A spectrum of immune dysregulation has been described following SARS-CoV-2 infections—from the cytokine storm in the acute phase, to hyperinflammatory syndromes that occur after the resolution of the initial infection.1 Multisystem inflammatory syndrome (MIS) was first reported in children in April 2020 as a hyperinflammatory syndrome with features similar...

Dear Editor, There is a high burden of genetic disorders in patients admitted to the intensive care unit (ICU), ranging from 45–56%,1,2 and delayed definitive diagnoses with a long diagnostic odyssey often contribute to increased healthcare costs.3 The application of clinical exome sequencing in ICU has been gaining traction, where...

The clinical spectrum of idiopathic inflammatory myopathies (IIM) has broadened over the past half century from a simple disease characterised primarily by muscle and skin manifestations, to a potentially life-threatening complex condition of multiple organ involvement. In the recent decade, the discovery and addition of novel autoantibody profiles including...

Dear Editor, Thrombosis is an unexpected complication of COVID-19 initially reported in 3 patients from China.1 These patients tested positive for immunoglobulin (Ig) A anticardiolipin (ACA), IgG anti-β2-glycoprotein I antibodies (aβ2GPI) and IgA aβ2GPI, though not for the lupus anticoagulant (LAC). In a Singapore study comprising 47,527 patients, 19 (0.04%) developed...

Dear Editor, Haemoglobin H (HbH) disease is a haemoglobinopathy affecting 3 of 4 α-globin genes on chromosome 16. It results from the deletion of 2 linked α-globin genes (α0-thalassaemia) on one chromosome and either a single α-globin gene deletion (--/-α) or non-deletional gene mutation (--/αTα) on the other chromosome.  The...

Glaucoma is a major cause of world blindness in developing and developed nations. The WHO Global data on blindness show that over half of the blind due to glaucoma reside in Asia, the majority being Chinese. This article is available only as a PDF. Please click on “Download PDF” on...

Children with rheumatological disease form a small but important proportion of the ill paediatric population. Most of the published data available are based on studies on Caucasian, Black or Hispanic children with relatively little information on Asian children including Chinese and Malays. This article is available only as a PDF....

Familial scleroderma was first documented in 1953 by Rees and Bennett who described the occurrence of a localised disease in a father and daughter. The first documentation of familial systemic disease was by Orabona and Albano who reported its occurrence in two sisters some five years later. This article is...

Ingested foreign bodies are a common condition in the practice of Otolaryngology. In particular, there is no doubt a greater tendency in the local community to consume fish without it being de-boned. This article is available only as a PDF. Please click on “Download PDF” on top to view the...

The acronym SAPHO refers to a syndrome characterised by synovitis, acne, pustulosis, hyperostosis and osteitis. In 1961, a link between acne conglobata and arthritis was first described by Windom et al. This article is available only as a PDF. Please click on “Download PDF” on top to view the full...

Rheumatoid arthritis is a systemic disease characterised by remissions and exacerbations that vary in severity and timing among people. Its chronic and degenerative course makes it imperative that a philosophy of maintaining the patient’s physical, psychological, and functional abilities as long as possible through an ongoing carefully planned treatment...

Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used for the treatment of various rheumatic conditions including rheumatoid arthritis (RA). The adverse effects of NSAIDs on the upper gastrointestinal tract (GIT) are well known and well described. This article is available only as a PDF. Please click on “Download PDF” on top...

Patient A, a 33-year-old male administrative coordinator presented with left buttock pain of 4 to 5 years duration which radiated down to the leg and lower back. There was no antecedent trauma. This article is available only as a PDF. Please click on “Download PDF” on top to view the...

Locally injected intra-synovial corticosteroids are useful to target selected joint, tendon sheath or bursal inflammation in children with pauciarticular or polyarticular juvenile chronic arthritis (JCA). Inflammation is decreased locally and with minimal systemic side effects. This article is available only as a PDF. Please click on “Download PDF” on top...

