Melioidosis in systemic lupus erythematosus: the importance of early diagnosis and treatment in patients from endemic areas

Serious infection is a common problem in immunosuppressed patients with systemic lupus erythematosus (SLE). Melioidosis is caused by the Gram-negative bacterium Burkholderia pseudomallei and may present as an acute fulminant pneumonia or septicaemia that is often fatal. The organism is endemic in much of South-east Asia but is being increasingly reported from other parts of the world, including India, Northern Australia and North and South America. In addition to occurring in people who come into contact with contaminated soil or water in endemic areas, the infection is more common in immunosuppressed patients and must be recognised early and treated with appropriate antibiotics. Importantly, it can activate many years after the initial exposure, causing diagnostic confusion. We present the cases of three patients with SLE who were admitted with fever and in whom Burkholderia pseudomallei was isolated from blood cultures. Following treatment with intravenous ceftazidime all patients made a good recovery. These cases demonstrate the importance of considering this infectious organism in patients from endemic areas with unexplained fever. They also illustrate how successful outcomes can be achieved in a frequently fatal disease if an early diagnosis is made and appropriate antibiotics are started promptly.

The Bone and Joint Decade 2000-2010: for prevention and treatment of musculoskeletal disease

The Bone and Joint Decade 2000-2010 has been established to increase awareness of the scale and impact of musculoskeletal disorders on the individual, health care systems and the society. It is a multi-disciplinary initiative involving professional bodies, patient care groups, research organisations and the community.

A comparative study of the clinical manifestations of systemic lupus erythematosus in Caucasians in Rochester, Minnesota, and Chinese in Singapore, from 1980 to 1992

OBJECTIVE

To examine the relationship between ethnicity and major organ involvement at and after diagnosis in community-based cohorts of Caucasian and Chinese systemic lupus erythematosus (SLE) patients resident in Rochester, Minnesota, and Singapore, respectively.

METHODS

Clinical manifestations at and after diagnosis were compared in Caucasian and Chinese SLE patients. The association between ethnicity and disease manifestations at and after diagnosis was determined using logistic regression and Cox proportional hazards models, respectively, adjusting for the influence of demographic, socioeconomic, disease-related, and therapy-related factors.

RESULTS

At diagnosis, Caucasian SLE patients were 3 times more likely than Chinese SLE patients to have serositis (odds ratio [OR] 3.11, 95% confidence interval [CI] 1.01-9.71), nearly 7 times more likely to have a hematologic disorder (OR 6.95, 95% CI 2.20-21.97), and far less likely to have a malar rash (OR 0.19, 95% CI 0.07-0.54) or positive antinuclear antibodies (OR 0.11, 95% CI 0.03-0.52). Ethnicity was not associated with the prevalence of proteinuria or central nervous system (CSN) and other major organ involvement at diagnosis. After diagnosis, there was a trend toward less development of proteinuria and other major organ involvement in Caucasians (relative risk [RR] 0.47, 95% CI 0.19-1.15, and RR 0.22, 95% CI 0.05-1.04, respectively).

CONCLUSION

Chinese SLE patients are far less likely to have serositis or a hematologic disorder at diagnosis and may be more likely to develop proteinuria or CNS or other major organ involvement over the course of the disease, compared with Caucasian SLE patients. This may contribute to the increased mortality seen in Chinese SLE patients.

Quality of life of patients with perennial allergic rhinitis: preliminary validation of the Rhinoconjunctivitis Quality of Life Questionnaire in Singapore

Though sufferers of perennial allergic rhinitis do not die from their ailment, they endure years of chronic nose disease that Interferes with many important aspects of their lives. A rhinitis-specific instrument to gauge the quality of life of patients with this disease was published in 1991. Here, we validated the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) for use in English-speaking patients with perennial allergic rhinitis. We established that the RQLQ distinguishes between patients and control, demonstrates internal consistency and is sensitive to change. This study suggests that the RQLQ can be used to assess the quality of life of patients with perennial allergic rhinitis in Singapore.

