Associations of B cell-activating factor (BAFF) and anti-BAFF autoantibodies with disease activity in multi-ethnic Asian systemic lupus erythematosus patients in Singapore

To measure the levels of B cell-activating factor (BAFF) and endogenous anti-BAFF autoantibodies in a cohort of multi-ethnic Asian systemic lupus erythematosus (SLE) patients in Singapore, to determine their correlation with disease activity. Serum samples from 121 SLE patients and 24 age- and sex-matched healthy controls were assayed for BAFF and anti-BAFF immunoglobulin (Ig)G antibody levels by enzyme-linked immunosorbent assay (ELISA). The lowest reliable detection limit for anti-BAFF-IgG antibody levels was defined as 2 standard deviations (s.d.) from blank. Correlation of serum BAFF and anti-BAFF IgG levels with disease activity [scored by SLE Activity Measure revised (SLAM-R)], and disease manifestations were determined in these 121 patients. SLE patients had elevated BAFF levels compared to controls; mean 820 ± 40 pg/ml and 152 pg ± 45/ml, respectively [mean ± standard error of the mean (s.e.m.), P < 0·01], which were correlated positively with anti-dsDNA antibody levels (r = 0·253, P < 0·03), and SLAM-R scores (r = 0·627, P < 0·01). In addition, SLE patients had significantly higher levels of anti-BAFF IgG, which were correlated negatively with disease activity (r = -0·436, P < 0·01), levels of anti-dsDNA antibody (r = -0·347, P < 0·02) and BAFF (r = -0·459, P < 0·01). The majority of patients in this multi-ethnic Asian SLE cohort had elevated levels of BAFF and anti-BAFF antibodies. Anti-BAFF autoantibody levels correlated negatively with clinical disease activity, anti-dsDNA and BAFF levels, suggesting that they may be disease-modifying. Our results provide further information about the complexity of BAFF pathophysiology in different SLE disease populations and phenotypes, and suggest that studies of the influence of anti-cytokine antibodies in different SLE populations will be required when selecting patients for trials using targeted anti-cytokine therapies.

Acute lupus myocarditis: clinical features and outcome of an oriental case series

Symptomatic myocarditis in systemic lupus erythematosus (SLE) is uncommon. We describe the clinical characteristics, management and outcomes of 11 SLE patients without any atherosclerotic risk factors, who presented with acute lupus myocarditis (ALM). All patients were female, 46% Chinese with mean age of 27 < 10 years at diagnosis of SLE. ALM was one of the initial manifestations of SLE in eight (73%) patients. The median duration from onset ALM to initiation of treatment was two weeks (range: 0.3-8). All had clinical feature of left ventricle dysfunction. The most common electrocardiographic feature was nonspecific ST/T wave changes (91%). Common echocardiographic findings included segmental wall motion abnormalities (81%) and decreased left ventricular ejection fraction (81%). Median SLE disease activity index at presentation was 16 (range: 4-30). All patients received high dose corticosteroids and 64% received intravenous pulse cyclophosphamide. There were two deaths (18%) from infections. The remaining nine survivors had no recurrence of ALM nor suffer any SLE-related damage (median SLICC damage score of 0), up to a median follow-up of four years (range: 2.5-10.1). Repeat echocardiography after six months or later showed normal LVEF in eight patients (89%). Early immunosuppressive therapy in ALM, with high dose corticosteroids and pulse intravenous cyclophosphamide, results in good cardiac outcome.

Major gastrointestinal manifestations in lupus patients in Asia: lupus enteritis, intestinal pseudo-obstruction, and protein-losing gastroenteropathy

Gastrointestinal (GI) symptoms are common in patients with systemic lupus erythematosus (SLE) and may be due to the disease itself, side-effects of medications, or non-SLE causes. However, GI manifestations of lupus attract far less attention than the other major organ involvements, are infrequently reviewed and rarely documented in published lupus databases or cohort studies including those from countries in Asia. According to three reports from two countries in Asia, the cumulative prevalence of SLE GI manifestations range from 3.8% to 18%. In this review, we focus on three major GI manifestations in patients from Asian countries: lupus enteritis, intestinal pseudo-obstruction, and protein-losing gastroenteropathy, for which early recognition improves outcome and reduces morbidity and mortality.