Osteoporosis is becoming an increasing public health problem in most countries. Osteoporosis literally means “porous bones” and involves skeletal fragility leading to an increased risk of fracture. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Gout occurs in 3 overlapping phases: a long phase of asymptomatic hyperuricaemia, a period of recurrent acute gouty attacks separated by asymptomatic intervals (interval gout), followed in about 10% of patients by chronic tophaceous gouty arthritis. Gout is one of the better understood of the arthritic disorders, and certainly...

The relationship between lipid disorders and arthritis is manifold. Hyperlipidaemia may manifest clinically in the musculoskeletal system. In 1968, Khachadurian studied 14 families of whom 18 homozygotes of Type II hyperlipidaemia were identified. Ten of these patients experienced a migratory polyarthritis resembling rheumatic fever. This article is available only as...

Rheumatoid arthritis (RA) is a chronic inflammatory arthritis which is occasionally associated with extraarticular manifestations. Although the first good clinical description was by Landre-Beauvais in 1800, the term rheumatoid arthritis was first used only in 1878 by Alfred Garrod. This article is available only as a PDF. Please click on...

Systemic sclerosis (SScl) is a generalised disease of the connective tissue characterised by fibrosis and vascular changes affecting the skin, lungs, gastrointestinal tract, kidneys, and heart. The American College of Rheumatology has proposed that for the purpose of clinical trials and surveys, the diagnosis is made if the patient...

Since the discovery of X-rays over a century ago, radiology has played a pivotal role in rheumatology and diseases of the joints. The innovations and advances in technology in imaging and interventional radiology today enable more precise and earlier detection, assessment and treatment. This article is available only as a...

Phospholipids (PLs) are components of cell membranes. Their function is not only to maintain the structure of the membranes but also to modify the function of proteins present on cell surface. This article is available only as a PDF. Please click on “Download PDF” on top to view the full...

In 1982, Davies and co-workers in Melbourne described the presence of a serum factor that stained the cytoplasm of neutrophil leukocytes by indirect immunofluorescence in 8 patients with generalised illness associated with segmental necrotising glomerulonephritis. This was followed two years later by a report by Hall and co-workers of...

Immunologic tolerance is a hallmark of the immune system whereby immune cells are tolerant of self antigen. Historically, this tolerance was thought to be secondary to the removal of self-reactive T cells during development and maturation in the thymus of the immune cells - clonal deletion. This article is available...

Systemic lupus erythematosus (SLE) is a chronic rheumatic disease characterised by protean clinical manifestations as well as the presence of multiple autoantibodies. Tissue deposition of autoantibodies and immune complexes can lead to tissue injury. This article is available only as a PDF. Please click on “Download PDF” on top to...

The complex and non organ-specific nature of systemic lupus erythematosus (SLE) has made it difficult for researchers to unravel the genetic defects and pathogenic mechanisms underlying this disease. Over the past 30 years, several mouse models of lupus bearing differing sets of phenotypes and genotypes, have collectively contributed a...

The fact that there is an increasing and growing need in societies for care of sufferers of rheumatic conditions can be shown from national statistics. In Australia, for example, arthritic and related musculoskeletal diseases may not dominate mortality statistics but they figure in the top three causes of acute...

The presence of multiple autoantibodies is the hallmark of systemic lupus erythematosus (SLE). Many of these autoantibodies target nuclear antigens e.g. histones, Sm, RNP, SSA, SSB and dsDNA may give rise to a positive antinuclear antibody (ANA) test. This article is available only as a PDF. Please click on “Download...

Lupus nephritis is a common manifestation of lupus associated with significant morbidity and mortality. The use of cytotoxic agents has resulted in improved renal outcomes but is associated with considerable morbidity, and their role in the management of lupus nephritis is not universally accepted. This article is available only as...