Healthy adults demonstrate less skin reactivity to commercial extracts of commonly ingested food than to D. farinae

The aim of this study is to determine the skin reactivity of healthy Oriental adults to commercial extracts of commonly ingested food and the house dust mite D. farinae, a common local aeroallergen. D. farinae and 18 food extracts were skin prick tested on adults without any personal history of atopic diseases and food allergy. The extracts of food not consumed by any subject on religious or personal grounds were not tested for that individual. A total of 103 healthy adults who fulfilled the selection criteria were skin prick tested. There were 35 males and 68 females. Their mean age was 29 years (SD +/- 7.5) with a range of 19 to 49 years. Sixty-eight percent were Chinese, 12.6% Malay, 12.6% Indian and 6.8% other Oriental races. Fifty-four (52.4%) were positive for D. farinae while only 12 (11.7%) were positive for at least one food extract The food extract that gave the most number of positive reactions was shellfish mix (5/102, 4.9%). A family history of atopy did not have any significant correlation with the results of skin test. It was concluded that healthy adults demonstrate less skin reactivity to extracts of commonly ingested food than to D. farinae.

Pemphigus foliaceus and oral lichen planus in a patient with systemic lupus erythematosus and thymoma

A 49-year-old woman with systemic lupus erythematosus, and a history of thymoma and chronic white plaques of the oral mucosa, developed a blistering eruption which was diagnosed as pemphigus foliaceus based on clinical, histological and direct immunofluorescence findings. However, the white plaques had both the clinical and histological features of lichen planus, as well as intercellular antibodies suggestive of pemphigus. Such conditions in combination have been documented previously, but this is believed to be the first report of the coexistence of all four in one individual. The common mechanism underlying these four conditions may well be an immunological disturbance.

The effects of ethnicity on disease patterns in 472 Orientals with systemic lupus erythematosus

OBJECTIVE

To determine the effects of ethnicity on disease manifestations in Oriental patients with systemic lupus erythematosus (SLE) and to describe the risk of developing renal or central nervous system (CNS) involvement with time.

METHODS

A retrospective study of 472 patients with SLE seen at the only Rheumatology Unit in Singapore. The effect of ethnicity on selected disease manifestations at diagnosis was assessed after adjusting for demographic variables using multiple logistic regression. The probability of developing selected disease manifestations with time was determined using the Kaplan-Meier product limit method.

RESULTS

At diagnosis, Malays had a higher risk of renal or CNS involvement than Chinese (OR 2.26, 95% CI 1.21 to 4.21, and OR 3.07, 95% CI 1.01 to 9.34, respectively), and Indians a lower risk of malar rash and a higher risk of oral ulcers than Chinese (OR 0.30, 95% CI 0.13 to 0.68, and OR 2.90, 95% CI 1.45 to 7.34, respectively). The prevalence of renal or CNS involvement in the entire cohort increased with time, reaching 75.6% (95% CI 66.1% to 85.0%) and 16.7% (95% CI 11.7% to 21.6%), respectively, after 18 years of disease.

CONCLUSION

Ethnicity influenced disease manifestations at diagnosis in this cohort of Oriental patients with SLE. Renal or CNS involvement developed in previously unaffected patients up to 18 years after diagnosis, highlighting the need for continued vigilance in patients with lupus.

Adult-onset Still's disease in an oriental population: manifestations, course and outcome in 16 patients

This retrospective descriptive study aims to characterise and compare the clinical manifestations, course and outcome of 16 Oriental patients with adult-onset Still's disease diagnosed in the last 4 years with published data based on Western populations and another Oriental (Japanese) series. Like the Japanese, we found a female preponderance, an older age at onset, and fewer patients with abdominal pain, myalgia, sore throat and serositis compared to the Western series. A longer delay in diagnosis occurred in patients lacking either arthritis or rash at presentation. Most patients had mild hyponatraemia and 2 patients had overt syndrome of inappropriate anti-diuretic hormone secretion. All patients showed a dissociation of elevated aldolase with normal to low creatine kinase levels. Over 50% relapsed within a year from diagnosis and needed slow-acting anti-rheumatic drugs as steroid-sparing agents. Two were given intravenous pulse cyclophosphamide therapy for progressive pneumonitis. Outcome was generally good with minimal functional impairment and no mortality.

