MyMedR

Fulltext An Unusual Presentation of Tuberculosis

Low, Qin Jian, Cheo, Seng Wee

Borneo Journal of Medical Sciences, 2019;13(2):45-48.

MyJurnal

The normal pericardium is a fibroelastic sac containing a thin layer of fluid that surrounds the heart. Cardiac tamponade, which may be acute or subacute, is characterized by the accumulation of pericardial fluid under pressure. Tuberculous pericarditis is a complication of tuberculosis which is often diagnose late due to the difficulty in establishing this diagnosis. We present a case of pericardial tuberculosis diagnosed in a 20-year-old young retroviral disease patient who presented with signs of cardiac tamponade. His clinical condition improved post-pericardial tapping and he was discharged with anti tuberculosis medications. This case highlight the importance of having a high level of suspicion as this condition is easily curable.

Fulltext A fatal case of metformin and gliclazide poisoning and its management

Low, Qin Jian, Chew, Soo Foong

Borneo Journal of Medical Sciences, 2017;11(3):35-40.

MyJurnal

Both metformin and gliclazide have been used extensively in the management of type II diabetes mellitus. Metformin and gliclazide overdose can lead to severe hypoglycaemia refractory to intravenous (IV) dextrose rescue therapy. A 21-year-old man complained of vomiting and felt dizzy after four hours of taking 70 tablets of Metformin 500 mg and 40 tablets of Gliclazide 80 mg. He had major depressive disorder and wanted to commit suicide. He was given IV Dextrose 50% 50 cc immediately. Octreotide had been used successfully to reverse the refractory hypoglycaemia caused by gliclazide overdose. Unfortunately, he developed severe lactic acidosis with acute kidney injury. Dialysis had been done by continuous venovenous haemodiafiltrationa and intravenous sodium bicarbonate 8.4% infusion was given. However, the patient succumbed due to the severe lactic acidosis and kidney failure despite of urgent dialysis. Octreotide infusion helps in preventing refractory hypoglycaemia secondary to sulfonylurea overdose by inhibit calcium-mediated insulin release. Metformin overdose causes severe lactic acidosis due to conversion of glucose to lactate. Sodium bicarbonate therapy in metformin induced lactic acidosis is also controversial. Though sulfonylurea and metformin are the most commonly-prescribed anti-hypoglycaemic agents, thus during prescribing everyone has to be careful about the overdoses and side effects of these drugs.

Fulltext An unusual case of concurrent dengue and malaria infection

Hong, Eric Qiu Weng, Cheo, Seng Wee, Low, Qin Jian

Borneo Journal of Medical Sciences, 2021;15(1):57-60.

MyJurnal

Dengue and malaria infections are common mosquito-borne infectious diseases in tropical and subtropical regions. The clinical manifestations of dengue and malaria often mimic each other, causing the predicament of early diagnosis without laboratory investigations. Concurrent dengue and malaria infection are often rare scenarios when both diseases occur in a particular patient at the same time. A high index of suspicion is therefore required to establish an early diagnosis to ensure complete success in its management. This case report is about concurrent dengue and malaria infection in a 54-year-old Pakistani man who presented with high-grade fever for three days before admission. On examination, he was febrile (38.8°C) with no other findings. His blood investigations were positive for NS1 antigen and IgM but negative for IgG. His peripheral blood film revealed the presence of Plasmodium vivax. He was treated for dengue fever with supportive management and started with oral Riamet (artemether and lumefantrine) along with oral primaquine 30 mg daily for two weeks’ duration. Following treatment, the patient demonstrated progressive clinical improvement and was subsequently discharged back to the community clinic for the continuation of care.

Fulltext Case Series of Pancytopenia Secondary to Pernicious Anaemia

Low, Qin Jian, Hong, Eric Qiu Weng, Cheo Seng Wee

Borneo Journal of Medical Sciences, 2019;13(2):55-59.

MyJurnal

Pernicious anaemia is an autoimmune disorder where vitamin B12 deficiency is caused by autoantibodies that interfere with vitamin B12 absorption by targeting intrinsic factor or parietal cells or both. It is commonly associated with anaemia, rarely pancytopenia. Here we reported two cases of pancytopenia due to undiagnosed pernicious anaemia. First case was a 26-year-old man presented with lethargy and reduced effort tolerance, associated with postural giddiness and palpitation. Clinically, he was pale with no other findings. On blood investigations, the patient was diagnosed pancytopenia secondary to pernicious anaemia. He was treated with daily subcutaneous injection of vitamin B12 cyanocobalamin 1 mg for one week followed by weekly injection for a month and subsequently with lifelong monthly subcutaneous injection. After receiving 2 weeks of B12 replacement, his full blood count had normalized and his symptoms resolved. Second case was a 65-year-old man presented with yellowish discolouration of the eyes with lethargy. On examination, he was pale with jaundice. On blood investigations, the patient was diagnosed pancytopenia secondary to pernicious anaemia. He was started with intramuscular injection of 1000 mcg vitamin B12 replacement daily for one week followed by monthly for 6 months. After one week of B12 replacement, his full blood count had normalized. He was started on lifelong 3 monthly injections of vitamin B12 replacement and he remained symptom free. Patients with pernicious anaemia often present with general signs and symptoms which occur insidiously. It is important that early diagnosis is made to avoid harmful complications such as neuropsychiatric disorders.

