Browse publications by year: 2021

Littoral cell angioma disguised as huge ovarian cyst: A thought to ponder

Nur Bazlaah B, Khairuzi S, Syariz Ezuan S, Ismayudin I, Poobalan K, Adzwani M, et al.

Med J Malaysia, 2021 Nov;76(6):921-923.
PMID: 34806686

Littoral cell angioma (LCA) of the spleen is a rare vascular tumour. It was thought to be a benign and incidental lesion. Given the relative lack of specific symptom in many cases, these tumours are found incidentally during abdominal surgery during a non-related procedure. Clinical manifestation of a huge adnexal mass and the atypical appearance of splenomegaly, explains the often misguided diagnosis. To the best of our knowledge, there has been no case of incidental finding of LCA disguised as a huge ovarian cyst in Malaysia. We present a case report of a focal solitary LCA incidental finding after splenectomy.
Baby boy blue … and mommy too! A rare case of methaemoglobinaemia presenting simultaneously in a mother-neonate pair

Foong SC, Hwang YC, Foong WC, Tan ML

Med J Malaysia, 2021 Nov;76(6):924-926.
PMID: 34806687

Methaemoglobinaemia occurs when there is >1% methaemoglobin in erythrocytes. In an infant, they can present either congenitally or in an acquired form. We present a rare case of methaemoglobinaemia presenting simultaneously in a mother and infant pair. The mother and infant were discharged well on Day-4 post-delivery with both mother and baby recording oxygen saturation levels of 100%. On Day-7, during a routine clinic visit, they were incidentally found to be centrally cyanosed. There were no other abnormalities. On investigation, the methaemoglobin levels were elevated in the infant (23.9%) and mother (14.3%). Treatment with ascorbic acid normalised mother's methaemoglobin levels; but baby's levels remained high until the administration of oral methylene blue. Both baby and mother remained well and pink at last follow-up at 2 years 8 months of age. This case illustrates difficulties in ascertaining the cause of methaemoglobinaemia. Postdelivery, the mother-neonate pair were pink, and their haemoglobin electrophoresis were normal, hence it was unlikely to be congenital methaemoglobinaemia. The team could not identify any triggering factors for acquired methaemoglobinaemia. There was also the uncertainty of the necessity to treat the baby. This is because treatment is not without harmful effects and despite the high methaemoglobin levels, the infant was otherwise well. Only a single published paper recommended that high methaemoglobin levels must be treated, and the recommendation was not supported by evidence. Lessons learnt from our case are that neonates with methaemoglobinaemia can be safely treated with oral methylene blue, but more research is needed on the benefitrisk profile of treatment.
Infected pancreatic pseudocyst following severe dengue infection

Lee SL, Ng CY, Sidhu J

Med J Malaysia, 2021 Nov;76(6):927-929.
PMID: 34806688

Severe dengue infection is life threatening as it can result in fatal complications such as intractable bleeding from coagulopathy, multiorgan failure from shock and haemophagocytic syndrome. There have been case reports of atypical manifestation of severe dengue infection such as pancreatitis, Guillian-Barre's syndrome, perforated viscus and myocarditis. However, to our knowledge, pancreatic pseudocyst from dengue-related pancreatitis has never been reported in the literature. We hereby report a case of infected pancreatic pseudocyst in a patient with persistent pyrexia, abdominal pain and raised inflammatory markers 10 weeks from the onset of severe dengue infection. Endoscopic ultrasound (EUS) guided transluminal drainage of the infected pancreatic pseudocyst with lumen-apposing metallic stent (LAMS) was performed with good clinical and radiological outcome.
Functional neurological disorder during the perinatal period: A case report