Clinical predictors of nephritis in systemic lupus erythematosus

We identified clinical predictors of lupus nephritis presenting more than 6 months after the diagnosis of lupus in a cohort of 335 lupus patients. Almost 24% (80/335) of patients developed nephritis more than 6 months after the diagnosis of lupus. Using a Cox proportional hazards model, we found hypertension, thrombocytopaenia and leukopaenia to be associated with lupus nephritis presenting more than 6 months after diagnosis, with adjusted relative risks of 2.5 (95% CI 1.3 to 4.7), 4.3 (95% CI 1.7 to 10.8) and 3.2 (95% CI 1.7 to 6.2) respectively. In this cohort, hypertension, thrombocytopaenia and leukopaenia were associated with lupus nephritis presenting more than 6 months after the diagnosis of lupus.

Systemic lupus erythematosus: initial manifestations and clinical features after 10 years of disease

We studied the initial manifestations and late features in our lupus patients. The clinical data of patients fulfilling the American College of Rheumatology criteria for systemic lupus erythematosus (SLE) were entered prospectively for newly diagnosed patients and cumulatively for those with at least 10 years of disease duration. Ninety-seven Group A (newly diagnosed; 86 females and 11 males; mean age 31 years; 83 Chinese, 11 Malays, and 3 Indians) and 58 Group B (more than 10 years disease duration; 56 females and 2 males; mean age 41 years; 50 Chinese, 5 Malays, and 3 Indians) lupus patients were studied. The commonest clinical features in Group A were: haematological (73%), arthritis (57%), malar rash (43%), renal disorder (31%) and photosensitivity (30%). Group B patients had haematological (78%), malar rash (73%), arthritis (69%), renal disorder (59%) and photosensitivity (33%). Renal disorder was significantly increased over the years (P < 0.001). Hypertension was present in 18% (Group A) and 59% (Group B) (P < 0.00001), diabetes mellitus in 5% (Group A) and 10% (Group B) (P = ns), atherosclerosis in 2% (Group A) and 7% (Group B) (P = ns). Cataract formation was not present in Group A patients but was present in 10% of Group B patients. Renal disorders and morbidity factors like hypertension and cataracts increased significantly over the years. Optimum treatment of lupus patients should therefore include close attention to these factors.

Abdominal computed tomography in systemic lupus erythematosus

Sixty-five abdominal computed tomography (CT) scans of 54 systemic lupus erythrematosus (SLE) patients were retrospectively evaluated together with their clinical records. This was to assess the spectrum of CT findings and to determine the value of abdominal CT in this group of patients. Over a 3.5-year period, abdominal CT scans had been requested for suspected renal vein or inferior vena cava thrombosis (n = 52, 80%), sepsis, mesenteric ischaemia, Conn's syndrome, evaluation of hepatosplenomegaly, portal hypertension and hydronephrosis. The most frequent indication for CT was suspected renal vein thrombosis (RVT). An SLE patient with previously stable renal function who rapidly develops nephrotic syndrome with deteriorating renal function has an increased risk of thromboembolic phenomenon. Also, renal vein thrombosis is difficult to diagnose clinically and prompt anticoagulation can help preserve remaining renal function. Of these with suspected RVT, two had RVT only and five had thrombosis in both renal veins and inferior vena cava. Two patients had CT features strongly suggestive of mesenteric ischaemia, one had bilateral hydronephrosis thought to be secondary to lupus cystitis and CT confirmed two abdominal abscesses. Other incidental CT findings were: subscapular renal haematoma, overall enlargement or diminution of renal size, serositis, bowel wall thickening, splenic, hepatic and pancreatic enlargement and mild para-aortic lymphadenopathy. Abdominal CT revealed many diverse findings and aided the management of these SLE patients.