Although George Still first described systemic onset juvenile rheumatoid arthritis (JRA) comprising fever, arthritis, lymphadenopathy and splenomegaly in 1897, it was not until 1971 that its nosologic entity presenting in adulthood was recognised by Eric Bywaters. Since then, well over 300 cases have been reported in the literature worldwide. This...

The current explosion of molecular biology encompassing genetics, morphogenesis, teratogenesis and pharmacogenomics for targeted drug therapy is about to have a profound impact upon the practice of medicine in the next century. A new discipline of molecular medicine is becoming a feature of clinical practice. This article is available only...

The head of caudate nucleus forms a prominent bulge in the lateral wall of the anterior horn of the lateral ventricle. Its blood supply is from the deep penetrators from the middle cerebral and anterior cerebral arteries. This article is available only as a PDF. Please click on “Download PDF”...

Twenty years ago, the therapy of glomerulonephritis (GN) was relatively simple as it was believed that treatment with prednisolone should be confined to patients with minimal change nephrotic syndrome and lupus nephritis. For those patients who failed to respond, they were treated with oral cyclophosphamide. This article is available only...

The spondyloarthropathies (SpA) comprise a heterogenous group of conditions that include ankylosing spondylitis (AS), psoriatic arthritis, reactive arthritis/Reiter’s syndrome, arthritis associated with inflammatory bowel disease and pauciarticular, late-onset juvenile chronic arthritis. Undifferentiated forms of the disease are also present. This article is available only as a PDF. Please click on...

It was Charcot (1868) who first made the formal pathological correlation between lesions in the central nervous system (CNS) and a disorder termed, ‘la sclérose en plaques’. Today, a number of other immune-mediated, demyelinating CNS diseases have been recognised and hence, classical multiple sclerosis (MS) is now specified as...

Intensive care has undergone rapid technological advancement in recent years enabling complex treatment of patients of advanced age and/or with advanced chronic diseases underlying their acute medical problems. New interventions have been introduced with success determined by their ability to save lives. This article is available only as a PDF....

Technological advances over the last 30 years have had an enormous impact on the way in which medicine is delivered today. This is particularly so in the specialty of intensive care where intensivists possess the necessary knowledge and tools to prolong life in many situations where patients would previously...

Patients with rheumatic disease are often immunocompromised as a result of either their disease or treatment. They may become ill either from a flare of their autoimmune disease or from complications of treatment, at times requiring intensive care. This article is available only as a PDF. Please click on “Download...

Rheumatoid arthritis (RA) is a systemic autoimmune disease characterised by symmetrical inflammatory arthritis. Most patients exhibit a chronic course. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Cyclooxygenase inhibitors are non-steroidal anti-inflammatory drugs (NSAIDs). They have been used in the treatment of rheumatic diseases for several decades. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

I am greatly honoured to deliver the 10th Seah Cheng Siang memorial lecture. I came into direct contact with Professor Seah in January 1965 when I joined the then Thomson Road General Hospital as his senior registrar. This article is available only as a PDF. Please click on “Download PDF”...

In the early 1700s, Lady Mary Wortley Montagu, wife of the British ambassador to Turkey, introduced the practice of variolation against smallpox into Western Europe. This act of immunisation had since been better understood. This article is available only as a PDF. Please click on “Download PDF” on top to...

Thyroid dysfunction can give rise to various psychiatric symptoms. While there is a persistent interest in the role of thyroid axis in affective disorders, there is limited data on the interaction of thyroid dysfunction with psychotic disorders such as schizophrenia. This article is available only as a PDF. Please click...

Systemic lupus erythematosus (SLE) is a chronic systemic connective tissue disease with a reported prevalence of 5 to 100/100,000. Women are affected much more commonly than men (ratio 9:1), particularly those in the child-bearing age (15:1). This article is available only as a PDF. Please click on “Download PDF” on...

It is said that, worldwide, over half a million maternal deaths occur annually. This might well be a conservative estimate, given the difficulties inherent in collecting the relevant data, compounded by the under-reporting and misclassification of such deaths. This article is available only as a PDF. Please click on “Download...

