PACCD’s First Scientific Symposium 2016; In Hindsight

PACCD’s First Scientific Symposium 2016;  In Hindsight
Cynthia S. Floro, M.D

At exactly 10 am on January 28,2016, the Conference Room of Sulo Riviera Hotel is filled with no less than 53 PACCD members anticipating the first Scientific Symposium of the year.

Aptly relevant, is the choice of topic selected by our Academic Committee Chair, Dr. Sonia Baluyot, the title of which is “CONNECTIVE TISSUE DISEASES BOTH IN ADULT AND CHILDREN”

Two Specialists in the field of Rheumatology served as our Guest Speakers. They are Dra. Marica A. Lazo, an Adult Rheumatologist and Dra. Leonila F. Dans, a Pediatric Rheumatologist. Both of whom are established practitioners in their Fields.

Dra. Marica Lazo started the Symposium with the in-depth lecture on SLE or Systemic Lupus Erythematosus.

According to her, SLE is one of the Chronic systemic autoimmune diseases with protean manifestations. More than 90% of SLE cases occur in women, most often in the child-bearing age. It may affect any organ system and its presentation and course are highly variable ( indolent or fulminant).

Skin involvement is the second most common manifestation of SLE, next to Arthalgias. She noted that 75% of all SLE patients develop skin lesion in the course of their disease.

This is also one of the most common Connective Tissue disease seen for consutation, with the average of 2-3 patients per day. And on the flipside, one of the diseases often not reported.

Symptoms may vary over time, but commonly include:
• Serositis
• Arthritis
• Photosensitivity
• Blood disorder
• Renal disorder
• ANA positive titter
• Immunological disorder
• Neurologic disorder
• Malar “Butterfly” rash
• Discoid rash

There are three forms of Cutaneous Lupus, namely:

1. Acute Cutaneous Lupus- which has the characteristic erythema over the cheeks and nasal bridge, sparing the naso-labial folds, making it appear like a malar “butterfly” rash.
2 . Subcutaneous Lupus – has the characteristic psoriasiform rash and annular polycystic rash

3. Chronic or Discoid Lupus – with lupus penniculitis/ lupus profundus

Other Cutaneous Manifestations may include:

Raynauld Phenomenon
Livedo reticularis
Vasculitis purpura
Telangeictasia
Urticaria

For the treatment, Dra. Lazo, mentions the medications commonly used :

• NSAIDs
• Antimalarial drugs
• Corticosteroids
•  Immunosuppresants.

She proceeds by discussing four other Connective Tissue Diseases namely:
Dermatomyositis
Scleroderma
Vasculitis
Psoriasis/ Psoriatic Arthritis

Among these, Psoriasis aroused the most interest in the attendees. Simply because, it is one of the most common immune-mediated inflammatory skin disorder seen by many of us in practice.

The key dermatologic signs in Psoriasis, include, papulosquamous plaques on the scalp and extensor surfaces of the body. Nail dystrophy is not uncommon. And once, a patient has nail pitting with accompanying back pain, it is more likely a case of Psoriatic arthritis, Dra. Lazo notes.

Treatment includes, topical steroids, Phototherapy and DMARDS ( Methotrexate, Cyclosporine and Biogenics, like, Etanercept, Infliximab, Adalimumab and Ustekinumab.

At the end of her lecture, she points out that, a good Medical History and thorough Physical Examination , guides a Physician to a Proper Diagnosis.

In closing, she gives the following Key Points in Diagnosis And Treatment.

• Skin changes occur in a variety of rheumatic diseases and may even be the initial manifesta- tation of a systemic disease
• Skin involvement in a rheumatic disease may  serve as an easy-to-access diagnostic and prognostic indicator
• Physicians need to be aware of the impact that  chronic and disfiguring skin changes may have on the quality of life of a patient with rheumatic  disease.

Immediately after, Dra. Leonila F. Danz, is called on the floor to discuss on ‘” Differentiating Skin Findings of Pediatric Rheumatic Conditions”.