Samuel Kanniah E, Subhas N, Silim UA, Loo JL, Tharumalingam T

Med J Malaysia, 2021 Nov;76(6):930-932.
PMID: 34806689

Functional neurological disorder (FND) is a rare neuropsychiatric illness that commonly presents to the medical setting as opposed to the psychiatric setting. FND is characterised by signs and symptoms affecting the voluntary motor or sensory function that cannot be explained by a specific neurological or general medical condition. FND in pregnancy and postpartum is rare. We report here a case of FND in a 32-year-old woman who presented with multiple medical problems during her perinatal period. She exhibited 'la belle indifference', history of vague unexplained medical symptomatology while all relevant investigations were normal. There were longstanding psychosocial and interpersonal difficulties with significant distress including multiple personal, marital, and family issues which stemmed from her childhood. This left her feeling inadequate as a mother to her infant. The diagnosis of FND was finalised by the multidisciplinary team consisting of a neurologist, physicians, and psychiatrists, based on longitudinal assessment. Psychological intervention for the patient included psychoeducation, supportive psychotherapy, stress management, and parental intervention. The key point in our management of the patient was the delivery of the diagnosis to help her understand the illness and treatment plan. For this patient, functional and psychological recovery is achievable with a good therapeutic alliance, early diagnosis of the illness, and the acceptance of her diagnosis.
Iced towel - a novel method to revert supraventricular tachycardia in a paediatric patient

Sadesvaran M, Mohd Shukri MF, Rahman A, Than Y, Liyana AA, Baharuddin KA

Med J Malaysia, 2021 Nov;76(6):933-936.
PMID: 34806690

Supraventricular tachycardia (SVT) is the commonest tachyarrhythmia among paediatric age group. Modified Valsalva manoeuvre can be attempted in a stable child. We discuss here a case of a 6-year-old boy who presented with stable SVT and iced towel was applied to his face to revert the tachyarrhythmia. This method was well tolerated by the child without any complications. The SVT was successfully reverted, and pictures were taken to capture the simple but effective method.
When polymyositis meets Graves' disease: A rare case report

Chai ST, Lim YS, Achok HN

Med J Malaysia, 2021 Nov;76(6):937-940.
PMID: 34806691

Polymyositis is rarely associated with Graves' disease. A 22- year-old woman was admitted for progressively worsening proximal muscle weakness of both upper and lower extremities. One month prior to admission, she was diagnosed with thyrotoxicosis and prescribed carbimazole 10mg twice daily. Neurological examination confirmed proximal myopathy and blood investigations revealed marked elevation of muscle enzymes, particularly creatine kinase. Electromyography demonstrated myopathic changes while right quadriceps muscle biopsy showed only traces of inflammatory myopathy. She was treated with pulsed intravenous methylprednisolone followed by tapering doses of oral prednisolone, which was eventually down-titrated to 5mg daily during subsequent clinic visits. The initial clinical improvement that she exhibited did not persist despite being rendered euthyroid. She was readmitted approximately one year later with the same complaint. A second course of intravenous methylprednisolone brought about clinical improvement as well as reduction of creatine kinase levels. A diagnosis of polymyositis was then made, for which she was managed with oral prednisolone 20mg daily in combination with gradual up-titration of azathioprine. She continued to show clinical and biochemical improvements during follow-ups. Polymyositis should be considered in the diagnostic workup of proximal myopathy in a patient with Graves' disease, especially in the setting of markedly raised muscle enzymes.
Idiopathic hyperprolactinemia - A challenge for primary care

Mohamed Juhan NAKF, Shalihin MSE

Med J Malaysia, 2021 Nov;76(6):941-945.
PMID: 34806692

Hyperprolactinemia is a condition of elevated serum prolactin, which usually occurs in women as compared to men. Most patients present to primary care clinics with a history of galactorrhoea, oligomenorrhea, amenorrhoea or infertility. Literature search reveals that there were few idiopathic causes of hyperprolactinemia, which resolved by itself without specific pharmacological or surgical treatment. This case is of a 39-year-old woman presented with amenorrhea for four months after Implanon removal and concomitantly noted to have galactorrhoea for four years without any medical attention. The condition persisted after cessation of breastfeeding. After undergoing several investigations including imaging studies, the underlying cause of hyperprolactinemia was noted to be idiopathic. Due to the unclear cause of its aetiology, this case caused various challenges to the primary care. Exhaustive physiological and pathological causes of hyperprolactinemia have been ruled out. Nevertheless, with adequate treatment, she gained her normal menstrual and resolved galactorrhoea symptoms.
The effects of Goldenhar Syndrome on hearing and speech development

