Browse publications by year: 2016

The emerging problems of Klebsiella pneumoniae infections: carbapenem resistance and biofilm formation

Chung PY

FEMS Microbiol Lett, 2016 10;363(20).
PMID: 27664057

Klebsiella pneumoniae is an opportunistic pathogen that commonly causes nosocomial infections in the urinary tract, respiratory tract, lung, wound sites and blood in individuals with debilitating diseases. Klebsiella pneumoniae is still a cause of severe pneumonia in alcoholics in Africa and Asia, and the predominant primary pathogen of primary liver abscess in Taiwan and Southeast Asia, particularly in Asian and Hispanic patients, and individuals with diabetes mellitus. In the United States and Europe, K. pneumoniae infections are most frequently associated with nosocomial infections. The emergence of antibiotic-resistant strains of K. pneumoniae worldwide has become a cause of concern where extended-spectrum β-lactamases (ESBLs) and carbapenemase-producing strains have been isolated with increasing frequency. The pathogen's ability to form biofilms on inserted devices such as urinary catheter has been proposed as one of the important mechanisms in nosocomially acquired and persistent infections, adding to the increased resistance to currently used antibiotics. In this review, infections caused by K. pneumoniae, antibiotic resistance and formation of biofilm will be discussed.

MeSH terms: Anti-Bacterial Agents/therapeutic use*; Bacterial Proteins/genetics; Bacterial Proteins/metabolism; beta-Lactamases/genetics; beta-Lactamases/metabolism; Humans; Klebsiella Infections/drug therapy*; Klebsiella pneumoniae/drug effects*; Klebsiella pneumoniae/growth & development; Opportunistic Infections/drug therapy; Opportunistic Infections/microbiology; Carbapenems/therapeutic use*; beta-Lactam Resistance/genetics*; Biofilms/growth & development*; Urinary Catheters/microbiology
'Non-criteria' neurologic manifestations of antiphospholipid syndrome: a hidden kingdom to be discovered

Islam MA, Alam F, Kamal MA, Wong KK, Sasongko TH, Gan SH

CNS Neurol Disord Drug Targets, 2016;15(10):1253-1265.
PMID: 27658514 DOI: 10.2174/1871527315666160920122750

Neurological manifestations or disorders associated with the central nervous system are among the most common and important clinical characteristics of antiphospholipid syndrome (APS). Although in the most recently updated (2006) APS classification criteria, the neurological manifestations encompass only transient ischemic attack and stroke, diverse 'non-criteria' neurological disorders or manifestations (i.e., headache, migraine, bipolar disorder, transverse myelitis, dementia, chorea, epileptic seizures, multiple sclerosis, psychosis, cognitive impairment, Tourette's syndrome, parkinsonism, dystonia, transient global amnesia, obsessive compulsive disorder and leukoencephalopathy) have been observed in APS patients. To date, the underlying mechanisms responsible for these abnormal neurological manifestations in APS remain unclear. In vivo experiments and human observational studies indicate the involvement of thrombotic events and/or high titers of antiphospholipid antibodies in the neuro-pathogenic cascade of APS. Although different types of neurologic manifestations in APS patients have successfully been treated with therapies involving anti-thrombotic regimens (i.e., anticoagulants and/or platelet antiaggregants), antineuralgic drugs (i.e., antidepressants, antipsychotics and antiepileptics) and immunosuppressive drugs alone or in combination, evidence-based guidelines for the management of the neurologic manifestations of APS remain unavailable. Therefore, further experimental, clinical and retrospective studies with larger patient cohorts are warranted to elucidate the pathogenic linkage between APS and the central nervous system in addition to randomized controlled trials to facilitate the discovery of appropriate medications for the 'non-criteria' neurologic manifestations of APS.

MeSH terms: Animals; Disease Models, Animal; Humans; Nervous System Diseases/etiology*; Nervous System Diseases/metabolism*; Antiphospholipid Syndrome/complications*; Antiphospholipid Syndrome/immunology; Antibodies, Antiphospholipid/blood; Antibodies, Antiphospholipid/metabolism*
Fulltext Coeliac disease: immunogenicity studies of barley hordein and rye secalin-derived peptides

