Acute pancreatitis as an initial presentation of SLE: a case report

Background: SLE is a complex multi- systemic autoimmune disease capable of affecting any organ system with varying presentations. Abdominal pain is a common manifestation of SLE and is reported to occur in about 8% to 40% of patients with SLE. The causes of abdominal pain are varied and require accurate assessment. Acute Pancreatitis is a cause of abdominal pain and is a rare initial SLE presentation. It is characterized by abdominal pain and raised serum amylase levels. We would like to report a patient diagnosed with SLE following an initial presentation of Acute Pancreatitis, which was complicated with a pancreatic pseudocyst. Case Report: The patient is an 18- year- old lady with no previous known medical illness who presented with a one day history of acute central abdominal pain radiating to the back. This was preceded by a two week history of fever and non- productive cough. Further history revealed that she had alopecia, malar rash and painless oral ulcers one year before this presentation but did not seek medical attention. Physical examination revealed a tender and distended abdomen. Blood investigations showed leukopenia, elevated amylase with a positive Anti- nuclear antibody, and coombs test. She was admitted to the ICU and treated with intravenous cyclophosphamide, methylprednisolone, immunoglobulin, and antibiotics. During her follow- up a month after discharge, she was found to have recurrent abdominal pain and distension. A repeated CT Abdomen showed a pancreatic pseudocyst, and she underwent an endoscopic cystogastrostomy. Currently, she is on regular follow- up and is currently maintained on Hydroxychloroquine, Azathioprine, and Prednisolone. Conclusion: In summary, Acute Pancreatitis is a relatively rare initial manifestation of SLE. The causes of Acute Pancreatitis are varied, and it is essential to recognize and differentiate Acute Pancreatitis due to active SLE from other causes as it may affect treatment decisions and subsequent mortality outcomes

Clinical features of patients with rheumatic diseases and COVID-19 infection in Sarawak, Malaysia

We read with great interest the article by Ye et al1 describing the clinical features and outcomes of patients with rheumatic diseases and COVID-19 in Wuhan, China. It concluded that length of hospital stay and mortality were similar between patients with rheumatic diseases and non-rheumatic groups, while respiratory failure was more common in patients with rheumatic diseases infected with COVID-19. D’Silva et al2 and Zhao et al3 subsequently highlighted the differences of clinical severity and outcomes in their respective cohorts of patients with rheumatic diseases and COVID-19. Fredi et al4 presented data from northern Italy which supported an association of elderly age and the presence of comorbidities with a poor outcome of COVID-19 infection, rather than the type of rheumatic disease or background medications. The Global Rheumatology Alliance5has recently published data of characteristics associated with hospitalisation for COVID-19 among patients with rheumatic diseases. We would like to share the clinical course of COVID-19 among patients with rheumatic diseases in Sarawak

Arthritis as an initial presentation of malignancy: two case reports

Abstract Background: Arthritis is rarely reported as a paraneoplastic manifestation of occult malignancy. We report herein two cases of paraneoplastic arthritis due to occult malignancy. Case 1: The patient was a 65-year-old woman of asian descent who was a former smoker with a history of spine surgery performed for L4/L5 degenerative disc disease. She presented with a 1-month history of oligoarthritis afecting both ankle joints and early morning stifness of about 3 hours. Laboratory tests were positive for antinuclear antibody at a titer of 1:320 (speckled) but negative for rheumatoid factor. She was treated for seronegative spondyloarthritis and started on prednisolone without much improvement. A routine chest radiograph incidentally revealed a right lung mass which was found to be adenocarcinoma of the lung. She was treated with geftinib and her arthritis resolved. Case 2: The patient was a 64-year-old woman of asign descent, nonsmoker, who presented with a chief complaint of asymmetrical polyarthritis involving her right wrist, second and third metacarpophalangeal joints, and ifrst to fifth proximal interphalangeal joints. She was treated for seronegative rheumatoid arthritis (RA) and started on sulfasalazine, with poor clinical response. Six months later, she developed abdominal pain which was diagnosed as ovarian carcinoma by laparotomy. Her arthritis resolved following treatment of her malignancy with chemotherapy. Conclusion: In summary, paraneoplastic arthritis usually presents in an atypical manner and responds poorly to disease-modifying antirheumatic drugs. Accordingly, we recommend screening for occult malignancy in patients presenting with atypical arthritis.