Diagnostic tests for food allergy

The diagnosis of food allergy is still based primarily on a detailed medical history and comprehensive physical examination. Clinical or laboratory tests only serve as an add-on tool to confirm the diagnosis. The standard techniques include skin prick testing and in-vitro testing for specific IgE-antibodies, and oral food challenges. Properly done, oral food challenges continue to be the gold standard in the diagnostic workup. Recently, unconventional diagnostic methods are increasingly used. These include food specific IgG, antigen leucocyte antibody and sublingual/intradermal provocation tests, as well as cytotoxic food and applied kinesiology and electrodermal testings. These lack scientific rationale, standardisation and reproducibility. There have been no well-designed studies to support these tests, and in fact, several authors have disproved their utility. These tests, therefore, should not be advocated in the evaluation of patients with suspected food allergy because the results do not correlate with clinical allergy and may lead to misleading advice and treatment.

Discordant assessment of lupus activity between patients and their physicians: the Singapore experience

Patients with systemic lupus erythematosus often assess their disease activity differently from their physicians. We studied the factors associated with this discordance. The data provided by 534 systemic lupus erythematosus patients were analyzed. We compared the physician and patient assessments of lupus activity on a visual-assessment scale from the same visit. We collected clinical data and scores from MOS 36-Item Short-Form Health Survey, Systemic Lupus Erythematosus Quality-of-Life Questionnaire, Rheumatology Attitudes Index, Systemic Lupus Erythematosus Disease Activity Index, and revised Systemic Lupus Activity Measure. Patients tended to score their disease activity higher than do their physicians, when these factors were present: poorer general health assessment, presence of thrombocytopenia, hypertension and urinary sediments, and difficulty in carrying groceries. Physicians tended to score the disease activity higher than do the patients in these circumstances proteinuria, hemolysis, use of azathioprine or cyclophosphamide, tiredness, photosensitivity, higher revised Systemic Lupus Activity Measure score, casturia, and patient report of being more easily ill than are other patients. There was only moderate correlation between the discordance in the baseline and the subsequent visits. The physician assessment of disease activity at baseline correlated better with an objective measure of disease activity (revised Systemic Lupus Activity Measure) in the subsequent visit than the patient assessment. In conclusion, discordance in the perception of disease activity between patients and physicians may be amenable to intervention.

Clinical manifestations and outcomes of antithrombotic treatment of the Tan Tock Seng Hospital Singapore antiphospholipid syndrome cohort

To examine the clinical manifestations, intensity of oral anticoagulation and outcomes in the prevention of recurrent thromboses in patients with antiphospholipid syndrome (APS) in a tertiary rheumatology centre in Singapore. Retrospective case review of consecutive patients with APS attending a rheumatology clinic from 1st January 2004 to 31st December 2005. There were 59 (44%) patients with definite APS and 75 (56%) with probable APS. Systemic lupus erythematosus (SLE) was the most common cause of secondary APS. Hypertension and hyperlipidaemia were the most common cardiovascular comorbidities. The most common manifestations were haematological (thrombocytopaenia and haemolytic anaemia), neurological (seizure, headache) and pulmonary hypertension. Among those with definite APS, there were similar proportions with arterial and venous thromboses. Recurrent thromboses occurred in 14 (23.7%) patient with definite APS receiving warfarin, comprising 14 (73.7%) episodes of arterial and 5 (26.3%) episodes of venous thromboses. Recurrent arterial thromboses occurred at international normalized ratio (INR) of <2 in 5 (35.7%), INR 2–3 in 6 (42.9%), INR > 3 in 3 (21.4%) episodes, respectively. Recurrent venous thromboses occurred at INR < 2 in 4 (80.0%) and INR > 3 in 1 (20.0%) episode, respectively. Twenty-eight episodes of bleeding occurred in 21 (35.6%) patients, the majority (78.6%) being minor bleeding. Two-thirds of all major bleeds occurred at INR ≥ 3. Venous and arterial thromboses were equally common in our patients with definite APS, although recurrent thromboses were more common in the arterial circulation. Target INR > 3 was associated with lower rates of recurrent arterial thromboses but higher rates of major and recurrent bleeding. Target INR ≥ 2 appeared to be sufficient to prevent recurrent venous thromboses.

