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Osteoarticular tuberculosis mimicking rheumatoid arthritis

Ong PS, Sulaiman W

Mod Rheumatol, 2012 Nov;22(6):931-3.
PMID: 22399018 DOI: 10.1007/s10165-012-0605-1

Tuberculosis (TB) remains a global burden despite extensive efforts to control it. TB arthritis commonly manifest as monoarthritis of weight-bearing joints. We report a rare presentation of osteoarticular TB involving multiple small joints of the hands, which mimicked rheumatoid arthritis (RA). Magnetic resonance imaging showed tenosynovitis. The patient was initially treated for seronegative RA but failed to respond. Subsequently, synovial biopsy led to the diagnosis. Antituberculosis treatment was given for 1 year.
Fulltext "Nine" syndrome and its MRI brain findings

Ng, Yong Muh, Kang, Pei San, Khor, Chiew Gek, Ong, Ping Seung, Ramanathan G.R. Letchuman

Neurology Asia, 2017;22(4):349-352.
MyJurnal

We describe a rare presentation of pontine infarction in a lady who was on dual antiplatelet therapy.
Her presentation includes one and a half syndrome, left facial nerve palsy and contralateral hemiataxia.
Magnetic resonance imaging (MRI) of the brain revealed acute infarction of the dorsal pons. A diagnosis
of “nine” syndrome secondary to lacunar stroke was made. She continued dual antiplatelet therapy
and her symptoms resolved completely over three months.
Fulltext Adult-onset Still's disease: a case report

Ong PS, Sulaiman W

Oman Med J, 2011 Sep;26(5):e022.
PMID: 28845225 DOI: 10.5001/omj.2011.96

Adult-onset Still's disease (AOSD) is a rare clinical entity with unknown etiology, characterized by arthritis, fever, evanescent rash and other systemic presentations. This report described a 45-year-old male who presented with sore throat, fever, arthritis, evanescent rash, raised liver enzymes and hyperferritinemia. He was diagnosed to have AOSD based on Yamuguchi criteria after the exclusion of other potential diagnoses. The patient partially responded to combined celecoxib and prednisolone. He was also prescribed methotrexate and his symptoms improved.
Fulltext Acute myocardial infarction as Eosinophilic granulomatosis with polyangiitis (formerly Churg Strauss syndrome) initial presentation. [Infarto agudo do miocárdio como apresentação inicial de granulomatose eosinofílica com poliangiite (anteriormente, síndrome de Churg Strauss)]

Sulaiman W, Ong PS, Mohd Noor S

Rev Bras Reumatol Engl Ed, 2014 Sep-Oct;54(5):393-6.
PMID: 25627304 DOI: 10.1016/j.rbr.2013.03.002

Eosinophilic granulomatosis with polyangiitis is a rare primary vasculitic disease characterized by hypereosinophilia, late onset asthma and extravascular eosinophil granulomas. We report a case presented initially with acute myocardial infarction which later only proceed with asthma, skin manifestations and peripheral neuropathy. Laboratory parameters showed hypereosinohpilia with negative perinuclear pattern of antineutrophil cytoplasmic autoantibodies (p-ANCA). Skin biopsy showed leucocytoclastic vasculitis with eosinophilic infiltration while coronary angiography was normal. The patient's symptoms improved with IV methylprednisolone, pulse cyclophosphamide and azathioprine.
Multifocal osteoarticular tuberculosis in a systemic lupus erythematosus (SLE) patient: a rarity or an underdiagnosed condition?

Lim SL, Ong PS, Khor CG

Mod Rheumatol Case Rep, 2020 07;4(2):237-242.
PMID: 33086999 DOI: 10.1080/24725625.2020.1754567

Tuberculosis (TB) and its association with rheumatic diseases have been widely recognised. Occurrence of multifocal skeletal involvement constitutes <5% of all skeletal TB cases. We present a Malay patient with multifocal osteoarticular TB (OATB). A 35 year-old SLE woman with background usage of corticosteroid therapy and Azathioprine presented with lupus nephritis flare. Renal biopsy revealed diffuse proliferative lupus nephritis and intravenous (IV) Cyclophosphamide 0.5 g/m2 (850 mg) was initiated. One week later, patient complained dorsum of left hand and right knee swelling. On physical examination, patient was afebrile and the left hand swelling was cystic in consistency while right knee was warm and tender. Erythrocyte Sedimentation Rate (ESR) was 50 mm/hr and C-Reactive Protein (CRP) was 9.4 mg/L. Her Mantoux test was positive with 20 mm induration. Wrist radiograph and chest radiograph was normal. Musculoskeletal ultrasound showed 4th extensor compartment tenosynovitis with Doppler signal and right knee effusion with synovial proliferation. Extensor tenosynovectomy and right knee aspiration was performed. Left hand excised tissue and right knee synovial fluid for acid-fast bacilli (AFB) stain, TB PCR, bacterial and fungal cultures were negative. Urgent histopathological examination of the excised tissue showed necrotising granulomatous inflammation. Patient was empirically started on TB treatment and subsequent mycobacterial culture confirmed the diagnosis of TB. The joints swelling resolved after one month of TB treatment. Multifocal OATB is an infrequent form of extrapulmonary TB and diagnosing OATB requires high index of suspicion particularly in SLE patient on immunosuppression. Prompt investigations are essential to the diagnosis of this rare condition for early initiation of anti-tuberculous therapy.
Fulltext Cardiomyopathy following COVID-19 vaccination in a patient with systemic lupus erythematosus

