Disseminated Cutaneous Tophi in a Patient with Chronic Tophaceous Gout and Renal Impairment: A Case Report of a Rare Manifestation of Gout.

BACKGROUND Gout is a metabolic disease characterized by deposition of monosodium urate (MSU) crystals called tophi. The typical location of tophi is in the joint and will chronically damage the joint. However, there is a rare atypical dermatologic manifestation of tophi that occur extensively in the skin. CASE REPORT A 46-year-old male presented with acute pain in multiple joints. He had a history of gouty arthritis with recurrence attacks, in the past 2 years ago. Over time, he had gradual eruption of multiple tophi and multiple yellowish nodules under his skin which sometimes would ulcerate. Laboratory value showed creatinine 2.3 mg/dL and uric acid 11.5 mg/dL. Ultrasound of the kidney showed nephrocalcinosis appearance. Urate crystal was identified in skin biopsy of the nodules. We diagnosed the patient with chronic tophaceous gout with extensive cutaneous involvement. Given the renal impairment, we gave methylprednisolone 3 doses of 8 mg for 5 days then tapered off, colchicine 0.5 mg every other day and allopurinol 1 dose of 100 mg. The patient had dramatic improvement of his pain and is now being followed up regularly. CONCLUSIONS We describe a rare and severe extensive cutaneous manifestation in a chronic tophaceous gout patient.

Low bone turnover in premenopausal women with type 2 diabetes mellitus as an early process of diabetes-associated bone alterations: a cross-sectional study.

BACKGROUND: Individuals with Diabetes Mellitus (DM) are at increased risk for fracture due to the decrease in bone strength and quality. Serum procollagen type I intact N-terminal (P1NP) and serum C-terminal cross-linking telopeptide of type I collagen (CTX) as markers of bone formation and resorption, respectively, have been reported to be decreased in T2DM. It remains unclear whether diabetes-associated alterations in the bone turnover of T2DM individuals are related to the longer duration of the disease or may occur earlier. Furthermore, previous studies on BTMs in T2DM individuals have mostly been done in postmenopausal women with T2DM, which might have masked the DM-induced alterations of bone turnover with concurrent estrogen deficiency. This study aims to assess the levels of serum P1NP and CTX as markers of bone turnover in premenopausal women with and without T2DM. METHODS: This cross-sectional study involves 41 premenopausal women with T2DM, and 40 premenopausal women without DM. Sampling was done consecutively. P1NP and CTX measurement was done using the electrochemi-luminescence immunoassay (ECLIA) method. Other data collected include levels of HbA1C, ALT, creatinine, eGFR and lipid profile. RESULTS: Median (interquartile range) P1NP in T2DM is 29.9 ng/ml (24.7-41.8 ng/ml), while in non-DM is 37.3 ng/ml, (30.8-47.3 ng/ml; p = 0.007). Median (interquartile range) CTX in T2DM is 0.161 ng/ml (0.106-0.227 ng/ml), while in non-DM is 0.202 ng/ml (0.166-0.271 ng/ml; p = 0.0035). Levels of P1NP and CTX in the T2DM group did not correlate with the duration of disease, age, BMI or the levels of HbA1C. CONCLUSIONS: Premenopausal women with T2DM indeed have lower bone turnover when compared with non-DM controls. This significantly lower bone turnover process starts relatively early in the premenopausal age, independent of the duration of DM. Gaining understanding of the early pathophysiology of altered bone turnover may be key in developing preventive strategies for diabetoporosis.

Reduced bone mineral density and serum C-telopeptide concentration in HIV-infected patients in Cipto Mangunkusumo Hospital.

AIM: To evaluate BMD and bone resorption marker in HIV-infected patients in Cipto Mangunkusumo Hospital, Jakarta. METHODS: A cross-sectional study was performed between February and May 2008 in adult HIV-infected patients who had not been treated with antiretrovirals. BMD was measured at the lumbar spine by dual energy X-ray absorptiometry (DEXA) bone densitometer (Lunar Prodigy, GE Medical System, USA), whereas CTX (C-terminal telopeptide) was measured by an automated analyzer (Elecsys 2010, Roche Diagnostics GmbH, Mannheim, Germany) using the b-Crosslaps serum reagents. RESULTS: Fourty-two patients were included, comprising 31 (73.8%) men and 11 (26.2%) women. Patients' median age was 28 years, ranging from 22 to 39 years old. The peak age group was 26-30 years old. Low BMD (osteopenia) was found in 11 (26.2%) of patients. Mean serum CTX level was significantly correlated with BMD (r=0.446; p=0.003). CONCLUSION: Patients with low CD4 count and low BMI tended to have higher serum CTX. HIV-infected, treatment-naive patients possess a significant risk for reduced BMD due to increase bone resorption activity. Further studies are needed to evaluate the association of disease severity and bone resorption markers.

Vitamin D status and hyperparathyroisism in postmenopausal osteoporotic patients in Cipto Mangunkusumo hospital Jakarta.