Wahab WA, Šuligoj T, Ellis J, Côrtez-Real B, Ciclitira PJ

Int J Exp Pathol, 2016 Aug;97(4):303-309.
PMID: 27659035 DOI: 10.1111/iep.12199

Coeliac disease (CD) is an inflammatory disorder of the small intestine. It includes aberrant adaptive immunity with presentation of CD toxic gluten peptides by HLA-DQ2 or DQ8 molecules to gluten-sensitive T cells. A ω-gliadin/C-hordein peptide (QPFPQPEQPFPW) and a rye-derived secalin peptide (QPFPQPQQPIPQ) were proposed to be toxic in CD, as they yielded positive responses when assessed with peripheral blood T-cell clones derived from individuals with CD. We sought to assess the immunogenicity of the candidate peptides using gluten-sensitive T-cell lines obtained from CD small intestinal biopsies. We also sought to investigate the potential cross-reactivity of wheat gluten-sensitive T-cell lines with peptic-tryptic digested barley hordein (PTH) and rye secalin (PTS). Synthesised candidate peptides were deamidated with tissue transglutaminase (tTG). Gluten-sensitive T-cell lines were generated by culturing small intestinal biopsies from CD patients with peptic-tryptic gluten (PTG), PTH or PTS, along with autologous PBMCs for antigen presentation. The stimulation indices were determined by measuring the relative cellular proliferation via incorporation of (3) H-thymidine. The majority of T-cell lines reacted to the peptides studied. There was also cross-reactivity between wheat gluten-sensitive T-cell lines and the hordein, gliadin and secalin peptides. PTH, PTS, barley hordein and rye secalin-derived CD antigen-sensitive T-cell lines showed positive stimulation with PTG. ω-gliadin/C-hordein peptide and rye-derived peptide are immunogenic to gluten-sensitive T-cell lines and potentially present in wheat, rye and barley. Additional CD toxic peptides may be shared.

MeSH terms: Hordeum/immunology*; Biopsy; Celiac Disease/immunology*; Celiac Disease/pathology; Cell Line; Cells, Cultured; Cross Reactions/immunology; Glutens/immunology*; Humans; Intestine, Small/immunology; Intestine, Small/pathology; Lymphocyte Activation/immunology; Secale/immunology*; T-Lymphocytes/cytology; T-Lymphocytes/immunology; Antigen Presentation/immunology; Cell Proliferation
Fulltext The influence of system quality characteristics on health care providers' performance: Empirical evidence from Malaysia

Mohd Salleh MI, Zakaria N, Abdullah R

J Infect Public Health, 2016 Nov-Dec;9(6):698-707.
PMID: 27659115 DOI: 10.1016/j.jiph.2016.09.002

BACKGROUND: The Ministry of Health Malaysia initiated the total hospital information system (THIS) as the first national electronic health record system for use in selected public hospitals across the country. Since its implementation 15 years ago, there has been the critical requirement for a systematic evaluation to assess its effectiveness in coping with the current system, task complexity, and rapid technological changes. The study aims to assess system quality factors to predict the performance of electronic health in a single public hospital in Malaysia.

METHODS: Non-probability sampling was employed for data collection among selected providers in a single hospital for two months. Data cleaning and bias checking were performed before final analysis in partial least squares-structural equation modeling.

RESULTS AND CONCLUSIONS: Convergent and discriminant validity assessments were satisfied the required criterions in the reflective measurement model. The structural model output revealed that the proposed adequate infrastructure, system interoperability, security control, and system compatibility were the significant predictors, where system compatibility became the most critical characteristic to influence an individual health care provider's performance. The previous DeLone and McLean information system success models should be extended to incorporate these technological factors in the medical system research domain to examine the effectiveness of modern electronic health record systems. In this study, care providers' performance was expected when the system usage fits with patients' needs that eventually increased their productivity.

MeSH terms: Adult; Female; Health Personnel*; Health Services Research*; Hospital Information Systems*; Hospitals, Public; Humans; Malaysia; Male; Middle Aged; Quality of Health Care*; Electronic Health Records
Fulltext Direct synthesis of nanodiamonds by femtosecond laser irradiation of ethanol

Nee CH, Yap SL, Tou TY, Chang HC, Yap SS

Sci Rep, 2016 Sep 23;6:33966.
PMID: 27659184 DOI: 10.1038/srep33966

Carbon nanomaterials exhibit novel characteristics including enhanced thermal, electrical, mechanical, and biological properties. Nanodiamonds; first discovered in meteorites are found to be biocompatible, non-toxic and have distinct optical properties. Here we show that nanodiamonds with the size of <5 nm are formed directly from ethanol via 1025 nm femtosecond laser irradiation. The absorption of laser energy by ethanol increased non-linearly above 100 μJ accompanied by a white light continuum arises from fs laser filamentation. At laser energy higher than 300 μJ, emission spectra of C, O and H in the plasma were detected, indicating the dissociation of C2H5OH. Nucleation of the carbon species in the confined plasma within the laser filaments leads to the formation of nanodiamonds. The energy dependence and the roles of the nonlinear phenomenon to the formation of homogeneous nanodiamonds are discussed. This work brings new possibility for bottom-up nanomaterials synthesis based on nano and ultrafast laser physics.