Fulltext Strongyloides Hyperinfection Syndrome in an Immunosuppressed Patient

Cheo, Seng Wee, Tan, Yee Ann, Low, Qin Jian

Borneo Journal of Medical Sciences, 2019;13(1):39-43.

MyJurnal

Strongyloides stercoralis is an intestinal nematode which is endemic in tropical and subtropical countries. The global prevalence of Strongyloides is unknown. Strongyloidiasis is found more frequently in the socioeconomically disadvantaged, in institutionalized populations, and in rural areas. The spectrum of disease varies. It may cause asymptomatic infection, mild eosinophilia or hyperinfection syndrome in the most severe form. Here we reported a case of Strongyloides hyperinfection syndrome in an immunosuppressed patient. This patient is a 54-year-old man with myasthenia gravis on long term azathioprine and prednisolone. He presented with fever associated with diarrhoea and was in septic shock. His blood culture was positive forKlebsiella pneumoniae.Strongyloides stercoralis larvae were detected in his sputum and stool sample. He was diagnosed to have Strongyloides hyperinfection and was treated with subcutaneous ivermectin. He recovered well. Our case demonstrated the association of Strongyloideshyperinfection with superimposed gram-negative sepsis as a consequence of prolonged immunosuppression. A high index of suspicion is needed in approaching patient with risk factors of hyperinfection syndrome.

Fulltext A Single Centre Annual Audit on Computed Tomography Pulmonary Angiogram: Demographic, Clinical Scoring System, Patients’ Outcome

Low Qin Jian, Teo Kuo Zhau, Mohd Nadzri Misni, Cheo Seng Wee

Borneo Journal of Medical Sciences, 2020;14(2):11-18.

MyJurnal

Computed tomography pulmonary angiogram (CTPA) is widely used in the investigation of suspected pulmonary embolism. CTPA is not without adverse effects as it involves intravenous contrast injection and radiation exposure. The annual incidence of pulmonary embolism is 60 – 70 per 100,000 populations and CTPA remains the commonest imaging modality1. This study aims to audit all CTPA performed at Hospital Sultanah Nora Ismail, Batu Pahat, Johor for the entire year of 2018 to illustrate the demographic data, symptoms, risk factors, clinical scoring system applied and patients’ outcome. A retrospective study was conducted to audit all CTPA performed between 1st January to 31st December 2018 via the radiology department electronic records and patients’ records. There were a total of 60 CTPA performed in the entire year of 2018 with 16 positive and 44 negative scans. Among the 16 positive scans, 7 (44%) had a Wells score above 6, 6 (38%) had a Wells score between 2 – 6 and 3 (18%) had a Wells score less than 2. Out of the 16 positive scans, 4 (25%) were known malignancy and 1 was a known case of anti-phospholipid syndrome. All 60 patients had electrographs and arterial blood gases performed prior to CTPA. D dimer was performed in 15 cases (5%). Among the 16 positive scan patients, 4 (25%) passed away during the same admission directly or indirectly related to pulmonary embolism. This annual computed tomography audit report will assist clinicians in making better diagnostic decision when dealing with patients with suspected pulmonary embolism.

Fulltext Prurigo Nodularis and Hodgkin’s Lymphoma: A Rare Association

Go, Zher Lin, Low, Qin Jian, Nurul Aisyah Abd Rahman, Ng, Ling Fong, Faizah Ahmad, Lau, Ngee Siang

Borneo Journal of Medical Sciences, 2019;13(3):59-63.

MyJurnal

Prurigo nodularis (PN) is an uncommon skin condition known to be associated with underlying systemic diseases. This case report is about PN secondary to underlying Hodgkin’s lymphoma. A 30-year-old man presented with this skin condition three months before lymphadenopathy and systemic symptoms due to lymphoma. He had made multiple visits to general practitioners for the disturbing rash, given multiple courses of topical treatment without relief. His PN showed marked improvement after initiation of chemotherapy. This case reminds that an unexplained skin condition should prompt clinicians for investigating for an underlying systemic disease. This case, to our knowledge, is the first Hodgkin’s lymphoma-associated prurigo nodularis reported in Malaysia.