Zizlavsky S, Anam K, Suwento R, Rahmawati I

Med J Malaysia, 2021 Nov;76(6):946-949.
PMID: 34806693

Goldenhar syndrome is a congenital abnormality with an incidence of 1 in 5,200 to 26,500 births. This syndrome is characterized by facial asymmetry, ear malformation, and/or defects in the eyes and vertebrae. The hearing disorder manifests as both conductive or sensorineural due to the abnormalities occurring in the inner and outer ear. We report a case of a 1-year-3-month-old child presenting with left anotia and right microtia, severe bilateral conductive hearing loss, and global delayed development. The patient was also found to have a hemifacial microsomia, a secundum atrial septal defect (ASD), and a ventricular septal defect (VSD). The patient was advised to use hearing aids and participate in speech therapy. The management of this Goldenhar syndrome patient should be done comprehensively, appropriate to the abnormalities found to achieve the best result.
I think I have double vision? Or not? Internuclear Ophthalmoplegia following right lacunar infarct

Lee HN, Subrayan V

Med J Malaysia, 2021 Nov;76(6):950-952.
PMID: 34806694

Internuclear Ophthalmoplegia (INO) is an inability of the ipsilateral adduction with a contralateral horizontal abducting saccade on attempted gaze to the contra-lesion side. Injury to the medial longitudinal fasciculus (MLF) will obstruct the signalling pathway between the ipsilateral abducens nucleus and the contralateral medial rectus muscle. Infarction accounts for 38% of INO cases with mostly being unilateral (87%), followed by demyelination (34%), which mostly being bilateral (73%). Lacunar infarct is the most common ischemic stroke. INO can be easily missed due to its subtle presentation with no complaints from the patients. A full cranial nerves assessment, includes the extraocular muscles movement, is important. Ischemic and demyelinating INO typically recover. We present here of a case of INO following right lacunar infarct in a 72-year-old Malay woman. She had hypertensive crisis due to missed medications. Her blood pressure was well controlled throughout the hospital admission and finally she was discharged home with continuation of care at her primary facility.
Clots in tuberculosis

Ng BH, Andrea YLB, Nuratiqah NA, Faisal AH, Low HJ

Med J Malaysia, 2021 Nov;76(6):953-955.
PMID: 34806695

Tuberculosis (TB) is a common communicable disease. Active TB infection may be complicated by both venous and arterial thrombosis which are often under-recognised. We report two patients with incidental TB associated thrombosis involving different venous systems. Both responded to anticoagulant and anti-tuberculous therapy (ATT). Patients with tuberculosis are at risk of VTE and careful monitoring for venous thromboembolism (VTE) is needed during ATT. Our case illustrates the importance of having a high index of suspicion for silent VTE as it may complicate active TB infection.
Infantile intracardiac thrombus in severe encephalo-myocarditis

Woodhull S, Choo KK, Terumalay SD, Liew PS, Tan ZY

Med J Malaysia, 2021 Nov;76(6):956-959.
PMID: 34806696

Myocarditis is an uncommon disease in childhood and has a wide range of clinical presentations, from subtle to devastating and thus requires a high index of suspicion. Intracardiac thrombus formation following myocarditis is rare and thus its management remains challenging and not well defined. We report a child whom presented with a viral prodrome, rapidly deteriorated into multi organ failure and developed fulminant viral myocarditis with encephalitis that was complicated with an intracardiac thrombus formation. We describe the challenges faced, the successful medical treatment offered and propose factors that can help guide appropriate treatment.
Epidemiology, clinical characteristics and treatment of SARS-CoV-2 infection in children: A narrative review