AIM: to determine the profile of vitamin D and parathyroid hormone (PTH) and the proportion of vitamin D inadequacy in a population of postmenopausal osteoporotic patients from a rheumatologic outpatient clinic. METHODS: a cross sectional study was conducted between October and December 2006 in the Rheumatology Clinic, Cipto Mangunkusumo Hospital with osteoporosis confirmed by bone mineral densitometry (T score less than -2.5 at the lumbar spine or hip). Patients were excluded if there was a history of oral glucocorticoid treatment within 30 days, vitamin D supplementation, and have renal and/or liver function impairments. Forty-two postmenopausal osteoporotic patients aged 51-77 years old who had been postmenopausal for 5-28 years were included in this study. Vitamin D inadequacy was defined as the plasma levels of 25(OH)D less than 50 nmol/L whereas hyperparathyroidism was defined as the PTH level more than 69 pg/dL. RESULTS: vitamin D inadequacy was found in 61.9% of patients and 34.6% of them or 23.8% of total patients were also having high PTH level. There was an inverse correlation between 25(OH)D with PTH levels and positive correlation between duration of menopause and PTH level. Vitamin D inadequacy is common (61.9%) in postmenopausal osteoporotic patients who visited Rheumatology outpatient clinic of Cipto Mangunkusumo Hospital Jakarta. CONCLUSION: the low concentration of 25(OH)D was correlated with PTH level and duration of menopause. This finding should be confirmed in a larger epidemiological study, either hospital-or community-based to assess vitamin D status among postmenopausal women in Indonesia.

Vitamin D and autoimmune disease.

Vitamin D as a part of the endocrine system is an important component in the interaction between the kidney, bone, parathyroid hormone, and the intestine, which maintains extracellular calcium level within normal limits, in order to keep the vital physiologic process and skeletal integrity. Vitamin D is also associated with hypertension, muscular function, immunity, and ability to encounter infection, autoimmune disease, and cancer. The role of vitamin D in immunity is a feedback reaction of paracrine to eliminate inflammation or to influence CD4 T-cell differentiation and or to increase the function of T suppressor cell or combination between both. The active form of vitamin D produces and maintains self immunologic tolerance, some studies show that 1,25(OH)2D inhibits induction of disease in autoimmune encephalomyelitis, thyroiditis, type-1 diabetes mellitus, inflammatory bowel disease (IBD), systemic lupus erythematosus, and collagen-induced arthritis and Lyme arthritis.

Cerebral thrombosis in systemic lupus erythematosus with the antibody antiphospholipid syndrome.

Systemic lupus erythematosus (SLE) has numerous manifestations. Haematology is the common system influenced by the disease. The antibody antiphospholipid syndrome, secondary hematology disorder in SLE, is related to high incidence of thrombosis. The thrombosis events like myocardial infarction and stroke are high in mortality. We reported a-36-year old woman treated for lung tuberculosis (TB) with secondary infection, nephritis lupus, and pancytopenia. The general condition has improved and the patient was planned to discharge while she suddenly fell down, unconscious and had seizure. The CT-scan showed an area of hypodensity on the left thalamus. Haematology results showed high level of fibrinogen and D-dimer as the signs of thrombosis. The anticardiolipin antibody was intermediately positive for IgG and IgM, but lupus anticoagulan was weakly positive. The serial test within 2 months still showed positive IgG. The patient received supportive treatment, heparinization, neurotropic drugs and anticonvulsant. She was discharged in good condition while continuing oral anticoagulant to prevent recurrent seizure.

Postural shortening due to primary hyperparathyroidism caused by parathyroid adenoma.

Osteoporosis can be primary or secondary. Secondary osteoporosis is the result of an underlying disease such as an endocrine abnormality, and an example of such is primary hyperparathyroidism. The most common cause of primary hyperparathyroidism is parathyroid gland adenoma. The diagnosis of primary hyperparathyroidism is based on the following biochemical examinations: parathyroid hormone, serum calcium, creatinine clearance, 24 hour urinary calcium, and another examination such as parathyroid gland scan. This is a rare case of an adult man who presented with a chief complaint of decreasing body height, back pain, difficulty in taking deep breaths and difficulty in his activities. The patient was diagnosed with primary hyperparathyroidism caused by parathyroid gland adenoma. His complaint was reduced after parathyroidectomy. His new complaint was that his tooth can be pulled out easily. We found high levels of parathyroid hormone and low levels of serum calcium caused by secondary hyperparathyroidism.

The diagnostic value of combined risk factor analysis and radiological imaging in determining osteoporosis in post-menopausal women.

AIM: To determine the diagnostic value of risk factor analysis (age, duration of menopause, body mass index and physical activities) and radiological imaging (Singh index and cortical index of the femoral neck) in diagnosing osteoporosis in post-menopausal women. METHODS: The study was cross sectional on 64 post-menopausal women without secondary risk factor for osteoporosis. They were classified proportionally using the Singh index. Bone density was measured using DEXA (dual x-ray absorptiometry) on the femoral neck and lumbal 2-4 spine areas. The Singh index and cortical index of the femoral neck were evaluated using femoral neck antero-posterior x-ray. Physical activities were measured using a Historical leisure activity questionnaire. Bivariat statistical analysis was conducted using the t-test and chi-square, whereas multivariate analysis was conducted using multinomial logistic regression. RESULTS: There was a significant association (p<0.05) between bone density and age, body weight, height, body mass index, duration of menopause and Singh index. With multinomial logistic regression analysis, it was demonstrated that only Singh index, the duration of menopause and body mass index had the highest sensitivity and specificity. The score system algorithm could be utilized in two steps, the first was to diagnose osteoporosis and the second was to distinguish between osteopenia and normal bone. This score system had a sensitivity of 91.4% and a specificity of 89.6%, a positive prediction value of 91.4% in determining osteoporosis, and a sensitivity of 66.7%, a specificity of 89.1% and a positive prediction value of 70.6% in determining osteopenia, whereas the negative prediction value was 75%. CONCLUSION: The score system algorithm is the best method for determining osteoporosis in post-menopausal women. If there is osteopenia, evaluation using DEXA is then required. The score system algorithm cannot be used to follow up the therapy.