A case of atrial septal defect presenting with recurrent syncope

Cheo SW, Low QJ

Malays Fam Physician, 2021 Jul 22;16(2):90-93.

PMID: 34386172 DOI: 10.51866/cr1125

Atrial septal defect (ASD) is a congenital heart disease often encountered in the adult population, as it is frequently asymptomatic in childhood. In untreated patients with ASD, some may go on to develop complications such as atrial arrythmias, pulmonary hypertension and Eisenmenger syndrome. Pulmonary hypertension is seen in 6 - 35% of this group of untreated patients in adulthood as a result of left-to-right shunting. Symptoms of pulmonary hypertension include progressive dyspnoea, ascites and syncope. Here, we would like to illustrate a case of ASD presenting with recurrent syncopal attack.

A young lady with dysphagia

Cheo SW, Mak WW, Low QJ

Malays Fam Physician, 2021 Jul 22;16(2):98-101.

PMID: 34386174 DOI: 10.51866/tyk1120

Chest radiograph is one of the most commonly employed imaging modalities in primary care. It may be done for symptomatic patients or routine health screening. Hence, it is important for a primary care physician to be able to interpret chest radiograph systematically in relation to patient's clinical history. Here, we would like to illustrate a case of abnormal chest radiograph detected during health screening.

Fulltext A diabetic lady with difficulty in breathing

Cheo SW, Ng KL, Low QJ

Malays Fam Physician, 2021 Nov 30;16(3):126-128.

PMID: 34938405 DOI: 10.51866/tyk1188

Fulltext A rare cause of proximal thigh discomfort and weakness with type 2 diabetes mellitus

Low QJ, Ng BHS, Cheo SW

Borneo Journal of Medical Sciences, 2018;12(1):57-63.

MyJurnal

Diabetic amyotrophy also known as Bruns-Garland syndrome is diabetic neuropathy subtype affecting the lumbosacral nerve roots and peripheral nerves. There is an ongoing debate on the pathophysiology behind this condition whether is it ischaemic, metabolic (hyperglycaemia) or inflammatory. A 36-year-old man with uncontrolled diabetes mellitus complained of unprovoked weight lost and right proximal thigh discomfort with weakness for one week duration. In neurological examination, his right hip flexion was at medical research council (MRC) grade 3, right hip extension MRC grade 4, his knee and ankle flexion and extension are normal (MRC grade 5). The muscle tones and reflexes were normal. Sensation and proprioception were intact bilaterally. Nerve conduction study (NCS) showed markedly reduced amplitude of the compound muscle action potentials and sensory nerve action potentials, while conduction velocities show only mild slowing. He was started on a course of oral prednisolone 10 mg daily and improved gradually. At three months follow-up, his right lower limb power has recovered fully and he can walk without any assistance. Diabetic amyotrophy was confirmed by suggestive clinical features supported by electrophysiological findings of the affected nerves. This condition is due to metabolic derangement and vasculopathy or immune mediated nerve injury. So, the healthcare providers should be aware about this rare complication of diabetes.

Fulltext Leonine facies

Low QJ, Cheo SW, Yap WYE

Indian J Dermatol Venereol Leprol, 2020 2 19;87(4):589-591.

PMID: 32068196 DOI: 10.4103/ijdvl.IJDVL_983_18

Fulltext Primary malignant melanoma of the pleura: a rare case

Low QJ, Ng BHS, Cheo SW

Borneo Journal of Medical Sciences, 2017;11(2):1-3.

MyJurnal

Primary pleural melanoma is a very rare condition
and highly aggressive tumour. A patient presented
with productive cough, haemoptysis, pluritic chest
pain and breathlessness. On investigation, she was
diagnosed as left-sided lung mass with pleural
effusion. Pleural biopsy confirmed malignant
melanoma of pleura and she was subsequently
referred to the oncology team for palliative
chemotherapy. In conclusion, primary pleural
melanoma remains a rare disease with no proven
effective treatment regime available.

Fulltext Images of the month: Intractable vomiting and neuromyelitis optica spectrum disorder

Cheo SW, Low QJ, Tan YA, Chia YK

Clin Med (Lond), 2020 May;20(3):e20-e21.

PMID: 32414735 DOI: 10.7861/clinmed.2020-0019

Neuromyelitis optica spectrum disorder (NMOSD) is a rare inflammatory disorder of the nervous system which can be potentially debilitating. Its prevalence is estimated to be around 0.5-10 per 100,000 population with predilection towards Asians and females. It can be diagnosed based on core clinical characteristics, serum aquaporin antibodies and neuroimaging features. It is important to pick up the diagnosis of NMOSD as the treatment is different from other demyelinating disease. Here, we illustrate a case of NMOSD presented with intractable vomiting.