IgG4- related disease, a case series from Sarawak Malaysia

Background: IgG4- related disease (IgG4- RD) is a novel entity of disease first recognised in 2003. It has wide spectrum of clinical manifestations, virtually affecting any organ. It’s epidemiology remain poorly described and treatment guideline still lacking. Methods: We describe 7 IgG4RD cases diagnosed and treated in 2 hospitals with rheumatologist in Sarawak from 2015 till 2020. Results: 4 males and 3 females were reported with age during diagnosis ranging from 34 to 74 years old. 4 patients had tumefactive lesions (lacrimal gland and salivary gland swelling), 2 had obstructive symptoms (obstructive uropathy due to retroperitoneal fibrosis, obstructive jaundice secondary to autoimmune pancreatitis) and 1 had renal failure and proteinuria as presenting symptoms. Time taken from onset of symptoms to diagnosis range from 8 months to 23 years. In all cases, histopathological findings were the prompt towards diagnosis of IgG4- RD. All patients fulfilled the ACR- EULAR classification criteria whereas only 3 met the 2010 JCR comprehensive diagnostic criteria, due to lack of IgG4 level in others. All patients showed rapid response to steroid therapy, complete resolution of salivary gland swelling were seen in 3 months, stent removal in those with obstructive symptoms were achieved in 6 months whereas resolution of proteinuria was seen in 2 months. All remained in remission currently with or without treatment. Initial dose of prednisolone used ranged from 0.2 to 0.6mg/kg/day, all with good effect. Conclusion: IgG4- RD is indolent but often highly destructive. It is treatable and if diagnosed early, damage is potentially reversible. In terms of diagnosis, we feel that the ACR- EULAR classification criteria is more practical compared to the JCR criteria in places where resources are limited and laboratory testing of serum IgG4 level is not available. Good awareness and high index of suspicion among clinicians, radiologists and pathologists are thus essential in timely diagnosis and prompt treatment of IgG4- RD

Fatal gastrointestinal manifestations of SLE: case reports

Background: SLE- related gastrointestinal involvement such as gastrointestinal vasculitis and thrombosis are clinically important, as it could progress to life- threatening outcome if not treated promptly. We describe 2 patients who were admitted to our hospital with fatal gastrointestinal manifestations of SLE. Method: Case Report. Results: Case 1: The patient was a 24- year- old Asian woman who was diagnosed with SLE in 2014 and class IV lupus nephritis in 2018. She presented with hypovolemic shock secondary to massive hematochezia. CT abdomen and angiography revealed multiple bleeding sites in jejunum and mesenteric vasculitis changes of the bowels. Gastroduodenoscopy and CT angioembolization of the mesenteric arteries were performed to stop the bleeding, and IV Methylprednisolone, IV Cyclophosphamide, IV Rituximab were administered. Eventually she succumbed to Transfusion- Related Acute Lung Injury (TRALI) from multiple blood transfusions. Case 2: The patient was a 61- year- old male smoker who was diagnosed with SLE with lupus nephritis in April 2020. He however refused renal biopsy or cyclophosphamide. He presented a few months later with fever and colicky abdominal pain for 2 days. A diagnosis of Superior Mesenteric Artery (SMA) Thrombosis with Bowel Ischemia was made, which was likely due to Catastrophic Anti- Phospholipid Syndrome (CAPS) with SLE, based on CT abdomen findings of SMA thrombosis, bilateral common femoral vein thrombosis and multiple splenic infarcts. Heparin infusion was initiated, and he was administered IV Methylprednisolone and Intravenous Immunoglobulin (IVIg). He developed Disseminated Intravascular Coagulation (DIVC) subsequently and succumbed to his illness at day 2 of admission. Conclusion: In summary, early diagnosis with prompt and adequate treatment of gastrointestinal manifestation of SLE is essential to avoid serious complications like haemorrhage or perforation with a high mortality rate

Gender differences in osteoporotic hip fractures in Sarawak General Hospital

ABSTRACT Introduction: Osteoporosis and osteoporotic fracture pose a major public health problem in our ageing population, and particularly concerning is the increased morbidity and mortality associated with osteoporotic hip fractures. While overall diagnosis and treatment for osteoporosis have improved, osteoporosis in men remains underdiagnosed and undertreated. We aim to describe the difference in clinical characteristics between elderly men and women with osteoporotic hip fractures in Sarawak General Hospital. Materials and Methods: All patients diagnosed with osteoporotic hip fracture admitted to Sarawak General Hospital from June 2019 to March 2021 were recruited, and demographic data and clinical features were obtained. Results: There were 140 patients with osteoporotic hip fracture, and 40 were men (28.6%). The mean age for males was 74.1 ± 9.5 years, while the mean age for females was 77.4 ± 9.1 years (p=0.06). The types of fracture consisted of neck of femur=78, intertrochanteric=61 and subtrochanteric=1. More men were active smokers (15% vs 1%, p<0.001). There were 20 men with secondary osteoporosis (50%), while 13 women (13%) had secondary osteoporosis (p<0.001). The causes of secondary osteoporosis among the men were hypogonadism, COPD, glucocorticoid-induced osteoporosis, renal disease, androgen deprivation therapy, thyroid disorder, prostate cancer and previous gastrectomy. There were two deaths among the men and four deaths among the women during the inpatient and 3 months follow-up period. There was no statistical significance between the mortality rates between male patients (5%) and female patients (4%) (p=0.55). Conclusion: There were more females with osteoporotic hip fractures, and there were significantly more males with secondary osteoporotic hip fractures