Bhullar AK, Chew ZC, Ong PS, Khor CG, Mohd Amin NH

Mod Rheumatol Case Rep, 2023 Jan 03;7(1):87-91.
PMID: 36069645 DOI: 10.1093/mrcr/rxac070

There are an increasing number of reports of myocarditis associated with mRNA-based COVID-19 vaccination. We describe the case of a female patient with underlying systemic lupus erythematosus, who developed heart failure symptoms following a second dose of the BNT162b2 vaccine. Despite her history of refractory systemic lupus erythematosus, the disease remained stable after she began rituximab treatment. She underwent serial transthoracic echocardiogram and cardiac magnetic resonance imaging for the evaluation of cardiomyopathy. She showed improvement in cardiac function after treatment with glucocorticoids and intravenous immunoglobulin therapy.
Factors Influencing Liver Abnormalities in Psoriatic Arthritis Patients: A Comprehensive Study

Ong PS, Tan LK, Mat H, Tohar N, Fathi AM, Kosenin NMA, et al.

Mediterr J Rheumatol, 2024 Jun;35(2):234-240.
PMID: 39211017 DOI: 10.31138/mjr.050723.fla

OBJECTIVE: The aim of this study was to establish the incidence of liver abnormalities in psoriatic arthritis patients and identify the factors that contributed to this condition.
METHODS: This is a longitudinal cohort study. Psoriatic arthritis (PsA) patients with liver enzymes abnormalities were identified. Our control group consisted of PsA patient from the same cohort who had no history of liver abnormalities. Factors associated with liver abnormalities were identified using univariate and multivariate analysis.
RESULTS: A total of 247 of PsA patients were included and out of those, 99 developed liver enzymes abnormalities. The mean age of the patients was 56 years old (±13.5) with 56.1% female and 39.4% Indian descendants. The univariate logistic regression demonstrated that disease duration of PsA (OR=1.06, 95% CI=1.01 - 1.10, p=0.012), diabetes mellitus (OR=2.16, 95% CI=1.26 - 3.70, 0.005) and non-alcoholic fatty liver disease (NAFLD) (OR=3.90, 95% CI = 1.44 - 10.53, p=0.007) were associated with abnormal liver function in PsA patients. No association was found with both conventional synthetic disease-modifying antirheumatic drugs or biologics.
CONCLUSION: Liver enzymes abnormalities in PsA patients were linked to disease duration, diabetes mellitus and NAFLD. For these high-risk populations, vigilant monitoring of liver function tests is vital for early detection and intervention.
A hierarchical cluster analysis for clinical profiling of tofacitinib treatment response in patients with rheumatoid arthritis

Janahiraman S, Shahril NS, Jayaraj VJ, Ch'ng S, Eow LH, Mageswaren E, et al.

Clin Rheumatol, 2024 Aug;43(8):2489-2501.
PMID: 38922551 DOI: 10.1007/s10067-024-07035-x

Tofacitinib is the first oral JAK inhibitor approved for treating rheumatoid arthritis (RA). To enhance our understanding of tofacitinib drug response, we used hierarchical clustering to analyse the profiles of patient who responded to the treatment in a real-world setting. Patients who commenced on tofacitinib treatment were selected from 12 major rheumatology centres in Malaysia. The aim was to assess their response to tofacitinib defined as achieving DAS28-CRP/ESR ≤ 3.2 and DAS28 improvement > 1.2 at 12 weeks. A hierarchical clustering analysis was performed using sociodemographic and clinical parameters at baseline. All 163 RA patients were divided into three clusters (Clusters 1, 2 and 3) based on specific clinical factors at baseline including bone erosion, antibody positivity, disease activity and anaemia status. Cluster 1 consisted of RA patients without bone erosion, antibody negative, low baseline disease activity measure and absence of anaemia. Cluster 2 comprised of patients without bone erosion, RF positivity, anti-CCP negativity, moderate to high baseline disease activity score and absence of anaemia. Cluster 3 patients had bone erosion, antibody positivity, high baseline disease activity and anaemia. The response rates to tofacitinib varied among the clusters: Cluster 1 had a 79% response rate, Cluster 2 had a 66% response rate, and Cluster 3 had a 36% response rate. The differences in response rates between the three clusters were found to be statistically significant. This cluster analysis study indicates that patients who are seronegative and have low disease activity, absence of bone erosion and no signs of anaemia may have a higher likelihood of benefiting from tofacitinib therapy. By identifying clinical profiles that respond to tofacitinib treatment, we can improve treatment stratification yielding significant benefits and better health outcomes for individuals with RA.