Interstitial pneumonia with autoimmune features

Low QJ, Teo KZ, Thien LK, Lim TH, Cheo SW

J R Coll Physicians Edinb, 2020 12;50(4):387-391.

PMID: 33469613 DOI: 10.4997/JRCPE.2020.407

BACKGROUND: Cardiac tamponade is a medical emergency. This study was carried out to determine the etiologies of cardiac tamponade and review the management and outcomes.

METHODS: We retrospectively analysed case records of patients who underwent pericardiocentesis for cardiac tamponade during the two consecutive years (1 January 2018 to 31 December 2019) at Hospital Sultanah Nora Ismail, Batu Pahat, in Johor, Malaysia.

RESULTS: There were ten patients (eight males, two females; age range 20 to 70 years old, mean age 36 years old) who underwent pericardiocentesis for cardiac tamponade during the said period. Malignancy (40%), tuberculosis (30%), idiopathic (20%), and bacterial (10%) were among the common causes of the pericardial effusion in this center. The commonest symptoms were breathlessness (90%), chest pain (60%), cough (50%), and unexplained fever (20%). Pulsus paradoxus was the most speciÿ c sign (100%) for the presence of echocardiographic feature of cardiac tamponade. Two of the patients with tuberculous pericarditis had retroviral disease; one patient had bacterial pericarditis due to salmonella typhi.

CONCLUSION: This study has conÿ rmed that there are many etiologies and presentation of cardiac tamponade; clinicians should be alert as urgent pericardiocentesis is lifesaving.

Fulltext A fascinating case of the ‘purple urine bag syndrome'

Low, Qin Jian, Lim, Tzyy Hue, Teoh, Kuo Zhau, Siow, Garry Peir Woeei, Go, Zher Lin, Tee, Vern Jun, et al.

Borneo Journal of Medical Sciences, 2018;12(3):59-62.

MyJurnal

Purple urine bag syndrome (PUBS) is a rare presentation of urinary tract infections (UTIs). It is commonly seen in constipated patients. There is a deep purple discoloration of contents of urine bag due to presence of indigo and indirubin pigments which are metabolites of tryptophan. We would like to describe an interesting case of purple urine bag syndrome of 88-year-old woman who presented with catheter-related urinary tract infection. She had low-grade fever and suprapubic discomfort for three days duration. She had increased white cell count and C-reactive peptide (CRP). Urinalysis showed protein 2+, nitrite and leucocyte esterase positive. Urine culture grew Escherichia coli and Klebsiella pneumoniae. She was treated with oral cefuroxime and recovered. This case report may be the first case of PUBS reported in this region.

Fulltext Erythematous plaques of the vulvo-perineal region

Low QJ, Lim TH, Hon SA, Cheo SW, Wagino N, Yap EWL

Malays Fam Physician, 2021 Nov 30;16(3):101-103.

PMID: 34938398 DOI: 10.51866/cr1276

Skin conditions are a common reason for consulting primary health care. The public frequently expects their primary health care providers to be able to recognise and treat common skin conditions with confidence. Primary care providers must be able to identify 'red flag' skin conditions that require dermatology referral. However, diagnosis is often delayed due to the non-specific clinical presentation, low incidence, slow evolution and long-term history of such lesions. We report the case of a patient with extramammary Paget's disease that presented to her primary care provider and subsequently underwent a wide local excision.

Fulltext A case of dapsone-induced methaemoglobinaemia

Tan YA, Ng KC, Cheo SW, Khoo TT, Low QJ

Clin Med (Lond), 2020 Sep;20(5):519-521.

PMID: 32934050 DOI: 10.7861/clinmed.2020-0364

Methaemoglobinaemia is an uncommon but potentially serious condition. It can be caused by congenital or acquired cause. Drug-induced methaemoglobinaemia is the commonest cause of acquired methaemoglobinaemia. The clinical signs and symptoms of methaemoglobinaemia include dyspnoea, desaturation, presence of saturation gap, headache, nausea and seizures depending on level of serum methaemoglobinaemia. We illustrate a case of dapsone-induced methaemoglobinaemia and its successful treatment by intravenous methylene blue.

Fulltext Reply letter to: Mixed messages and the disparity between various levels of care in chronic kidney disease management

Cheo SW, Low QJ, Lim TH, Mak WW, Yip CAK, Wong KW

Malays Fam Physician, 2022 Jul 24;17(2):123-124.

PMID: 35949995 DOI: 10.51866/mol.002.51866/lte.171r

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