African League Against Rheumatism (AFLAR) preliminary recommendations on the management of rheumatic diseases during the COVID-19 pandemic

Objectives To develop recommendations for the management of rheumatic and musculoskeletal diseases (RMDs) during the COVID-19 pandemic. Method A task force comprising of 25 rheumatologists from the 5 regions of the continent was formed and operated through a hub-and-spoke model with a central working committee (CWC) and 4 subgroups. The subgroups championed separate scopes of the clinical questions and formulated preliminary statements of recommendations which were processed centrally in the CWC. The CWC and each subgroup met by several virtual meetings, and two rounds of voting were conducted on the drafted statements of recommendations. Votes were online-delivered and recommendations were pruned down according to predefined criteria. Each statement was rated between 1 and 9 with 1–3, 4–6 and 7–9 representing disagreement, uncertainty and agreement, respectively. The levels of agreement on the statements were stratified as low, moderate or high according to the spread of votes. A statement was retired if it had a mean vote below 7 or a ‘low’ level of agreement. Results A total of 126 initial statements of recommendations were drafted, and these were reduced to 22 after the two rounds of voting. Conclusions The preliminary statements of recommendations will serve to guide the clinical practice of rheumatology across Africa amidst the changing practices and uncertainties in the current era of COVID-19. It is recognized that further updates to the recommendations will be needed as more evidence emerges

Defining gout and hyperuricemia in sub-Saharan Africa: A review

Objective: Gout is an inflammatory disease characterized by  hyperuricemia. There is paucity of data on epidemiology and its overall impact in an African setting. Once thought to be rare in Africa, the numbers are increasing with more Africans adopting a western lifestyle. In view of these observations, this review looks to shed light on gout in sub-Saharan Africa.Recent findings: Drivers of the surge in numbers of gout and hyperuricemia in Africa include the adoption of western lifestyle, higher socio-economic status, male sex and excess alcohol consumption. Further contributions are from the rising number of lifestyle diseases such as obesity, hypertension and diabetes.Conclusion: There are increasing numbers of publications refl ecting a growing recognition of gout in sub Saharan Africa (sSA).Key words: Gout, Hyperuricemia, sub-Saharan Afric

Coexistence of gout and rheumatoid arthritis in Nairobi, Kenya

Background: There is a widespread belief that gout and RA rarely coexist in the same patient. Given that there is an excess burden of cardiovascular disease in patients with RA, this is compounded by hyperuricemia. The purpose of this study was to describe the clinical profiles of patients with coexistent gout and rheumatoid arthritis.Methodology: This was a retrospective study to be carried out at the Nairobi Arthritis Clinic. The sample population comprised of all medical records of patients with RA and gout. The files were retrospectively reviewed from January 2009 to December 2017.Results: The cohort included 13 patients with the diagnosis of rheumatoid arthritis and gout seen at the clinic between January 2009 and December 2017. Majority of the study participants were male (9/13) with a mean age of 60.8 years. The mean age of diagnosis of rheumatoid arthritis and gout was 55.25 years and 63 years respectively. The participants were obese with a mean of 31.4. Majority tested positive (10/13) for either or both rheumatoid factor and anti-citrulated peptide antibody. Urate acid crystals were identifi ed in 10 of the 13 participants. All the participants had used glucocorticoids with a further 4 on diuretics which were later stopped.Conclusions: Coexistence of rheumatoid arthritis and gout is still rare in Kenya. Being male and obese having either rheumatoid arthritis or gout increasing the chance of developing both diagnoses. A large number had tophithus in patientswith tophaceous gout not improving on standard therapy an alternative diagnosis could be rheumatoid arthritis.Keywords: Gout , Rheumatoid arthritis, Keny

Cryptococcal meningitis; a rare cause of headache in lupus: case report and literature review