The theme of this issue of the Annals, Academy of Medicine at the beginning of the year is suitably on osteoporosis. Osteoporosis, with its multi-faceted, multidisciplinary approach, has been identified as one of the four clinical fields selected also for emphasis by the Bone and Joint Decade initiative. This article...

Corticosteroids are known to affect bone through multiple pathways (Fig. 1), influencing both bone formation and bone resorption, and these mechanisms have been reviewed. The most important effects appear to be on bone formation due to direct effects on cells of the osteoblastic lineage although indirect effects related to...

Primary meningococcal arthritis (PMA) and endogenous meningococcal endophthalmitis are both uncommon presentations of meningococcal infection that should be considered in the differential diagnosis of reactive arthritis and acute dermatitis-arthritis syndrome. We describe a case of PMA and meningococcal endophthalmitis occurring together. This article is available only as a PDF. Please...

Health-related quality of life (HRQoL) refers to patients’ perceptions of their own functioning and well-being. HRQoL is increasingly being used as a primary or secondary endpoint in clinical research and is essential in economic evaluation of new and often expensive therapies. This article is available only as a PDF. Please...

Pulmonary hypertension (PHT) is seen in 0.5% to 14% of systemic lupus erythematosus (SLE) patients and is associated with a grave prognosis. The overall 2-year mortality is more than 50% despite vasodilators, anticoagulants, systemic corticosteroids and cytotoxic drugs. This article is available only as a PDF. Please click on “Download...

The only published study on Behcet’s disease in Singapore by Tan E et al (34 patients at the National Skin Centre) found that only 15% had arthritis and 6% had eye complications with no other systemic manifestations. These findings are different from epidemiological studies from other countries published in...

Patients who talk after traumatic brain injury (TBI) and then subsequently deteriorate into a coma are defined as those with an initial Glasgow Coma Score (GCS) verbal score of 3 or greater, and then deteriorate to a GCS of 8 or less. Less than 10% of patients with minor...

Patients with chest pain often pose a diagnostic conundrum to the attending physician especially when symptoms are not typical of angina and the electrocardiogram nondiagnostic. Troponin levels are frequently measured at presentation to prognosticate the patient. This article is available only as a PDF. Please click on “Download PDF” on...

Positron emission tomography (PET) is distinct from other imaging modalities in its ability to probe the physiology and biochemistry of normal and abnormal tissues. It is based on the same principle of tracer kinetics used in conventional nuclear medicine. This article is available only as a PDF. Please click on...

Myopia is a refractive condition in which the image of a distant object is formed anterior to the retina of the unaccommodated (relaxed) eye. It occurs when the refractive power of the eye is too great compared to the length of the eyeball and this may occur because the...

A number of authors have recently proposed that myopia is increasing at an “epidemic” rate, particularly in East Asia, and especially among populations of Chinese descent. It has been reported that the prevalence of myopia among some populations in this area has reached 90%. This article is available only as...

Complementary and alternative medicine (CAM) has been gaining acceptance throughout the world. The efficacy of CAM is unproven, yet it remains popular with the general public, with many of them utilising it for a whole spectrum of ailments. This article is available only as a PDF. Please click on “Download...

An outbreak of atypical pneumonia was recognised in Singapore soon after the release of a global alert by the World Health Organization (WHO) on 12 March 2003. This disease was later named severe acute respiratory syndrome (SARS). This article is available only as a PDF. Please click on “Download PDF”...

Severe acute respiratory syndrome (SARS) is a recently defined illness caused by a novel coronavirus. The outbreak in Singapore originated from Hong Kong via mainland China. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Despite improved antimicrobial therapy over the past 30 years, there has been little change in the incidence, outcome, or, causative organisms in septic arthritis. Staphylococcus aureus is the commonest cause of septic arthritis and various series reported rates of 17% to 80%. This article is available only as a PDF....