MeSH terms: Ethanol; Carbon; Lasers; Light; Physics; Meteoroids; Nanostructures; Physical Phenomena; Nanodiamonds
The central role of national programme management for the achievement of malaria elimination: a cross case-study analysis of nine malaria programmes

Smith Gueye C, Newby G, Tulloch J, Slutsker L, Tanner M, Gosling RD

Malar J, 2016 Sep 22;15(1):488.
PMID: 27659770

A malaria eradication goal has been proposed, at the same time as a new global strategy and implementation framework. Countries are considering the strategies and tools that will enable progress towards malaria goals. The eliminating malaria case-study series reports were reviewed to identify successful programme management components using a cross-case study analytic approach.

MeSH terms: Goals; Malaria; Mosquito Control; Research Design
Fulltext Shewanella algae Peritonitis in Patients on Peritoneal Dialysis

Shanmuganathan M, Goh BL, Lim C, NorFadhlina Z, Fairol I

Perit Dial Int, 2016 9 24;36(5):574-5.
PMID: 27659933 DOI: 10.3747/pdi.2015.00287

Patients with peritonitis present with abdominal pain, diarrhea, fever, and turbid peritoneal dialysis (PD) fluid. Shewanella algae peritonitis has not yet been reported in PD patients in the literature. We present the first 2 cases of Shewanella algae peritonitis in PD patients. Mupirocin cream is applied on the exit site as prophylactic antibiotic therapy.

MeSH terms: Administration, Topical; Anti-Bacterial Agents/administration & dosage; Catheters, Indwelling/microbiology*; Ceftazidime/administration & dosage; Follow-Up Studies; Gentamicins/administration & dosage; Humans; Infusions, Intravenous; Male; Middle Aged; Peritoneal Dialysis/adverse effects*; Peritoneal Dialysis/methods; Peritonitis/drug therapy*; Peritonitis/etiology; Peritonitis/microbiology*; Severity of Illness Index; Mupirocin/administration & dosage; Treatment Outcome; Gram-Negative Bacterial Infections/diagnosis*; Gram-Negative Bacterial Infections/drug therapy; Shewanella/isolation & purification*; Rare Diseases
Fulltext A Rare Case of Roseomonas gilardii Peritonitis in a Patient on Continuous Ambulatory Peritoneal Dialysis

Malini S, Goh BL, Lim TS

Perit Dial Int, 2016 09 10;36(5):578.
PMID: 27659935 DOI: 10.3747/pdi.2016.00103
MeSH terms: Anti-Bacterial Agents/therapeutic use*; Drug Therapy, Combination; Female; Follow-Up Studies; Humans; Infusions, Parenteral; Kidney Failure, Chronic/therapy; Middle Aged; Peritoneal Dialysis, Continuous Ambulatory/adverse effects*; Peritoneal Dialysis, Continuous Ambulatory/methods; Peritonitis/drug therapy*; Peritonitis/etiology; Peritonitis/microbiology*; Severity of Illness Index; Treatment Outcome; Gram-Negative Bacterial Infections/diagnosis; Gram-Negative Bacterial Infections/drug therapy; Rare Diseases; Methylobacteriaceae/drug effects; Methylobacteriaceae/isolation & purification*
Impact of Ramadan focused education program on hypoglycemic risk and metabolic control for patients with type 2 diabetes

Tourkmani AM, Hassali MA, Alharbi TJ, Alkhashan HI, Alobikan AH, Bakhiet AH, et al.

Patient Prefer Adherence, 2016;10:1709-17.
PMID: 27660420 DOI: 10.2147/PPA.S113324

Fasting during the month of Ramadan could lead to acute complications and increased hypoglycemic risk of patients with type 2 diabetes. Therefore, diabetes is one of the diseases that need careful observation and special considerations during Ramadan including patients' education and counseling.
Sex differences in stroke: a socioeconomic perspective

Delbari A, Keyghobadi F, Momtaz YA, Keyghobadi F, Akbari R, Kamranian H, et al.

