This case report is about a rare disease with unusual presentation. Failure to recognise atypical presentation may lead to error in managing the patient and cause disastrous complications. Here we highlight a case of Terrien Marginal Degeneration in both eyes with atypical presentation; namely pseudopterygium. A 22 year old man was referred to our centre for iatrogenic right eye corneal perforation after having an atypical pterygium removed at another hospital. On arrival, his vision was 1/60 in both eyes with bilateral cornea Terrien Marginal Degeneration. His right eye anterior chamber was deep with a conjunctival flap covering the perforation site which was located from the 2.30 - 3.30 clock position nasally with no aqueous leak. However after a day his right eye anterior chamber became flat and there was fast aqueous leak from the perforation site. An emergency C shaped peripheral corneal lamellar keratoplasty was performed to seal the perforation. Post operatively his right eye improved to 6/24.
Male breast cancer accounts for only 1% of cancers in men and 1% of breast cancers. Cutaneous metastases occur less than 10% of all patients with visceral malignancies and are considered a rare and late event in progression of metastatic disease. A 45-year-old man presented with a lump in the left breast which was confirmed to be infiltrating ductal carcinoma. He underwent a left mastectomy and axillary clearance followed by chemotherapy and radiotherapy to the left chest wall. However, he was non-compliant to adjuvant tamoxifen due to hot flushes. One year later, he presented with biopsy proven cutaneous metastases. Initially he had complete excision of the lesions, however, two months later more skin lesions appeared predominantly over the chest wall and back. Hormonal therapy failed to control the metastases as such he was treated with systemic chemotherapy. He is currently on third line chemotherapy.
A massive goiter may constrict the trachea resulting in shortness of breath. Recurrent laryngeal nerve compression may cause vocal cord paralysis. We highlight a case of a 62- year-old female with a 30 year history of an anterior neck swelling gradually increasing in size. She presented with acute symptoms of upper airway obstruction and voice changes. Emergency thyroidectomy was performed by dividing the middle part of the gland using ultrasonic scissors. The recovery was uneventful and the patient regained normal vocal cord function post operatively.
Sensorineural hearing loss following trauma is a common finding in daily clinical practice and usually associated with a poor prognosis. Our case illustrates a patient who was involved in motor vehicle accident sustaining bilateral severe to profound sensorineural hearing loss but subsequently recovered fully after two years. Unless there is clear trauma to the cochlea or auditory nerve, a substantial duration of follow up is needed in the treatment of such cases.
We report a case of melioidosis presenting as peritonitis in a patient on continuous ambulatory peritoneal dialysis (CAPD). A 47-year-old man, a lorry driver, with end-stage renal disease due to diabetes mellitus on CAPD presented in PD-related peritonitis. He was started on intraperitoneal cloxacillin and ceftazidime, and changed to intraperitoneal vancomycin and meropenam after day 5 due to nonresponse. Burkholderia pseudomallei was identified from the dialysate culture. He was treated with intraperitoneal meropenam for two weeks, and IV ceftazidime for 4 weeks. He responded, and the Tenckhoff catheter was not removed. He was discharged well and continued on oral sulfamethoxazole/trimethoprim for six months. This patient had done his PD exchanges in a lorry.
Blastic plasmacytoid dendritic cell neoplasm (a.k.a. NK cell lymphoma, CD4+CD56+ haematodermic neoplasm) is a rare aggressive tumour that arises from plasmacytoid dendritic cell precursors. We report the first case from Malaysia of a 79-year-old Chinese woman who presented with purpuric plaques and nodules produced by pleomorphic CD4+, CD56+, CD68+, CD123+ and CD303+, but CD2APmononuclear cell infiltrates. Leukemic dissemination occurred and she succumbed to disease without treatment 4 weeks after diagnosis and 9 months after onset of cutaneous disease.
The potential harms of herbs to the pregnant mothers and their foetuses as well as the effect of herbs taken by nursing mothers on their babies remain largely unknown. Common perception is that herbal medicines ingestion during pregnancy and confinement period is a common practice among multi-racial Malaysian mothers. The purpose of this study was to explore the usage of herbal medicines during pregnancy and post-partum period among mothers who gave birth at a tertiary hospital in a metropolitan city of Malaysia. This cross sectional study was conducted between October and December 2010. The subjects were interviewed twice after giving birth: before hospital discharge and 6 to 8 weeks later. A total of 323 mothers were recruited for this study. The prevalence of herbs ingestion during pregnancy was 13.9%, with half of the users consuming it during the first trimester. A total of 163 (52.9%) mothers ingested herbs during the post-partum period. Significantly more Chinese (p=0.01) and Malay (p=0.04) mothers ingested herbs during pregnancy and post-partum period, respectively. Infants of mothers who ingested herbs had a higher rate of neonatal jaundice compared to infants of mothers who did not ingest herbs during the post-partum period (P=0.001).