There has been a resurgence of tuberculosis (TB) in many countries, including developed nations, especially with the HIV pandemic and the increase in immigration.1,2 In underdeveloped and developing nations, this infectious disease is still very common. TB peritonitis (TBP) is rarely encountered and is estimated to occur in 0.1%...

Obesity is becoming a problem of epidemic proportions and is perhaps, the most pervasive medical problem faced by medical providers today. It is a problem affecting about 10% to 15% of our school-going population in Singapore, affecting disease burden in virtually every medical subspecialty. This article is available only as...

Sleep problems are common in children. For example, snoring occurs in more than 25% of Singapore children1 and obstructive sleep apnoea (OSA) occurs in 1% to 3% of children. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

The metabolic syndrome (MS) is characterised by a clustering of metabolic risk factors and an insulin-resistant state.1 Its prevalence is high in Western, as well as Asian, populations.2-4 There are numerous correlations between the MS and hypertension, although this is not always the case.5 Resistance to insulin-mediated glucose disposal...

The incidence and prevalence of diabetes mellitus (DM) worldwide is increasing, due almost exclusively to an increase in non-insulin-dependent (type 2) DM, which represents more than 90% of all cases of diabetes.1 Presently, there is a global pandemic of type 2 DM and its clinical sequelae. The World Health...

Seronegative spondyloarthropathies (SpA), a group of arthritides characterised by axial skeletal involvement and the absence of rheumatoid factor, are now enjoying a resurgence of research interest due to recent therapeutic advances. With the availability of anti-tumour necrosis factor (anti-TNF) agents, the short-term improvement in patient outcome in terms of...

Joint aspiration with synovial fluid analysis can provide information which complements that which is available from the history and physical examination of the patient, and can help to differentiate various causes of arthritis. It is most useful in monoarthritis, where septic arthritis as a medical emergency needs to be...

Spinal cord injury (SCI), whether of traumatic or non-traumatic aetiology, often results in significant and catastrophic dysfunction and disability. It physically and psychologically affects not only the individual, but also the family and society. Early rehabilitation in an organised multidisciplinary SCI care system has been shown to be beneficial,...

Strokes in childhood are generally considered to be rare with an incidence of about 2.7 per 100 000 children per year.1 The aetiologies of stroke in children differ considerably from adults and multiple risk factors commonly co-exist. A large stroke registry in North America reported that a large proportion...

Essential hypertension is a chronic disease involving the primary elevation of systemic blood pressure (BP). While the main causes of essential hypertension has not been identified, this disease is currently attributed to a host of genetic and environmental factors.1 Worldwide, hypertension is increasingly prevalent in both developed and developing...

Diffuse idiopathic skeletal hyperostosis (DISH), also known as Forestier’s disease, is a non-inflammatory enthesopathy of unknown etiology. Affecting predominantly men, it results in flowing, robust ossification of the anterior longitudinal ligament of the spine. This article is available only as a PDF. Please click on “Download PDF” on top to...

The prognosis of patients with stage IV melanoma or recurrent melanoma is poor with an estimated median survival period of 6 months. The recent revised version of the American Joint Committee on Cancer (AJCC) staging system for cutaneous melanoma has further sub-divided melanoma metastatic sites to 3 specific categories;...

Decisions regarding potential surgery for metastatic disease are influenced by estimates of patient survival. For example, patients with long life expectancy may be appropriately treated with extensive resection and durable reconstruction to provide long lasting function and mobility; in contrast, a patient with a very short life expectancy may...

Although colorectal cancer is common in Western countries, in the past, it has been uncommon in Asian countries. However, its prevalence has gradually been increasing. Since 1982, malignant cancers have been the leading cause of death in Taiwan. This article is available only as a PDF. Please click on “Download...

Singapore is a country of high income with a low level human immunodeficiency virus (HIV) epidemic, the yearly incidence of disease currently standing at 121.7 new infections per million population per year. Certain features of Singapore’s HIV epidemic are notable. Firstly, despite active screening programmes amongst high-risk populations and...