Microbial infections are the leading causes of morbidity and mortality in patients with Systemic Lupus Erythematosus (SLE). Cryptococcal Meningitis (CM) infection is often underestimated and misdiagnosed in patients with SLE. This partly is due to its nonspecific clinical presentations at the early stage of the disease. It commonly presents with fever and headache and has a high mortality rate in SLE patients. They are a paucity of case reports in literature worldwide. We present a case of a lupus patient who presented with confusion and in the background of chronic headache and partially treated meningitis which turned out to be cryptococcal meningitis. The case illustrates the need to have a high index of suspicion so as to initiate early treatment and avert mortality. Key words: Systemic lupus erythematosus, Cryptococcal meningitis, Keny

More than skin colour: challenges of diagnosis and managing Raynaud’s phenomenon in a Kenyan lady

We report the case of a 35-year-old female with Raynaud’s associated with mixed connective tissue disease. The patient presented with a two-week history with pain, ulceration, and “darkening” of her fingers and feet. She had been diagnosed with mixed connective tissue disease two years earlier and had Raynaud’s as one of the symptoms. She was subsequently lost to follow up due to financial constraints. Despite our efforts, we were not able to save her limbs from amputation

Audit on the management of early rheumatoid arthritis in Nairobi

Background: Clinical audit for rheumatoid arthritis on patients over  the age of 18 years in Nairobi, Kenya within the first three months of referralto a specialist.Objective: The audit gives detailed information on the following; access to care, quality of treatment and care received by patients from their  rheumatology team in these first 3 months and the early impact of arthritis on the patient’s life.Design: This was a cross-sectional survey.Results: The audit included 100 patients referred to the Nairobi Arthritis Clinic between January and April 2018. A majority (54%) had symptoms for  more than 6 months before being referred to a rheumatologist. Most of the patients (83%) were seen within 3 weeks of referral. Disease ModifiyingAntirheumatic Drugs (DMARDs) were commenced in 90% within 6 weeks of being seen at the clinic. Treatment to target was done in 98% of the patients with a further 60% able to access the clinic within a day of flare of symptoms.Conclusion: The audit revealed the need to improve on referral time to the rheumatologist. It was encouraging to note that once they saw therheumatologists the patients were commenced on the proper treatment with the treat to target strategy. An area that needs improvement is the time to access the rheumatologist in case of side effect from the treatment or flare of the disease. Key words: Rheumatoid arthritis, Audit, Management, Nairob

Systemic lupus erythematosus with intestinal pseudoobstruction: a case report and review of the literature

Intestinal pseudo-obstruction is a rare complication of Systemic Lupus Erythematosus (SLE). Due to diagnostic challenges, it can go largely unrecognized. It is characterized by features of mechanical obstruction of the small or large bowel in the absence of an anatomic lesion obstructing the flow of intestinal contents. There are a paucity of case reports in literature worldwide. We report two cases of intestinal pseudoobstruction in which one patient survived. The two cases illustrate the need for a high index of suspicion for diagnosis and early intervention with systemic high dose corticosteroids and IVIG. This will avert surgical intervention and reduce the mortality rate from this manifestation of lupus.Keywords: Systemic lupus erythematosus, Intestinal pseudo-obstructio

Systemic lupus erythematosus with acute inflammatory demyelinating polyneuropathy: a case report

We recently managed a case of acute inflammatory demyelinating polyneuropathy associated with SLE. A 20-year-old newly diagnosed SLE patient presented with a three-week history of acute bilateral ascending weakness associated with inability to walk. Physical examination revealed muscle strength in the legs with graded 2/5 proximally and 2/5 distally bilaterally and absence of deep tendon reflex in both knees and ankles. The muscle strength in upper limb was 3/5 proximally and 3/5 distally bilaterally. Paresthesia was observed in distal limbs with glove and stocking distribution. Cerebrospinal fluid analysis was normal. Electrophysiologic survey indicated asymmetrical mixed sensory motor demyelination and radiculopathy. The diagnosis of SLE was established based on her initial symptoms including fevers, fatigue, malar rash, myalgia, and positive ANA. Treatment with intravenous immunoglobulin and methylprednisolone resulted in clinical improvement.Keywords: Systemic lupus erythematosus, Acute inflammatory demyelinating polyneuropathy, Guillain-Barre syndrom

Describing in ammatory muscle disease in Kenya: A single tertiary centre experience in Kenya