Enhanced expression of interferon-inducible protein-10 correlates with disease activity and clinical manifestations in systemic lupus erythematosus

Our objective was to investigate the serum levels of interferon-inducible protein-10 (IP-10) in systemic lupus erythematosus (SLE) and their correlation with disease activity and organ manifestations. Serum IP-10 levels were assessed in 464 SLE patients and 50 healthy donors. Disease activity was assessed by the revised SLE Activity Measure, and the concomitant active organ manifestations, anti-ds DNA antibody titres, complement levels and erythrocyte sedimentation rates recorded. Peripheral blood mononuclear cell (PBMC) synthesis of IP-10 in SLE patients and controls was determined by in vitro cultures stimulated with mitogen or lipopolysaccharide. Elevated serum IP-10 levels were observed in SLE patients, which were significantly higher in the presence of active haematological and mucocutaneous manifestations. SLE PBMCs exhibited enhanced spontaneous IP-10 production in vitro. Serial IP-10 levels correlated with longitudinal change in SLE activity, even at low levels where anti-dsDNA antibody and complement levels remain unchanged. These data demonstrate that IP-10 levels are increased in SLE and serum IP-10 may represent a more sensitive marker for monitoring disease activity than standard serological tests.

Immediate food hypersensitivity among adults attending a clinical immunology/allergy centre in Singapore

INTRODUCTION

The patient characteristics, clinical features and causative foods in 74 consecutive adult patients with immediate food hypersensitivity were studied.

METHODS

A retrospective review of 74 consecutive adults who presented during the study period from July 1, 1994 to April 30, 2002 was performed.

RESULTS

There were 35 male and 39 female patients, with a mean age of 36.3 +/- 10.9 (range, 19-66) years. The most common causative foods were seafood crustaceans, molluscs and bird's nest. Prawn and crab were the most commonly implicated crustacean, and limpet the commonest culprit mollusc. The main symptoms were periorbital angioedema (64.9 percent), dyspnoea/wheezing (44.6 percent) and urticaria (44.6 percent). 66 percent of the patients developed anaphylaxis. 34 (45.9 percent) had concomitant allergic rhinoconjunctivitis, asthma, eczema or combinations of these atopic diseases. Only six (8.1 percent) patients had a family history of food allergy. Skin prick tests (SPT) to commercially-prepared food allergens were positive in 22 of 36 patients (61.1 percent) tested. SPT to the fresh, cooked or canned food products were positive in 11 of 20 (55 percent) cases where the food allergen was not commercially available. Open food challenges were required for diagnosis in two patients who had negative SPT.

CONCLUSION

The most common food allergens in our patients were seafood crustaceans, molluscs and bird's nest. More than half of the patients had concomitant allergic rhinitis, asthma and/or eczema. The pattern of food allergy in Singapore differs from Caucasian populations, likely to be because of different regional dietary patterns and methods of food preparation.

Anaphylaxis in adults referred to a clinical immunology/allergy centre in Singapore

INTRODUCTION

To study the clinical features and causes of anaphylaxis in consecutive adult patients referred to a clinical immunology/allergy centre in Singapore.

METHODS

A retrospective review of 67 consecutive adults with anaphylaxis who presented from July 1, 1998 to February 28, 2002 was performed. Anaphylaxis was defined as a severe life-threatening systemic IgE-mediated hypersensitivity reaction. Non-steroidal anti-inflammatory drug-induced idiosyncratic reactions and other non-IgE mediated reactions were excluded. Hypotension and bronchospasm were not required to make a diagnosis. The aetiology was determined from clinical history followed by measurement of allergen-specific IgE levels, skin prick test with commercially-available allergen extracts or prick-prick test with the fresh/cooked/canned food products.