Coincident cold urticaria in a married couple: case report and a literature review

We describe an interesting coincidence in which a woman developed acquired idiopathic cold urticaria and her husband systemic cold urticaria eight months later. The occurrence of cold urticaria in a tropical country like Singapore is rare. Each case illustrates the typical features of that particular type of cold urticaria, including the appropriate response to the challenge test and its self-limited nature.

A retrospective study of 13 Oriental children with juvenile dermatomyositis

This is a retrospective study of 13 Oriental children with juvenile dermatomyositis (JDM). We reviewed data found in the hospital records of children diagnosed to have definite (n = 4), probable (n = 7) and possible (n = 2) JDM who presented over a 10-year period at 4 centres in Singapore and compared our results with the experience of others. We found an overall female preponderance (female to male ratio of 3.3:1) but an equal sex ratio in children below 5 years of age. The majority (92%) had insidious onset and good outcome. Diagnosis was often delayed because of the insidious onset, and because weakness occurred late, was mild or absent. Only one child had an acute presentation and refractory course. She died despite aggressive therapy. Clinical features, complications and mainstay medication used were similar to Western studies.

SLE mortality in an oriental population

We analysed the causes of 67 deaths, over a 4 y period, in our oriental population with systemic lupus erythematosus (SLE). The median disease duration was 48 +/- 60.5 months (range 1-250 months). The mean age at diagnosis and death were 30 and 35.1 y respectively. SLE alone accounted for death in 30 patients (44.8%), infection in 27 (40.3%), pulmonary embolism in 5 (7.5%), malignancy in 4 (5.9%) and rheumatic heart disease in 1 (1.5%). The major organ involvement in those with active disease at death were SLE related thrombocytopenia (n = 23/44, 52.3%), nephritis (n = 21/44), 47.7%), cerebral lupus (n = 16/44, 36.4%), and pulmonary haemorrhage (n = 12/44, 27.3%). As in other series, SLE and infection were the principal causes of death in our population. During this 4 y period, there was no late death due to atherosclerosis.

Allergic reactions to phenytoin in a general hospital in Singapore

Phenytoin is used for the treatment and prevention of fits. We investigated all patients reported to have phenytoin allergy in our hospital and found 42 confirmed cases. Sixty-nine percent were female and 83.3% were Chinese. The mean age of the patients was 46.5 years. The reactions reported were maculopapular rash (71.4%), Stevens-Johnson syndrome (14.3%), fever (4.8%), generalized exfoliative dermatitis (2.4%), toxic epidermal necrolysis (2.4%), vasculitis (2.4%) and agranulocytosis (2.4%). In conclusion, the majority of reported allergic reactions to phenytoin were cutaneous (92.9%) and one fifth of these were potentially life-threatening.

Allergen skin test and total IgE in adults with rhinitis in Singapore

The aim of this study was to determine the allergen skin test positivity and total serum IgE of adult patients in Singapore with clinical features suggestive of allergic rhinitis. The study was carried out prospectively from January to August 1990. All patients had one or more of three symptoms (1) rhinorrhoea or nasal congestion, (2) itching nose or throat and (3) sneezing, as well as pale edematous nasal mucosa. Twenty inhalant allergens (Greers Laboratory, USA) were used for skin prick test (SPT). Serum total IgE was measured using 3M FAST test. Eighty-five consecutive patients, 54 males and 31 females, were studied. Their mean age (SD) was 26.8 (6.1) years. More than half (55.3%) had severe symptoms affecting work. Twenty percent did not have any positive skin reaction compared with 44.9% of age-matched healthy controls; 62.4% had 2 or more positive reactions compared to only 37.2% of controls. These differences were statistically significant (p < 0.002). The two most commonly, positive allergens were Dermatophagoides farinae (76.5%) and house dust (61.2%). No significant difference was found in the skin test positivity between males and females. Forty-three patients also had serum total IgE measurement and their geometric mean IgE was 240 IU/I which was significantly higher than the geometric mean IgE of healthy controls (88 IU/I, P = 0.0005).