Clin Interv Aging, 2016;11:1207-1212.
PMID: 27660426

BACKGROUND: A number of studies have explored the issue of sex differences in stroke from biomedical perspective; however, there are still large gaps in the existing knowledge. The purpose of this study was to assess whether the differences in socioeconomic status and living conditions between men and women may explain the part of the sex differences in incidence and outcomes of stroke.
METHODS: All stroke participants aged ≥60 years admitted in Vaseie Hospital in Sabzevar, Iran, from March 21, 2013, until March 20, 2014, were included in this study. Computerized tomography and magnetic resonance imaging were used to confirm stroke. A series of χ2 tests were performed and Statistical Program for Social Sciences, Version 21.0, was used to investigate the potential differences between older men and women in stroke incidence and outcomes.
RESULTS: A total of 159 incident stroke cases were documented during 1 year. The annual rate of stroke was statistically significantly higher in elderly women than in elderly men (401 vs 357 per 100,000; P<0.001). Female elderly participants had significantly lower socioeconomic status, poorer living conditions, and higher lifetime history of depression, hypertension, and diabetes mellitus than their male counterparts.
CONCLUSION: The findings from this study showed that elderly women are more adversely affected by stroke in terms of incidence and outcomes of stroke than elderly men. The most noticeable result is that sex differences in socioeconomic status and living conditions may result in increased incidence of stroke and poorer outcomes in elderly women. Therefore, it is imperative to identify vulnerable elderly women and provide them appropriate treatment and services.
Fulltext Malaysian Journal of Medical Sciences' Publishing Report (2014-2015)

Zulkapli NA, Sobi S, Mohd Zubaidi NA, Abdullah JM

Malays J Med Sci, 2016 Jul;23(4):1-4.
PMID: 27660539 DOI: 10.21315/mjms2016.23.4.1

The Malaysian Journal of Medical Sciences (MJMS) has conducted a simple analysis of its scholarly publication, based on the auto-generated data compiled from ScholarOne Manuscripts(™), an innovative, web-based, submission and peer-review workflow solution for scholarly publishers. The performance of the MJMS from 2014-2015 is reported on in this editorial, with a focus on the pattern of manuscript submission, geographical contributors and the acceptance-rejection rate. The total number of manuscript submissions has increased from 264 in 2014, to 272 in 2015. Malaysians are the main contributors to the MJMS. The total number of manuscript rejections following the review process was 79 (29.9%) in 2014, increasing to 92 (33.8%) the following year, in accordance with the exacting quality control criteria applied by the journal's editor to the submitted manuscripts.

MeSH terms: Peer Review; Quality Control; Internet; Workflow
Fulltext Exploring Cortical Plasticity and Oscillatory Brain Dynamics via Transcranial Magnetic Stimulation and Resting-State Electroencephalogram

Noh NA

Malays J Med Sci, 2016 Jul;23(4):5-16.
PMID: 27660540 MyJurnal DOI: 10.21315/mjms2016.23.4.2

Transcranial magnetic stimulation (TMS) is a non-invasive, non-pharmacological technique that is able to modulate cortical activity beyond the stimulation period. The residual aftereffects are akin to the plasticity mechanism of the brain and suggest the potential use of TMS for therapy. For years, TMS has been shown to transiently improve symptoms of neuropsychiatric disorders, but the underlying neural correlates remain elusive. Recently, there is evidence that altered connectivity of brain network dynamics is the mechanism underlying symptoms of various neuropsychiatric illnesses. By combining TMS and electroencephalography (EEG), the functional connectivity patterns among brain regions, and the causal link between function or behaviour and a specific brain region can be determined. Nonetheless, the brain network connectivity are highly complex and involve the dynamics interplay among multitude of brain regions. In this review article, we present previous TMS-EEG co-registration studies, which explore the functional connectivity patterns of human cerebral cortex. We argue the possibilities of neural correlates of long-term potentiation/depression (LTP-/LTD)-like mechanisms of synaptic plasticity that drive the TMS aftereffects as shown by the dissociation between EEG and motor evoked potentials (MEP) cortical output. Here, we also explore alternative explanations that drive the EEG oscillatory modulations post TMS. The precise knowledge of the neurophysiological mechanisms underlying TMS will help characterise disturbances in oscillatory patterns, and the altered functional connectivity in neuropsychiatric illnesses.