Tobacco is the leading cause of preventable death and is the fourth most common risk factor for disease. Nearly 6 million deaths occur worldwide every year, which equates to one death every 6 seconds or one in 10 adult deaths. Cigarette smoke contains over 7000 chemicals and compounds, of...

Male breast cancer is a rare disease entity, traditionally said to represent <1% of all diagnosed breast cancers. Recent statistics, however, suggest that its incidence may be on the rise, although the clinical significance of this is unknown. This rarity has precluded large randomised controlled trials, and most treatment...

Prostate cancer (PCa) is the second most frequently diagnosed cancer in men, with a worldwide incidence of approximately 900,000 in 2008. Internationally, there is marked variation in incidence, ranging from 104.2 per 100,000 in some Western populations, to 4.1 per 100,000 in South and Central Asia. However, there has...

The World Health Organization (WHO) estimates that every year, almost a million people die from suicide — a mortality rate of 16 per 100,000, or 1 death every 40 seconds. WHO also posits that in some countries, suicide is one of the three leading causes of death among those...

A 74-year-old male with newly diagnosed melanoma of the right mastoid region, underwent resection of the lesion followed by F-18 fluoro-deoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) for staging. Figure 1 demonstrates a whole body maximal intensity projection image while Figures 2 and 3 show cross-sectional images through the elbows...

A good history and a detailed physical examination is often sufficient to make a diagnosis of a recurrent anterior dislocation of the shoulder, even in the absence of a radiologically documented dislocation of the joint. The anterior apprehension test has recently been supplemented with the relocation, crank, and load...

A 48-year-old female presented with pain and swelling in the bilateral proximal interphalangeal (PIP), metacarpophalangeal (MCP) and wrist joints for the past 20 days. It was acute in onset, severe in intensity to such an extent that she was unable to make a fist. It was associated with acute...

Over the past decade, the non-invasive prenatal test (NIPT) has increasingly been used as a method for prenatal screening for trisomy 21 (T21) and other aneuploidies, complementing the traditional approach of first trimester screening (FTS). FTS comprises ultrasound of the nuchal thickness and blood test to measure the levels...

Little is known about the genetics of Parkinson’s disease (PD) in Southeast Asian populations.1 We extended knowledge of the Southeast Asian monogenic PD landscape by describing a Malaysian Malay family with early-onset PD (EOPD), defined as onset at <50 years of age and a rarely reported homozygous PRKN exon...

Aseptic arthritis can often be associated with viruses— in the Singapore context—dengue or chikungunya viruses. The association of varicella-zoster virus (VZV) with arthritis however, is rare. Few cases of aseptic arthritis associated with VZV have been documented in the paediatric literature in the past 50 years and fewer still...

Membranous nephropathy is an organ-specific autoimmune disease and is the most common cause of adult-onset nephrotic syndrome. The diagnosis of membranous nephropathy mainly depends on pathological characteristics observed through various techniques such as diffuse thickening of the glomerular basement membrane and spike formation by light microscopy, granular deposition of...

Coronavirus disease 2019 (COVID-19) is an ongoing global pandemic infection by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It is established that increasing age and comorbidities such as cardiovascular diseases are associated with risk of infection, more severe disease and adverse outcomes. Obesity is an epidemic globally, causing...

Patients with rheumatic diseases frequently consult primary care physicians, internists and orthopaedic surgeons. In the past, few doctors took interest in these diseases. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Gout is a common metabolic disease that causes arthritis which is often painful and sometimes disabling. It results from the deposition of monosodium urate monohydrate crystals in the joints and soft tissue giving rise to an acute inflammatory response. This article is available only as a PDF. Please click on...

Back pain is a common but often self-limiting problem. However, it is important to recognise causes of chronic backache such as ankylosing spondylitis which are potentially disabling but treatable. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.