RESULTS

The mean age of patients was 32.9 +/- 10.9 (range 19-57) years. There were 44 (65.7 percent) males and 23 (34.3 percent) females. The main causes were food (44.8 percent), insect stings (32.8 percent) and idiopathic (22.4 percent). There were no cases due to drugs or natural rubber latex. Seafood (crustaceans and molluscs) comprised 66.7 percent of food-induced anaphylaxis. Honeybee and wasp stings together comprised 45 percent of insect venom anaphylaxis. The most common manifestations were dyspnoea (59.7 percent), urticaria (58.2 percent), angioedema (44.8 percent), and syncope (43.3 percent). Hypotension was documented in only 28.4 percent of cases.

CONCLUSION

Food (crustaceans and molluscs) was the most common cause followed by insect stings or bites. The inability to identify the causative insect in 50 percent of cases with insect venom anaphylaxis limited the role of specific immunotherapy. Compared to other reported series, there were no cases of drug or latex anaphylaxis.

Insect venom hypersensitivity: experience in a clinical immunology/allergy service in Singapore

INTRODUCTION

To study the profile of patients with allergy to the venom of insect stings.

METHODS

31 consecutive cases referred to our clinical immunology/allergy outpatient service from June 1, 1998 to June 30, 2002 were reviewed.

RESULTS

These patients comprised 3.5 percent of 889 cases referred during the study period. Their mean age was 28.8 +/- 10.5 (range 19-57) years and the majority were males (90.3 percent). Of these, 20 (64.5 percent) were Chinese, four (12.9 percent) were Malays and seven (22.6 percent) were of other races. 19 patients (61.3 percent) were men from the uniformed services including 12 (63.2 percent) full-time National Servicemen. 71 percent (22 patients) were stung for the first time. Urticaria (22 cases, 71.0 percent), dyspnoea (13, 41.9 percent), angioedema (12, 38.7 percent) and syncope (ten, 32.3 percent) were the most common manifestations of insect allergy. Anaphylaxis occurred in 22 (71.0 percent) cases, constituting 30.1 percent of all cases of anaphylaxis referred to our service during the study period. Although the causative insect was identified as honeybee (12, 38.7 percent), ant (four, 12.9 percent), wasp (three, 9.7 percent), and fire ant (two, 6.5 percent) by the majority of patients, ten (32.2 percent) patients were unable to identify the causative insect. The two patients stung by fire ants were Americans working in Singapore who had been stung while in the United States. Among those with anaphylaxis, honeybee, wasp and fire ant venom, for which specific immunotherapy is available, were identified as the cause in 40.9 percent, 4.5 percent, and 4.5 percent, respectively.

CONCLUSION

Insect venom hypersensitivity made up 3.5 percent of allergy/immunology referrals and 32.8 percent of cases of anaphylaxis referred to our institution. The majority were military servicemen who developed allergic reactions during the course of duty. The inability to identify the causative insect in 50 percent with sting anaphylaxis limits the role of specific immunotherapy in our patients.

Development and preliminary validation of a systemic lupus erythematosus-specific quality-of-life instrument (SLEQOL)

OBJECTIVES

Systemic lupus erythematosus (SLE), a chronic illness with an unpredictable and variable course, profoundly affects the quality of life (QOL). General health questionnaires are used to assess QOL in SLE, but a disease-specific instrument could offer enhanced responsiveness and content validity. We detail the steps we took to develop and validate a new SLE-specific QOL instrument, SLEQOL.

METHODS

Rheumatology professionals nominated items that they felt were important determinants of QOL of SLE patients. One hundred SLE patients were asked to assess the importance and frequency of occurrence of these items and to suggest those that had not been listed. Item reduction was performed using Rasch model and factor analyses to create a new questionnaire in English. This final questionnaire was administered to a cohort of 275 patients to study its psychometric properties.

RESULTS

Fifty-one items covering a wide range of QOL concerns were identified. The patients' responses led to the elimination of 11. The new questionnaire of 40 items was found to have Cronbach's alpha of 0.95 and to consist of eight domains covering physical, mental and social QOL issues. It has good test-retest reliability, poor to fair cross-sectional correlation with the SF-36, with poor correlation with lupus activity or damage indices. The SLEQOL was more responsive to change than the SF-36.