MeSH terms: Brain; Cerebral Cortex; Depression; Electroencephalography; Humans; Neuronal Plasticity; Long-Term Potentiation; Evoked Potentials, Motor; Transcranial Magnetic Stimulation
Fulltext Treatment Outcomes of Patients with Multidrug-Resistant Tuberculosis (MDR- TB) Compared with Non-MDR-TB Infections in Peninsular Malaysia

Elmi OS, Hasan H, Abdullah S, Mat Jeab MZ, Ba Z, Naing NN

Malays J Med Sci, 2016 Jul;23(4):17-25.
PMID: 27660541 MyJurnal DOI: 10.21315/mjms2016.23.4.3

Treating patients with multidrug-resistant tuberculosis (MDR-TB) strains is more complicated, complex, toxic, expensive, than treating patients with susceptible TB strains. This study aims to compare the treatment outcomes and potential factors associated between patients with MDR-TB and non MDR TB infections in peninsular Malaysia.

MeSH terms: Antitubercular Agents; Humans; Malaysia; Mycobacterium tuberculosis; Treatment Outcome; Tuberculosis, Multidrug-Resistant
Fulltext The Combination of Sonography and Physical Examination Improves the Patency and Suitability of Hemodialysis Arteriovenous Fistula in Vascular Access

Mat Said N, Musa KI, Mohamed Daud MA, Haron J

Malays J Med Sci, 2016 Jul;23(4):26-32.
PMID: 27660542 MyJurnal DOI: 10.21315/mjms2016.23.4.4

We compared the patency and the suitability of arteriovenous fistula (AVF) created for vascular access by two approaches: (a) physical examination with preoperative vascular mapping and (b) physical examination alone.

MeSH terms: Arteriovenous Fistula; Arteriovenous Shunt, Surgical; Physical Examination
Fulltext Psychometric Properties of the Heart Disease Knowledge Scale: Evidence from Item and Confirmatory Factor Analyses

Lim BC, Kueh YC, Arifin WN, Ng KH

Malays J Med Sci, 2016 Jul;23(4):33-45.
PMID: 27660543 MyJurnal DOI: 10.21315/mjms2016.23.4.5

Heart disease knowledge is an important concept for health education, yet there is lack of evidence on proper validated instruments used to measure levels of heart disease knowledge in the Malaysian context.

MeSH terms: Health Education; Heart Diseases; Knowledge
Fulltext Office exercise training to reduce and prevent the occurrence of musculoskeletal disorders among office workers: a hypothesis

Shariat A, Mohd Tamrin SB, Arumugam M, Danaee M, Ramasamy R

Malays J Med Sci, 2016 Jul;23(4):54-8.
PMID: 27660545 MyJurnal DOI: 10.21315/mjms2016.23.4.7

Pain in specific areas of the body (including the lower back, neck, and shoulders) due to extended periods of sitting and inactivity is the most widespread musculoskeletal disorder worldwide and has consequences that are both socio-economic and personal. This condition is particularly prevalent in industrialised countries, affecting roughly 70% to 80% of adults at some point in their lives; approximately 1% of the U.S. population is chronically disabled by this type of pain disorder. A practical way to reduce the prevalence of musculoskeletal pain among office workers would have a significant positive impact. More work is required to develop a package of exercises designed to prevent and treat musculoskeletal pain in office workers. Such a package would be preferable to pharmacological treatments, which can have undesirable side effects. The main objective of this package would be to increase the flexibility and strength of trunk muscles in order to decrease the soreness, pain, and degree of discomfort. In this article, we introduce our proposed package of exercises, which are based on guidelines issued bythe American College of Sports Medicine.

MeSH terms: Adult; Humans; Musculoskeletal Diseases*; Musculoskeletal Pain
Fulltext Onyx in Brain Arteriovenous Malformation Embolisation

Hashim H, Muda AS, Abdul Aziz A, Abdul Hamid Z

Malays J Med Sci, 2016 Jul;23(4):59-64.
PMID: 27660546 MyJurnal DOI: 10.21315/mjms2016.23.4.8

Embolisation has long been used as an adjunct to surgical resection in the treatment of brain arteriovenous malformation (bAVM). The most commonly used embolic material, n-butylcyanoacrylate glue, requires experience and skill to handle its quick and unpredictable flow and polymerisation. A new liquid embolic agent, ethylene vinyl alcohol copolymer (Onyx), is less adhesive and polymerises slowly, which provides better control for radiologists performing embolisation.

