that was collected from the BAL had resulted after the patient was discharged home. The level returned very elevated (>500). The patient was contacted and she reported that her symptoms did not improve with the steroids. She was still requiring up to four liters of oxygen at home. She was asked to return to the hospital to work up an undiagnosed fungal or PJP pneumonia. A repeat bronchoscopy was performed and a PJP PCR was tested on the BAL. This returned positive. She was started on Bactrim for 14 days to treat PJP pneumonia. She was weaned down to 2 liters of oxygen and was doing well from a pulmonary standpoint at her outpatient follow up visit 2 weeks later. Discussion: The Fungitell assay test in this case was crucial to help guide us to the correct diagnosis. In patients who are immunocompromised, physicians should utilize specialty testing such as Fungitell when it is available. Compared to microbial fungal culture, Fungitell results faster, has a higher sensitivity and a higher negative predictive value. (Figure Presented).
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Background: Tuberculosis remains to be the most common lung infection in the Philippines. Compliance to medication leads to significant improvement. A portion of the population however remains untreated leading to complication such as bronchiectasis. In the approach to treatment, etiologies such as a possible genetic abnormality must be considered aside from a post inciting event. Case: This is a case of D.A. 20 year old, female who came in due to difficulty of breathing. She grew up having recurrent upper and lower respiratory tract infection. She was previously treated with pulmonary tuberculosis for 6 months last 2011. She was initially admitted at the COVID wards during the surge because any patient with pulmonary complains with bilateral infiltrates will be tagged as COVID suspect until a negative RT PCR result becomes available. She was admitted with complains of difficulty of breathing with desaturation. Her body mass index is 12.8 which is underweight. Pertinent physical examination shows bilateral coarse crackles with clubbing which suggest a chronic disease. Complete work up was done. Echocardiography which revealed an ejection fraction of 74%, severe pulmonary hypertension with dilated right atrium and right ventricle. Chest radiography revealed bronchiectatic changes with infiltrates while a confirmatory chest computed tomography scan revealed post infection pulmonary fibrosis with cystic bronchiectasis both lung fields. Spirometry revealed a severe obstructive ventilatory defect with no response to bronchodilator and a probable restrictive ventilatory defect which explains why the patient had higher frequency of admissions. Paranasal sinus xray to rule out Kartagener's syndrome was done which revealed normal results. Microbiologic studies such as sputum TB culture and sputum gene xpert was negative. The sputum culture revealed Stenotrophomonas maltophilia which was treated with intravenous antibiotics. To rule out other possible differentials for the cystic bronchiectasis, karyotyping was facilitated which revealed a normal female karyotype (46 XX). She was managed as a case of cor pulmonale, post tuberculous bronchiectasis, bacterial pneumonia, with considerations of mucociliary defects such as cystic fibrosis. It was unfortunate that a sweat chloride test was not done as it was not available in the country. Conclusion: In a country with endemic infectious pulmonary diseases such as tuberculosis, there is an anticipated sequelae of post infection bronchiectasis and fibrosis. Even if resources are scare and diagnostic tests are limited, repeated lung infection in a young patient warrants further investigation as congenital causes of structural lung diseases may initially present as an infectious process. (Figure Presented).
ABSTRACT
BACKGROUND AND AIMS: The COVID-19 pandemic has brought to the forefront a wide spectrum of renal injuries that included glomerulopathies, some of which were recently highlighted in various case reports. These consist of focal and segmental glomerulosclerosis (FSGS) and minimal change disease (MCD).1 These changes were found among seemingly vulnerable populations such as the African American and Caucasian ethnicities with paucity of reports among other races. We present two cases of biopsy-confirmed MCD secondary to COVID-19 infection among adult Filipino patients. METHODS: Case Report RESULTS: Case 1 A 40-year-old Filipino female with a history of right total mastectomy 2 years prior for a low-grade phyllodes tumor and no other medical comorbidities was admitted due to stillbirth. She was noted to have bipedal edema with a positive COVID-19 RT-PCR swab. Further workup revealed a serum creatinine 1.04 mg/dL, urine RBC 1/HPF and a 24-h urine protein of 9.22 g with hypoalbuminemia and dyslipidemia. Serologic workup was noted to be negative. She was started on Losartan, Atorvastatin, and Furosemide. A kidney biopsy was performed which demonstrated unremarkable light microscopy and immunofluorescence and widespread podocyte-foot process effacement. These biopsy findings were interpreted to be consistent with minimal change disease. She was started on Prednisone at 1 mg/kg/day with continuation of both Losartan and Atorvastatin. Six weeks after, the patient achieved complete remission with resolution of both hypoalbuminemia and dyslipidemia. She also reports no further recurrence of edema. Case 2 A 61-year-old Filipino male with a history of type 2 diabetes mellitus, hypertension, dyslipidemia and mild COVID-19 infection 4 months prior now presented with diarrhea. A routine COVID-19 RT-PCR swab revealed a re-infection. Physical examination noted bipedal edema. Further workup demonstrated a serum creatinine 3.39 mg/dL, urine RBC 2/HPF and urine ACR 2.6 g/g. Serologic tests were negative. He was diagnosed with Nephrotic Syndrome and underwent kidney biopsy. Findings showed an unremarkable light microscopy and immunofluorescence with widespread podocyte-foot process effacement. These findings were found to be consistent with minimal change disease and acute tubular injury. He was started on Prednisone (1 mg/kg/day), Losartan, Furosemide and Atorvastatin. Eight weeks later, the patient achieved complete remission with resolution of edema. CONCLUSION: It is currently suspected that APOL1 risk variants found in reported cases of COVID-19-associated glomerulopathies are underlying toxic gain-of-function mutations that drive kidney disease.2 It is interesting to note that APOL1 renal risk variants are found exclusively in African-derived chromosomes and are rarely found among European or Asian chromosomes.3 Even though an APOL1 genotyping was not performed, our case reports provide the first examples of MCD among individuals without a high-risk genotype (APOL1) by epidemiology and enlarge the literature on MCD in COVID-19. We posit that there may be other underlying predispositions or mechanisms that may be driving glomerulopathy formation among COVID-19 patients aside from their inherent APOL 1 risk. Both of our patients were started on steroid therapy with a tapering regimen and achieved complete remission on subsequent follow-up. Existing reports suggest that most cases of COVID-19-associated MCD will often achieve resolution of AKI and proteinuria with steroid therapy, even in those with high-risk APOL1 genotype, emphasizing the need for an accurate histologic classification.4 (Figure Presented).
