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

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.

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

Pulmonary tuberculosis and COVID-19 coinfection: Hickam’s Dictum revisited

COVID-19 and pulmonary tuberculosis (PTB) coinfection is associated with increased mortality and presents a unique diagnostic challenge to the clinician. We describe three cases of newly diagnosed PTB in COVID-19 patients treated at our centre and their clinical and radiological features. The challenges associated with diagnosis and management are also explored. Patient 1 was a case of smear positive, endobronchial tuberculosis incidentally diagnosed due to CT changes, and eventually made good recovery. Patient 2 was a case of COVID-19 who succumbed but was diagnosed posthumously due to a positive sputum culture for tuberculosis. Patient 3 showed radiographic features of PTB and was treated empirically for TB. In conclusion, COVID-19 and PTB coinfection should be suspected in the presence of constitutional symptoms, prior immunocompromised states, prolonged respiratory symptoms or fever, or unresolved radiological abnormalities, more so in regions where TB is endemic. List of abbreviations TB tuberculosis PTB pulmonary tuberculosis CT computed tomography WHO World Health Organization NPOP nasopharyngeal and oropharyngeal CTPA computed tomography pulmonary angiogram HRCT high resolution computed tomography GGO ground glass opacities ATT anti-tuberculous therapy IGRA interferon-gamma release assay * Corresponding author. Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia. E-mail addresses: [email protected] (L.E. Nyanti), [email protected] (Z.H. Wong), [email protected] (B. Sachdev Manjit Singh), [email protected] (A.K.W. Chang), [email protected] (A.T. Jobli), [email protected] (H.H. Chua). Contents lists available at ScienceDirect Respiratory Medicine Case Reports journal homepage: www.elsevier.com/locate/rmcr https://doi.org/10.1016/j.rmcr.2022.101653 Received 5 February 2022; Received in revised form 12 March 2022; Accepted 13 April 202

Pulmonary tuberculosis and COVID-19 coinfection: Hickam’s Dictum revisited

COVID-19 and pulmonary tuberculosis (PTB) coinfection is associated with increased mortality and presents a unique diagnostic challenge to the clinician. We describe three cases of newly diagnosed PTB in COVID-19 patients treated at our centre and their clinical and radiological features. The challenges associated with diagnosis and management are also explored. Patient 1 was a case of smear positive, endobronchial tuberculosis incidentally diagnosed due to CT changes, and eventually made good recovery. Patient 2 was a case of COVID-19 who succumbed but was diagnosed posthumously due to a positive sputum culture for tuberculosis. Patient 3 showed radiographic features of PTB and was treated empirically for TB. In conclusion, COVID-19 and PTB coinfection should be suspected in the presence of constitutional symptoms, prior immunocompromised states, prolonged respiratory symptoms or fever, or unresolved radiological abnormalities, more so in regions where TB is endemic

Pulmonary tuberculosis and COVID-19 coinfection : Hickam's Dictum revisited

COVID-19 and pulmonary tuberculosis (PTB) coinfection is associated with increased mortality and presents a unique diagnostic challenge to the clinician. We describe three cases of newly diagnosed PTB in COVID-19 patients treated at our centre and their clinical and radiological features. The challenges associated with diagnosis and management are also explored. Patient 1 was a case of smear positive, endobronchial tuberculosis incidentally diagnosed due to CT changes, and eventually made good recovery. Patient 2 was a case of COVID-19 who succumbed but was diagnosed posthumously due to a positive sputum culture for tuberculosis. Patient 3 showed radiographic features of PTB and was treated empirically for TB. In conclusion, COVID-19 and PTB coinfection should be suspected in the presence of constitutional symptoms, prior immunocompromised states, prolonged respiratory symptoms or fever, or unresolved radiological abnormalities, more so in regions where TB is endemic

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

Chilaiditi’s sign, a cause of pseudo-pneumoperitoneum: A case report

The differentiation between a pseudo-pneumoperitoneum and true pneumoperitoneum on an initial chest radiograph is challenging but essential to clinical practice. The former is managed conservatively whereas the latter may require surgical intervention. Chilaiditi’s sign describes a rare incidental radiological finding of gas filled bowel interpositioned between the right hemi-diaphragm and the liver, which is visible on a plain abdominal or chest radiograph. It is often misdiagnosed as a pneumoperitoneum. Correct diagnosis of Chilaiditi’s sign in an asymptomatic patient can prevent unnecessary procedures. We have reported one incidental chest radiograph with Chilaiditi’s sign in a patient presenting and treated for pneumonia. The report aims to illustrate the diagnostic dilemma experienced by clinicians in distinguishing a true versus pseudo-pneumoperitoneum on a chest radiograph