A nationwide HBV vaccination for neonates in the Expanded Programme on Immunization (EPI) was implemented in Malaysia in 1989. The objective of this study was to investigate the prevalence of HBsAg, anti-HBs and anti-HBc among the new student intakes in the Faculties of Medicine and Dentistry, University of Malaya from 2005 to 2011.
Atrial fibrillation (AF) is usually asymptomatic and often associated with established cardiovascular risk factors such as hypertension. The prevalence atrial fibrillation in patients admitted to Malaysian hospitals has been determined, but asymptomatic atrial fibrillation (AAF) in hypertensive patients in the primary care setting is not established. This study reports the prevalence of AAF in hypertensive patients in Malaysia, in a primary care setting. The overall prevalence of AAF was 0.75% with no differences between the gender. The prevalence of AAF increases with age - in the age groups of 30-39, >40-49, >50-59, >60-69, 70-79 and >80 years old were 0%, 0.17%, 0.35%, 2.32%, 2.59%, and 0% respectively. Hypertensive patients with age of ≥ 61 year old were associated with a probability of 10.6 times higher for AAF. We suggest the age threshold to screen for AAF to be age of 60. It is estimated that there are 49,029 Malaysians with AAF in 2010. A large population is at risk of AAF-related complications. There is justification for an even greater emphasis on diagnostic, primary and secondary prevention strategies.
Study site: Klinik Kesihatan Bintulu, Sarawak, Malaysia
Fluorouracil, doxorubicin, cyclophosphamide protocol (FAC) is a commonly used regimen for breast cancer due to its proven efficacy, acceptable toxicity, high affordability. While hepatic insufficiency dosing for doxorubicin and fluorouracil have been set, there is paucity of data in the literature on how to reduce doses in renal insufficiency. We sought to determine whether there is an association with pre-chemotherapy creatinine clearance, and the occurrence of clinically significant grade 3 to 5 neutropenia during the course of FAC chemotherapy.
Trauma is an ever increasing problem and it is the leading cause of morbidity and mortality in the under 40s age group. The main purpose of this study is to determine the pattern of death related to trauma cases presenting to the emergency department (ED) of a university hospital. This was a retrospective analysis of 75 consecutive trauma case records at a university hospital for a one year period. The most common cause of deaths is motor vehicle crashes. The mean score for the injury severity score (ISS) and revised trauma score (RTS) on arrival to the ED among the succumbed patients were 27.8 (s.d 8.6) and 5.7 (s.d 1.1) respectively. 58.7% of deaths occurred within 48 hours after the admission. Less than 50% of studied patients were still alive beyond 45 hours post admission and less than 10% still alive beyond 11 days. Our analysis also showed that 28% (n=21) and 56% (n=41) of the studied sample had a probability of survival between 50% to 75% and more than 75% respectively upon arrival based on the initial vital signs in the ED and the trauma and injury severity score (TRISS) methodology. Overall, we observed similar injury mechanisms, demographics and causes of death compare to other studies. The figures from this study, mandate further exploration of preventive issues and management improvements that should be applied not only to the current trauma system, but also to the health care system in general.
The clycoxygenase (COX) enzyme forms locally active prostaglandins responsible for producing inflammation and pain. Classical non-steroidal anti-inflammatory drugs (NSAID) inhibit the COX-2 enzyme that produces inflammatory prostaglandins as well as the COX-1 enzyme that produces gastric mucosa protecting prostaglandins. By specifically inhibiting only the COX-2 enzyme, coxibs thus reduce pain but do not damage the gastric mucosa. However, COX-2 at the vascular endothelium produces antithrombotic prostaglandins, and so by inhibiting COX-2 enzyme, the coxibs promote thrombosis. Rofecoxib and valdecoxib have been withdrawn because of the adverse cardiovascular events they induce. Amongst presently available coxibs cardiovascular risk is highest with enterocoxib and lowest with celecoxib. NSAIDS also increase cardiovascular events, the risk is highest with diclofenac and lowest with naproxen. Paracetamol and corticosteroids induce hypertension, while steroids also adversely affect the heart from metabolic change as well as fluid retention. Aspirin is an anti-thrombotic agent because of its ability to inhibit the COX-1 enzyme that produces the pro-aggregatory thromboxane. However, it increases gastrointestinal bleeding, can promote fluid retention and is nephrotoxic, all of which may lead to adverse cardiovascular outcomes. Patients at especially high risk of cardiovascular events from analgesic use include the elderly, and those with heart failure, hypertension, rheumatoid arthritis, chronic renal disease, chronic obstructive airway disease and previous myocardial infarction, cerebrovascular disease or peripheral vascular disease. Adverse cardiovascular events can occur within a week of initiation of analgesic treatment.