CONCLUSIONS

We have developed a new 40-item SLEQOL in English and showed that it is valid for use in SLE patients in Singapore. It offers better content validity and responsiveness to change than the SF-36.

Why generic and disease-specific quality-of-life instruments should be used together for the evaluation of patients with persistent allergic rhinitis

BACKGROUND

The importance of assessing health-related quality of life (HRQL) of patients with allergic rhinitis (AR) has been well established, but the specific roles of rhinitis-specific or general health instruments have not been delineated.

OBJECTIVE

We analysed the psychometric properties of a disease-specific instrument, the Rhinoconjunctivitis Quality-of-Life Questionnaire (RQLQ) and the general health instrument, the Medical Outcome Short-Form 36 (SF-36) as they are employed in combination in patients with persistent AR in clinical practice.

METHOD

We analysed the data collected from a prospective study of 43 newly diagnosed patients with persistent AR and 44 controls. We interviewed the patients four times, at baseline, weeks 4, 8 and 10.

RESULTS

The RQLQ and SF-36 have good discriminative property, internal consistency, and test-retest reliability. The RQLQ is superior to the SF-36 as an evaluative instrument because more of its domains respond to change, the magnitude of change was greater, and the response was faster. The SF-36 is more susceptible to floor and ceiling effects. Both instruments are unsuitable for mildly symptomatic patients based on Rasch model analysis. Each questionnaire assesses a distinct and significant portion of the total HRQL of persistent AR.

CONCLUSION

The SF-36 and RQLQ are good for discriminating rhinitis patients from controls, but the former is poor for detecting changes in QOL. Both are inappropriate for mildly symptomatic patients. Each instrument measures non-overlapping halves of the measurable HRQL. For an assessment of the HRQL in persistent AR that is complete and responsive both instruments should be employed together.

Reversible acute gastrointestinal syndrome associated with active systemic lupus erythematosus in patients admitted to hospital

Patients with systemic lupus erythematosus (SLE) frequently have gastrointestinal (GI) symptoms. These are usually self-limiting and related to treatment side-effects or concurrent illness. However, abdominal pain may be due to bowel ischaemia which can lead to infarction and perforation. The likelihood of these serious events is increased in individuals with pain severe enough to require assessment in hospital or a SLEDAI score > 5. This paper describes a group of patients with active SLE and GI symptoms severe enough to require admission to hospital using a retrospective review of 52 SLE patients admitted to hospital with acute abdominal symptoms. The results showed that abdominal pain (87%), vomiting (82%) and diarrhoea (67%) had been present for a mean of 4.4 +/- 6.5 days and SLEDAI score was > or = 4 in 83% of patients. CT scanning showed evidence of serositis and bowel involvement in 63% of patients who underwent this investigation. Intravenous (iv) fluids were used in 87%, parenteral steroids in 90% and iv cyclophosphamide in 31%. Most (n = 51) were discharged well. Recurrence of GI symptoms occurred in 12 patients. The conclusions are that active SLE may manifest as an acute gastrointestinal syndrome. Early diagnosis, bowel rest, supportive medical therapy and treatment with corticosteroids and/or immunosupressives can result in a good outcome.

Behcet's disease: experience in a tertiary rheumatology centre in Singapore and a review of the literature

INTRODUCTION

The only reported study on Behcet's disease (BD) in Singapore found that only 15% of 34 BD patients managed at a tertiary dermatology centre had arthritis and 6% had eye complications with no other systemic manifestations. The aim of our study was to characterise the clinical manifestations and outcome of patients with BD at a tertiary rheumatology centre in Singapore.

MATERIALS AND METHODS

The International Study Group (ISG) and the O'Duffy (OD) criteria were used. The demographics, manifestations and outcome of our patients with BD were recorded.

RESULTS

Thirty-seven patients were included in our study. Twenty-three (62.2%) satisfied both ISG and OD criteria. Fourteen (37.8%) did not fulfil the ISG criteria but fulfilled the OD criteria and of these 6 were the incomplete form and 8 the complete form. The male to female ratio was 1:1.1. The mean age of onset of disease was 32.7 years (range, 15 to 58 years). The commonest presentations were recurrent oral ulcers (37, 100%), genital ulcers (24, 64.9%), joint (21, 56.8%) and cutaneous manifestations (18, 48.6%). The most common systemic manifestations were arthritis (16, 43.2%), gastrointestinal manifestations (15, 40.5%) and uveitis (13, 35.1%). There were 2 cases of Neuro Behcet's and 2 cases of venous thrombosis. Visual impairment from uveitis was the commonest cause of morbidity. There were no deaths in our series of BD.