A case of adult onset Still's disease presenting with fever and a rash

Adult onset Still's disease is a rare condition presenting with high spiking fever, transient maculopapular rash, myalgias, polyarthralgias or arthritis, lymphadenopathy, hepatosplenomegaly and a sore throat, associated with leucocytosis and neutrophilia. Early diagnosis is difficult because clinical features are non-specific. We report a 33-year-old Chinese female with this condition who presented with recurrent high spiking fever and rash over a 4-month period. We highlight the sequence of events leading to this diagnosis with emphasis on the cutaneous changes.

Primary systemic allergy to human insulin: recurrence of generalized urticaria after successful desensitization

Primary systemic allergy to human insulin is rare. We report a case of recurrent immediate local reactions followed eventually by generalized urticaria to recombinant human insulin (Humulin) in an insulin-dependent diabetic. Skin test to Humulin R was positive, and the patient was successfully desensitized using a modified rapid desensitization protocol. Two weeks later, he had another episode of generalized urticaria after Humulin R injection. His treatment was resumed at a lower dose, and within a week he was able to tolerate his usual regimen of insulin. To our knowledge, this is the first report of a recurrence of systemic reaction after successful desensitization.

Left ventricular myxoma, adrenal tumour and cutaneous vasculitis--a case report

Cardiac myxoma has myriad presentations including cutaneous vasculitis. It has also been associated with endocrine neoplasm in Carney's Complex. We report a Chinese patient with cutaneous vasculitis and Raynaud's phenomenon suggesting a collagen vascular disease. In the course of investigation, echocardiogram showed a possible left ventricular myxoma and computed tomography of the abdomen demonstrated a left adrenal tumour. Cardiac myxoma should be considered in the differential diagnosis of vasculitis.

Adult onset polymyositis/dermatomyositis: clinical and laboratory features and treatment response in 75 patients

OBJECTIVES

To determine possible similarities and differences in clinical and laboratory features and treatment response between patients in Singapore with polymyositis (PM) and dermatomyositis (DM) and reported series.

METHODS

Case records of adult patients (16 years old and above) referred to the 3 main electromyographic (EMG) laboratories in Singapore between 1 June 1986 and 31 May 1991 were reviewed if the referring diagnosis was myositis or myopathy for investigation. A computer search for adult patients with a diagnosis of PM/DM (ICD codes 710.3, 710.4, 517.8) who attended the main rheumatology and neurology centre during this period was also carried out. The criteria for PM/DM proposed by Bohan and Peter was adopted.

RESULTS

The incidence of PM/DM was 7.7 cases per million population per year. There were 35 PM and 40 DM cases with a median age at diagnosis of 50.7 years (SD: 16.7) and significantly more females in the PM group (p < 0.05). At presentation, 86.7% had proximal myopathy, 34.7% had arthralgia/arthritis and 18.7% had cutaneous vasculitis. The creatine kinase level was elevated in 89.3% of patients and positive EMG and muscle biopsy in 79.4% and 76.4% respectively. Systemic lupus erythematosus was the commonest associated connective tissue disease. The percentage of patients with malignancy was higher in DM compared with PM (p < 0.01) and they were significantly older (mean age 61.8 years) (p < 0.001). Patients who achieved remission were significantly younger (mean age 46.4 years, p < 0.05). The overall mortality rate was 26.7% with infection and malignancy as the main causes of death.

CONCLUSION

The results of the study suggest ethnicity does not influence the expression of PM/DM in view of the considerable similarities in frequency and clinical expression of disease in the population studied compared with series from other countries.