MeSH terms: Adhesives; Brain; Intracranial Arteriovenous Malformations; Embolization, Therapeutic; Enbucrilate; Ethylenes; Polyvinyls; Radiologists
Fulltext A Ten-Year Kuala Lumpur Review on Laser Posterior Cordectomy for Bilateral Vocal Fold Immobility

Mawaddah A, Marina MB, Halimuddin S, Mohd Razif MY, Abdullah S

Malays J Med Sci, 2016 Jul;23(4):65-70.
PMID: 27660547 MyJurnal DOI: 10.21315/mjms2016.23.4.9

Bilateral vocal fold immobility (BVFI) is commonly caused by injury to the recurrent laryngeal nerve (RLN) and leads to stridor and dyspnea of varying onsets. A retrospective study was done at the Department of Otorhinolaryngology of Universiti Kebangsaan Malaysia Medical Centre on laser microsurgical posterior cordectomy for BVFI. The objectives were to identify the average duration of onset of stridor from the time of insult and to evaluate the outcome of laser posterior cordectomy as a surgical option. From 1997 to 2007, a total of 31 patients with BVFI were referred for surgery. Twelve patients had tracheostomy done prior to the procedure, whereas 19 patients were without tracheostomy. Ten patients were successfully decannulated, and only 4 patients had complications related to the procedure. The minimum onset of stridor was 7 months, maximum onset of stridor was 28 years, and the mean onset of stridor was 8.7 years. The commonest complication observed was posterior glottic adhesion following bilateral posterior cordectomy. Laser endolaryngeal posterior cordectomy is an excellent surgical option as it enables successful decannulation or avoidance of tracheostomy in patients with BVFI. The onset of stridor took years after the insult to the recurrent laryngeal nerves.

MeSH terms: Dyspnea; Humans; Larynx; Malaysia; Otolaryngology; Recurrent Laryngeal Nerve; Respiratory Sounds; Retrospective Studies; Tracheostomy; Vocal Cord Paralysis; Vocal Cords
Fulltext Thymectomy for Myasthenia Gravis: A 10-year Review of Cases at the Hospital Universiti Sains Malaysia

Muhammed J, Chen CY, Wan Hitam WH, Ghazali MZ

Malays J Med Sci, 2016 Jul;23(4):71-8.
PMID: 27660548 MyJurnal DOI: 10.21315/mjms2016.23.4.10

A thymectomy is considered effective for patients with myasthenia gravis (MG). Although a few studies have described the role of a thymectomy in the treatment of MG in Asians countries, there are no published data on the application of this surgical approach for MG in Malaysia. We aimed to describe the clinical outcomes of MG patients who underwent a thymectomy and the factors affecting these outcomes.

MeSH terms: Asia; Humans; Malaysia; Myasthenia Gravis; Thymectomy
Fulltext Rare Presentation of Pseudomyxoma Retroperitonei: Stretching the Limits

Hasan R, Kumar S, Rao AC, Kadavigere R

Malays J Med Sci, 2016 Jul;23(4):79-85.
PMID: 27660549 DOI: 10.21315/mjms2016.23.4.11

A 55-year-old woman presented with a mucopurulent sinusal discharge from the right supragluteal region, with symptoms over the previous five months. This abscess began as a slowly swelling growth, which eventually turned into a discharging sinus, and she was diagnosed with a gluteal abscess. The patient underwent incisional drainage, and intra-operatively, the sinus tract could be seen extending to the retroperitoneum. A subsequent CT scan and an MRI of the abdomen revealed a large heterogeneous retroperitoneal cystic mass on the right side of midline, extending inferiorly into the anterior thigh along the iliopsoas. Superiorly, a tubular projection extended from the lesion, indenting the ileocaecal junction, while a fluid filled cutaneous fistulous tract was seen, extending to the right flank. A diagnosis of pseudomyxoma retroperitonei, likely of retrocaecal appendicular origin, was proposed. An explorative laparotomy with an appendectomy, and the evacuation of the retroperitoneal collection were completed. The subsequent histopathology confirmed the diagnosis of appendicular mucinous cystadenoma, with pseudomyxoma retroperitonei.

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