CONCLUSION

BD is a relatively rare rheumatologic condition in Singapore. However, because its systemic complications are not rare, early diagnosis and prompt treatment are essential.

Primary immunodeficiency diseases in Singapore--the last 11 years

OBJECTIVES

To describe the clinical features, disease complications, treatment modalities and overall outcome of 39 local patients with Primary Immunodeficiency Diseases (PID) in Singapore over the last 11 years.

METHODS

Paediatric and adult patients who presented to the The Children's Medical Institute, National University Hospital, Tan Tock Seng Hospital and KK Women's and Children's Hospital between January 1990 and December 2000 were identified. Their diagnoses were categorised into six groups according to the IUIS (International Union of Immunological Societies, affiliated to World Health Organisation) classification: antibody deficiencies, combined immunodeficiencies, immunodeficiencies associated with other major defects, congenital phagocytic defects, complement deficiencies and other well-defined immunodeficiency syndromes. Patients were selected from screening of inpatients with discharge diagnoses associated with primary immunodeficiency and of patients undergoing tests for immunodeficiency. Patient data were collated from case files and compiled using a standard questionnaire.

RESULTS

There were 39 Singaporean patients diagnosed and treated for PID during the study period. The age at diagnosis ranged from three weeks to 69 years. Antibody deficiency (41%) was the most common form of PID. Seven patients had a family history of PID. Recurrent bacterial respiratory tract infections were the most common clinical manifestation. Associated conditions included autoimmune diseases, allergies and malignancies. Infection was the commonest cause of mortality. Eighteen patients (46.2%) with antibody or combined deficiencies received regular intravenous immunoglobulin (IVIG) as the primary treatment modality. Two children successfully received sibling-matched haematopoietic stem cell transplantation (HSCT).

CONCLUSIONS

Antibody deficiencies are the most common form of PID in Singapore. Treatment with antibiotics, IVIG and HSCT are the main therapeutic modalities currently available. Early referral to an immunologist is needed to achieve good outcomes.

Hospitalization of individuals with systemic lupus erythematosus: characteristics and predictors of outcome

We performed a retrospective study of patients with systemic lupus erythematosus (SLE) admitted to hospital during a one-year period to describe characteristics associated with a poor outcome. There were 348 episodes of hospitalization of 223 individuals. The cause of admission was clinical flare of SLE (58%), infection (37%) and thromboembolic disease (8%). Readmission occurred in 35.8% and was associated with: active nephritis (HR 2.53, P < 0.01), flare of lupus (HR 2.0, P < 0.01) and more ACR criteria (HR 1.34 per extra criteria, P < 0.01). Individuals with multiple reasons for admission had a longer duration of stay [one = four days (2, 6), two = five days (3, 7) and three = 9.5 days (6.5, 14.5), P < 0.01]. There were 11 deaths (3.2% of admissions). The deaths were due to infection in nine cases (four with concurrent active SLE). In multivariate modelling, the main predictors of death were: previous multiple admissions (OR 12.4, P < 0.01), the presence of infection (OR 7.3, P < 0.01) and younger age (OR 0.93 per increase of one year, P = 0.03). The presence of active lupus nephritis and multisystem disease makes readmission more likely and individuals with multiple problems at the time of admission have longer hospital stays. Young patients with frequent readmissions and coexistent infections are most likely to die.

Relapsing polychondritis--an Oriental case series

INTRODUCTION

Relapsing polychondritis (RPC) has been described mainly in Caucasian populations. Reports from other ethnic groups are few.

OBJECTIVES

To describe the clinical characteristics, management and outcome of RPC patients seen in an Oriental population in Singapore.