Background: Infl ammatory muscle diseases are a rare group of connective tissue diseases. There is a paucity of documented literature on indigenous Africans in sub-Saharan Africa. We present herein the clinical patternsof infl ammatory muscle diseases encountered at a rheumatology clinic, Nairobi, Kenya.Objective: To describe the clinical spectrum of infl ammatory myopathies at a tertiary rheumatology clinic in Nairobi. These included clinical,  haematological and immunological characteristics of patients with Inflammatory myopathies.Methods: Medical records of 10,998 patients presenting to the Nairobi Arthritis Clinic for various rheumatological conditions were reviewed. The records of 46 patients with muscle weakness with or without skin rash were selected and reviewed between January 2012 and December 2017 were retrospectively reviewed and reclassifi ed as polymyositis (PM) and dermatomyositis (DM) based on the Bohan and Peter diagnostic criteria.Results: Forty-six patients (F=36, M=9) were diagnosed with polymyositis and dermatomyositis. Twenty-fi ve had possible dermatomyositis, eighteen had possible polymyositis with another three who had an overlap of polymyositis with other diseases. There were 3 patients with juvenile dermatomyositis. Majority of the patients were referred of which 14 had an alternative diagnosis to myositis. The mean age for PM was 36.36 years and for DM 41.13 years. The creatinine kinase mean was 2845.4 (697-7063)u/l. Serology for ANA tested positive in 8 patients (PM=4, DM=4). The most common symptoms of DM patients included Gottron papules (12), heliotropes rash (15) and shawl sign (5). Myositis antibody screening was not performed in any of the patients.Conclusion: Infl ammatory myopathies are still rare in Kenya. The clinical spectrum is largely similar to what is known in written literature. From  referral notes and diagnosis of the primary physician, there is a paucity of information about these diseases. None of the patients had myositis  antibody panel due to either unavailability or high cost of doing the tests. More effort should be on increasing awareness of diagnosis and management of these diseases.Key words: Inflammatory muscle disease, Polymyositis, Dermatomyositis, Nairobi, Keny

Prevalence of functional disability in patients with rheumatoid arthritis attending the rheumatoid outpatient clinic at Kenyatta National Hospital

Background: Rheumatoid Arthritis (RA) causes serious joint erosion,  deformity and severe functional disability if not diagnosed early and followed by a timely initiation of Disease Modifying Anti- Rheumatic Drugs (DMARDs). Studies have shown that functional disability is a major determinant on the patients’ quality of life and it is a strong predictor of morbidity, work disability and mortality. Functional disability is measured by patient-oriented tools such as the Health Questionnaire Disability Index (HAQDI) which is the gold standard tool.Objective: This study aimed to determine the prevalence of RA functional disability and its association with disease activity, socio-demographic and clinical characteristics in patients with rheumatoid arthritis on follow up at the Rheumatology Outpatient Clinic in Kenyatta National Hospital (KNH).Design: This was a descriptive crosssectional hospital-based study.Setting: Rheumatology Outpatient Clinic (ROPC) at the Kenyatta National Hospital (KNH); the largest public national and referral hospital in Kenya.Subjects: One hundred and six patients who fulfi lled the 2010 American College of Rheumatology and the European League Against Rheumatism (ACREULAR) criteria.Results: There were 102(96.2%) females and 4(3.8%) males recruited into the study with a female to male ratio of 10:1. The prevalence of functional disability was 72.6% with a mean HAQ-DI of 0.41±0.38 which is interpreted as mild disability. Active disease was present in 90.6% of the patients with a median CDAI of 11(IQ range 6.5-22) and mean CDAI score of 15.95±13.08 which represents moderate disease activity and only 9.4% were in remission. The average duration of disease was 5.1 years.  Functional disability was signifi cantly correlated with disease duration and treatment duration.Conclusion: The study demonstrated a high prevalence of functional disability and a higher disease activity of among RA patients in our setting despite being on DMARDs. There was a signifi cant correlation between functional disability and disease duration. However, there were no  correlations between functional disability and any of the sociodemographic study variables; age, sex, marital status, employment, education and smoking history