With her warm personality, attendees are able to get back to the momentum of the Lectures right after a good one.

She begins, by mentioning that skin changes in Pediatric Rheumatic Conditions can be very confusing in coming- up with a diagnosis. Like what Dra. Lazo says, a good Clinical history and Physical Examination is the key.

She emphazises the following essential clinical features in ruling out Differential Diagnosis:

Approach to Diagnosis:
• Site of involved joint
• Duration and Frequency of symptoms
• Number of Joints involved
• Associated Extra-articular manifestations

At UP-PGH Pediatric Rhuematology Clinic where she practices, she points 5 case- mixed diseases commonly seen. In the year 2015, statistics show:

• SLE – most common case, about 23%
• Juvenille Idiopathic Arthritis 15%
• Vasculitis 17%
• Rheumatic Fever 12%
• Juvenille Dermatomyositis 3 %

Juvenile Rheumatoid Arthritis, or Juvenile Idiopathic Arthritis, is the most common type of arthritis in children under the age of 17. Like Rheumatic Fever, she says, both have spiking fever and the typical evanescent rash , with joint pains , swelling and morning stiffness.

To rule out other skin diseases rather than Rheumatic Fever, Jones Criteria for Diagnosis of Acute Rheumatic Fever must guide the Physicians. Of courses after an evidence of positive Streptococcal infection. These are:

Major Manifestations:
• Carditis
• Polyarthritis
• Chorea
• Erythema marginatum
• Subcutaneous nodules

Minor Manifestations
• Arthralgia
• Fever
• Elevated ESR, CRP
• Prolonged PR

Vasculitis or Henoch Schonlein Purpura, she continues, is the commonest form of vasculitis in children.There is purpura affecting the lower limb or occasionally widespread with fever but is self-limiting. She observes, that children who underwent appendectomy get it more than those who did not.

Juvenile Dermatomyositis, on the other hand, has a characteristic violaceous rash over the eyelids with periorbital edema. It may appear like a child has eye shadow make-up on, she adds. Other findings include Gottron papules, heliotrope rash, calcinosis cutis, and proximal muscle weakness.

Scleroderma or Sytemic Sclerosis, she goes on, is characterized by formation of fibrosis in the skin that leads to the thickness and firmness of involved skin. Reynauld’s phenomenon is an example. There is increase fibroblast activity resulting in abnormal growth of connective tissue, resulting in vascular damage and fibrosis.

Topical steroids, antihistamines and NSAIDs can be used to ease the symptoms. However, oral corticosteroids do not help. Dapsone and methotrexate are also being used, but she cautions that no treatment is uniformly effective.

She concludes her lecture by saying that, a Physician should request for a skin biopsy in case of doubts, but gives us the following guidelines :

• SLE – has malar rash, oral sore, different from Koplik’s  spots of Measles
• Henoch Shchonlein Purpura – has palpable purpura
• KAWASAKI Disease – has desquamation, strawberry tongue
•  JDM – Gotton’s papules, Heliotrope
• Scleroderma – with distal sclerosis

By the end of the Lectures, attendees have nothing but satisfied look on our faces.

For starting a New Year, this good PACCD Scientific Symposium is a welcome treat . It makes a good anticipation for the coming ones. In addition, it doesn’t only feed our minds with knowledge, but the food served at lunch time, completes the pleasure.

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PACCD 1st SCIENTIFIC SYMPOSIUM, January 28, 2016 at Sulo Riviera Hotel, Quezon City (from L to R)Dr. Vinson B. Pineda, PACCD President, Dr. Rosario Divina R. Perez, PACCD Auditor, Dr. Isagani C. Cruz, PACCD Asst. PRO, Dr. Leonila F. Dans and Dr. Marica A. Lazo, PACCD Lecturers, Dr. Sonia G. Baluyot, PACCD CME Chairperson