ABSTRACT
BACKGROUND: Acute respiratory injury is the main culprit for majority of the morbidity and mortality among COVID-19. However, there is a high prevalence of cardiovascular complication among these patients. Assessment of echocardiographic parameters provides clinical characteristics for utilization in the management of patients with COVID-19. OBJECTIVE: To determine the predictors of mortality and analyze the echocardiographic findings of Filipino patients with COVID-19 Pneumonia and its correlation to the severity of the disease. METHOD: This is a retrospective observational cohort study of the echocardiographic findings among 173 Filipino patients who acquired COVID-19 pneumonia from June to August 2020. Logistic regression analysis was used to identify predictors of dichotomous outcome variable. RESULTS: The results showed that there was a significant direct correlation between the severity of COVID-19 and wall motion abnormality (r = 0.171;p = 0.024). There was also a significant direct correlation between length of hospital stay and the wall motion abnormality (r = 0.140;p = 0.050). Furthermore, there was a significant difference noted in the proportion of subjects with or without wall motion abnormality according to mortality (p = 0.007). The results also exhibit significant difference in the left ventricular end diastolic diameter (LVEDD), left ventricular ejection fraction (LVEF) and left atrium according to mortality as shown by the p values 0.001, 0.001 and 0.030 respectively. However, there is no significant correlation noted between the severity of COVID-19 and mortality to the right ventricular size and function. Multivariate analysis using logistic regression, two variables were found to be significant predictors of mortality, this includes LVEDD and LVEF. CONCLUSION: Among Filipino patients with COVID-19 pneumonia, the study demonstrated that left ventricular end diastolic diameter and left ventricular ejection fraction are significant predictors for mortality.
ABSTRACT
Introduction: Collapsing Glomerulopathy (CG) is a rare entity presenting as nephrotic syndrome and rapidly progressive renal deterioration. It has been first identified among African-American patients with nephrotic syndrome. Subsequently, it has been called HIV-associated nephropathy (HIVAN) after a number of patients with HIV were found to have CG. It has re-emerged recently among patients with COVID-19 dubbing it as the new HIVAN. In the Philippines, Focal Segmental Glomerulosclerosis (FSGS) is the second most common glomerular disease but with no available data on the subtypes.To our knowledge, this is the first case of collapsing glomerulopathy in the country to be published. Methods: This is a case report of primary Collapsing Glomerulopathy seen in our institution. Results: The case is a 36 year-old Filipino female admitted due to edema which started 2 weeks post-partum. She is gravida 3 para 3 (1203), with no complications in all the pregnancies. She had no known comorbidities. Social history was negative for intravenous or illicit drug use. She initially sought consult with her obstetrician where work up showed hypoalbuminemia and diffuse hepatic disease on ultrasound. She was referred to a gastroenterologist where albumin infusion and paracentesis was done but with no improvement. She developed anasarca and was admitted in our institution. Paracentesis was attempted but only minimal ascitic fluid was obtained. Serum ascites albumin gradient was low and baseline laboratories showed high creatinine at 146 mmol/L, hypoalbuminemia at 16 g/L and +3 albumin on urinalysis. Further testing showed a 24-hour urine protein of 11 grams. ANA and anti-DsDNA were negative and c3 and c4 levels were normal. Hepatitis profile was negative for infection. Abdominal CT scan revealed a hypoenhancing pancreatic tail lesion, breast cyst and nodule. Tumor markers showed high CA-125, CA 19-9 and CA 15-3. Breast ultrasound showed simple breast cyst. Gyneocology consult was called where pap smear done was negative for malignancy. Surgery service recommended observation and monitoring for the pancreatic and breast lesions. Kidney biopsy was delayed due to new onset bacterial pneumonia. COVID-19 RT-PCR test was negative. Kidney biopsy was done after lysis of fever. Pending pathologic diagnosis, patient was discharged clinically improved with no edema. She was sent home on prednisone, ARB, statin, fenofibrate and anti-platelet. On follow up at the outpatient clinic, the kidney biopsy result came out to be collapsing glomerulopathy, acute tubular injury, mild interstitial fibrosis and atrophy. HIV test was done and came out negative. Bipedal edema has recurred and albumin/creatinine ration was 731mg/g. She was then started on tacrolimus. She has been on regular follow up and currently has no edema and has ACR of 79mg/g and normal creatinine level. Conclusions: This is an interesting case as the primary glomerular disease has been masked by the initial laboratory findings. The ultrasound showed parenchymal liver disease. Further work-up revealed multiple lesions in the pancreas, breasts and lymph nodes with high tumor-markers which led us to think of paraneoplastic nephrotic syndrome. The renal biopsy revealed a rare diagnosis with no previous local data. This serves as an index case for primary collapsing glomerulopathy in a Filipino patient on remission after being treated with tacrolimus. No conflict of interest