RESUMO
OBJECTIVE: A study was conducted evaluating the process of a rheumatology consultation. METHODS: Data on consultation times was obtained from 100 patient processes over three months. Prior to data collection, unstructured interviews were conducted with the entire staff of the rheumatology clinic in Shalamar Hospital, to understand the consultation process. Based on this, consultation was divided into distinct segments (vitals, history and examination, specialist registrar consultation, specialist consultation, documentation and exercise/prescription handing over) and data was collected for the time taken for the patient to complete each segment. Designation of the personnel conducting the process, diagnosis, current visit number and general notes were also recorded. RESULTS: Patients with rheumatoid arthritis (RA) consulted for an average time of 33.4 and 27.4 minutes for new and established patients respectively in our observations. Patients with systemic lupus erythematosus (SLE) on the other hand spent 34.5 and 37 minutes for new and established patients respectively. The greatest time spent during any segment of the consultation was during documentation, which averaged 10 minutes per patient. CONCLUSION: Our study found that consultation times at Shalamar Hospital's rheumatology clinic align with international guidelines. Implementing a triaging method could optimize resource allocation, while entrusting specialist nurses with stable patient follow-ups could enhance patient flow and provision of health education.
RESUMO
Synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome, a rare disorder with a spectrum of manifestations and overlapping osseous and cutaneous symptoms, shares pathogenesis with various autoimmune diseases. SARS-CoV-2 has been previously linked to various autoimmune diseases like Guillain-Barré syndrome (GBS), a multi-inflammatory syndrome in children (MIS-C), or rheumatoid arthritis, but there is no existing work showing a link between SAPHO syndrome and COVID-19 yet. Here, we present a case of a middle-aged Asian male who presented with minimum swelling of his right second toe, 21 days post-COVID. After a series of investigations, namely, MRI scans, 99mTc-methylene diphosphonate three-phase bone scan, and bone biopsy, followed by a positive culture and sensitivity test of the same toe, a trial of vancomycin was given to the patient to treat bacterial osteomyelitis. This resulted in no improvement, pointing toward a misdiagnosis. A conclusion of sterile osteomyelitis of his right second and third metatarsal heads and phalanges due to SAPHO syndrome, as a possible complication of SARS-CoV-2 infection, was made. There are a number of classification systems for diagnosing this syndrome, one of which was modified by Kahn and was used in our case. Atypical presentations of rare disorders like SAPHO syndrome and their relation to SARS-CoV-2 infection are still to be fully discovered and investigated. Their prevention, timely diagnosis, and management may help in alleviating the discomfort and fear associated with the unknown for the patients.
RESUMO
Systemic lupus erythematosus (SLE) is a systemic, autoimmune, multisystem disease. Lupus enteritis accompanied by intestinal pseudo-obstruction (IPO) is a serious and rare initial manifestation that can lead to high mortality and morbidity in case of delay in diagnosis and treatment. Here, we present a very complicated case of a 36-year-old female Pakistani patient with lupus enteritis accompanied by IPO and bilateral hydronephroureter. The patient had a three-month history of fever, weight loss, recurrent diarrhea, vomiting, alopecia, and photosensitivity. She had a malar and discoid rash, with signs and symptoms of IPO and neuropsychiatric lupus. Her labs revealed positive anti-nucleosome antibodies (8 U/mL), anti-Ro antibodies (100 U/mL), and anti-La antibodies (53 U/mL); equivocal anti-dsDNA antibodies (7 U/mL) and anti-Sm antibodies (7 U/mL); direct Coomb's positive hemolytic anemia; raised C-reactive protein and erythrocyte sedimentation rate levels; low complement (C3 and C4) levels; and pyuria. IPO was evident on abdominal X-ray and CT scan. Her Systemic Lupus Erythematosus Disease Activity Index was 24, indicating severe disease flare. She was treated with intravenous methylprednisolone, hydroxychloroquine, and intravenous 500 mg cyclophosphamide. Her lab parameters and clinical mini-mental score improved, from 0/30 to 18/30. She was discharged on oral prednisolone 0.5 mg/kg/day, hydroxychloroquine, trimethoprim-sulfamethoxazole (prophylaxis for Pneumocystis jirovecii pneumonia), and mineral and vitamin supplements. She was followed up on the 15th day of discharge for the next dose of cyclophosphamide, and her clinical and lab parameters were normal at that time with gradual improvement in cognition. Lupus enteritis with coexisting IPO and bilateral hydronephroureter poses a diagnostic and therapeutic challenge because of atypical and uncommon manifestations of lupus and overlapping features with intestinal tuberculosis and other inflammatory bowel conditions.