Left bundle branch block (LBBB) during anaesthesia is uncommon. During general anaesthesia, LBBB may be related to hypertension or tachycardia and its acute onset makes the diagnosis of acute myocardial ischemia or infarction difficult. We would like to present a case report of a healthy patient who developed LBBB intra operatively. Acute LBBB should lead to suspicion of acute coronary syndrome until proven otherwise. Inability to exclude an acute cardiac event resulted in postponement of surgery twice after general anaesthesia was administered. Cardiological investigation of our patient showed physiological left ventricular hypertrophy (LVH), "athlete's heart" which was the most likely cause of the LBBB under anaesthesia.
Synchronous primary non-small cell lung cancers (NSCLC) are rare and may be discovered unexpectedly following lung resection. Discrimination from intrapulmonary metastases is important to guide treatment and prognosis but is difficult solely on clinical or radiological findings. Histopathological evaluation with immunohistochemistry (IHC) markers can prove decisive and should feature in the diagnostic algorithm of such patients. We report a rare case of two synchronous primary NSCLCs diagnosed post operatively following pathological examination of the resected lobe, highlighting the value of IHC and discuss the management of such patients.
A neck mass with soft consistency suggests the diagnosis of a cyst which is usually congenital in origin. Needle aspiration yielding blood should alert the physician the possibility of hemangioma although it is very rare. Ultrasonography and computed tomography will delineate the extent and nature of the lesion and provide the roadmap for surgical excision. We report a case of a girl who presented with a painless neck mass which was later found to be a hemangioma originating from the sternohyoid muscle. The morphology and immunohistochemical stain were consistent with hemangioma.
Papillary thyroid carcinoma is a common thyroid malignancy reported world wide. It affects females more commonly in the 4th to 6th decades of life. The patients usually present with a painless anterior neck mass and occasionally with lymph node involvement. We report a case of an elderly male who presented with hoarseness and hemoptysis, which warranted bronchoscopy. Biopsy of the intraluminal tracheal mass revealed the diagnosis of papillary thyroid carcinoma. Computed tomography scan of the neck confirmed the presence of the primary lesion in the right thyroid lobe with invasion into the adjacent trachea and esophagus.
OBJECTIVES: Alpha thalassaemia is wide spread in Malaysia and is a public health problem. This study aimed to describe the carrier frequencies of α‒thalassaemia and its distribution among major ethnic groups in three states of Malaysia.
METHODS: Educational forums were organised and study was explained to students from three schools. Students were invited to take part in the screening with parent consent. A total of 8420 adolescent students aged 16 years volunteered to participate in the study. Peripheral blood samples were analysed for complete blood counts, haemoglobin quantification and typing, and serum ferritin levels. Genomic DNA was used for screening alpha thalassaemia alleles by PCR based molecular methods.
RESULTS: We identified seven α‒globin gene defects in 341 (4.08%) students: amongst them α(+)‒ and α(0)‒thalassaemias were detected in 232 (2.77%) and 107 (1.28%) students respectively. Genotype ‒α(3.7)/αα was the most prevalent among sub-populations of Malay, indigenous communities of Sahab and Indian, while ‒‒(SEA)/αα deletion is more prevalent in Malaysian Chinese. It is estimated that 63 pregnancies annually are at risk of Hb Bart's hydrops fetalis.
CONCLUSIONS: We have demonstrated the prevalence and mutation patterns of α‒thalassaemia in the 16 year olds in three states of Malaysia. High α(0)‒thalassaemia deletions amongst the study subjects place these carriers at an increased risk of conceiving fetuses with HbH disease and Hb Bart's hydrops fetalis should they choose another heterozygous partner. It is therefore highly recommended to institute community screening programmes and provide prospective carriers with genetic counselling to help them make informed choices.