METHODS

The case records of RPC patients treated in our department from 1989 to 2001 were reviewed. Only 12 fulfilled the McAdam-Michet-Damiani-Levine diagnostic criteria and these were studied.

RESULTS

The female-to-male ratio in our series was 3:1. There were 10 ethnic Chinese and two Malay patients. The age of onset of symptoms ranges from three to 65 years, with a mean of 34 years. A diagnosis was made from two weeks to three years after onset, with a median of 4.5 months. There were 10 patients with pinna, nine articular, eight ocular, six laryngotracheal, five inner ear, four nasal and one cardiac involvement. Five presented with fever. None of them had cutaneous, renal or central nervous system involvement. Ten had raised ESR at presentation. One patient developed discoid lupus erythematosus two years later. All 12 patients received prednisolone with eight of them requiring additional immunosuppressants. Two patients had resistant disease failing to respond adequately to various immunosuppressants together with prednisolone. There was no mortality amongst the nine patients who had remained on follow-up at the time of this report. Five of the six patients with laryngotracheal involvement had tracheostomy and one of them had airway stenting as well.

CONCLUSION

Our series suggests that although the clinical manifestations of RPC are similar in the Oriental and the Caucasian populations, Oriental patients may have less cutaneous, renal or nervous system involvement and more serious airway complications.

Low-dose pulse methylprednisolone for systemic lupus erythematosus flares is efficacious and has a decreased risk of infectious complications

We sought to test our clinical impression that using a low dose methylprednisolone pulse (MEP; < or = 1500 mg over 3 days) in treating flares of systemic lupus erythematosus (SLE) was effective and associated with fewer serious infections. We retrospectively studied SLE patients who received MEP between 1989 and 2000. A 'low dose' group of 26 patients who had received 1-1.5 g and a 'high dose' group of 29 patients who received 3-5 g of MEP were identified. SLEDAI scores and prednisolone doses were recorded at the time of MEP pulses and 6 months later. All serious infections (requiring admission and i.v. antibiotics) occurring during this 6 month period and their outcomes were recorded. Both groups had similar demographic data, initial SLEDAI scores, i.v. cyclophosphamide use, and SLE organ involvement. Despite high- and low-dose MEP being efficacious in controlling disease activity (lowering of SLEDAI scores and subsequent prednisolone dose) there were only nine episodes of serious infection in seven patients in the low-dose group compared with 20 episodes in 17 patients from the high-dose group (P = 0.04). In both groups a majority of infections (75 and 77% in the high- and low-dose groups) occurred in the first month after MEP. Those with a low serum albumin (< 20 g/l) had an increased risk of mortality (OR 44, 90% CI 6.19-312.98) and a trend towards greater numbers of infections. Low-dose MEP was effective in controlling SLE flares and associated with fewer serious infections than traditional high-dose MEP.

Intermittent epoprostenol infusions in systemic lupus erythematosus associated pulmonary hypertension--a series of three cases

INTRODUCTION

Pulmonary hypertension (PHT) associated with systemic lupus erythematosus (SLE) has a grave prognosis. Continuous prostacyclin infusion significantly reduces pulmonary arterial pressure (PAP) and may improve survival in patients with primary and secondary PHT. We report our experience with intermittent epoprostenol (EPO) infusion in SLE patients with PHT.

CLINICAL CHARACTERISTICS

We reviewed patients with SLE associated PHT who were treated with intermittent EPO infusions in 1998. All 3 patients had severe PHT, with maximum systolic PAP (PASP) of 58, 96 and 67 mm Hg, respectively, when measured using Doppler echocardiography, and were in New York Heart Association functional class III.

TREATMENT

All patients were given 6 infusions of EPO monthly via peripheral venous access without significant side effects.

OUTCOME

The PASP of all patients remained stable during the therapy. The therapeutic response as measured by patient symptoms and PASP was variable. No patient had significant reduction of PASP during the 6-month treatment period. Two patients developed rebound elevation of PASP after cessation of treatment, while the PASP of the other patient remained stable for 10 months.

CONCLUSION

Although intermittent EPO infusion did not substantially reduce PASP, it prevented further rise in PAP during the treatment period, suggesting that this regimen may benefit a subset of SLE patients with PHT.

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.