Ayittey FK, Chiwero NB, Dhar BK, Tettey EL, Saptoro A

Int J Clin Pract, 2021 Dec;75(12):e15012.
PMID: 34806816 DOI: 10.1111/ijcp.15012

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has infected millions of people around the world, with most cases recorded among adults. The cases reported among children have been acknowledged to be minimal in comparison to adults. Nevertheless, coronavirus disease 2019 (COVID-19) has been reported to affect children of all ages, including newborns. The symptoms among children have also been identified to be similar to those observed among adults, although paediatric patients have been noted to display a spectrum of clinical features ranging from asymptomatic to moderate symptoms. Despite ample publications on the ongoing pandemic, the literature is only replete with guidelines on treating SARS-CoV-2 infection among older people. In this narrative review, comprehensive updates on the infection in children have been discussed. The latest information on the spread of the disease among children around the world, the clinical features observed among the paediatric population, as well as recommended pharmaceutical treatments of COVID-19 among this special group of patients have been covered. Further, expert consensus statements regarding the management of this highly contagious disease among pregnant women and neonates have been discussed. It is believed that this comprehensive review will provide updated information on the epidemiology and clinical features of the ongoing pandemic among paediatric patients. Additionally, the guidelines for handling SARS-CoV-2 among pregnant women and children, as reviewed in this article, are anticipated to be useful to frontline clinicians battling this fatal disease around the globe.
Asia Pacific Stroke Organization

Tan KS, Lin RT, Yoon BW, Suwanwela N, Mehndiratta MM, Venketasubramanian N

Stroke, 2021 12;52(12):e844-e845.
PMID: 34807747 DOI: 10.1161/STROKEAHA.121.035397
MeSH terms: Asia; Humans; Organizations, Nonprofit/organization & administration*; Pacific Islands; Societies, Medical/organization & administration*; Stroke*
Fulltext Phylogeography and phylogeny of Rhinoviruses collected from Severe Acute Respiratory Infection (SARI) cases over successive epidemic periods in Tunisia

Haddad-Boubaker S, Ben Hamda C, Ghedira K, Mefteh K, Bouafsoun A, Boutiba-Ben Boubaker I, et al.

PLoS One, 2021;16(11):e0259859.
PMID: 34807924 DOI: 10.1371/journal.pone.0259859

Rhinoviruses (RV) are a major cause of Severe Acute Respiratory Infection (SARI) in children, with high genotypic diversity in different regions. However, RV type diversity remains unknown in several regions of the world. In this study, the genetic variability of the frequently circulating RV types in Northern Tunisia was investigated, using phylogenetic and phylogeographic analyses with a specific focus on the most frequent RV types: RV-A101 and RV-C45. This study concerned 13 RV types frequently circulating in Northern Tunisia. They were obtained from respiratory samples collected in 271 pediatric SARI cases, between September 2015 and November 2017. A total of 37 RV VP4-VP2 sequences, selected among a total of 49 generated sequences, was compared to 359 sequences from different regions of the world. Evolutionary analysis of RV-A101 and RV-C45 showed high genetic relationship between different Tunisian strains and Malaysian strains. RV-A101 and C45 progenitor viruses' dates were estimated in 1981 and 1995, respectively. Since the early 2000s, the two types had a wide spread throughout the world. Phylogenetic analyses of other frequently circulating strains showed significant homology of Tunisian strains from the same epidemic period, in contrast with earlier strains. The genetic relatedness of RV-A101 and RV-C45 might result from an introduction of viruses from different clades followed by local dissemination rather than a local persistence of an endemic clades along seasons. International traffic may play a key role in the spread of RV-A101, RV-C45, and other RVs.

MeSH terms: Child; Child, Preschool; Biological Evolution; Female; Genotype; Humans; Infant; Phylogeny; Pneumonia; Rhinovirus/classification*; Rhinovirus/genetics*; Rhinovirus/pathogenicity; Tunisia/epidemiology; Genetic Variation/genetics; Evolution, Molecular; Capsid Proteins/genetics; Severe Acute Respiratory Syndrome/epidemiology*; Severe Acute Respiratory Syndrome/virology; Epidemics; Phylogeography/methods
Mental Health of University Students in Southeastern Asia: A Systematic Review

Dessauvagie AS, Dang HM, Nguyen TAT, Groen G

Asia Pac J Public Health, 2021 Nov 19.
PMID: 34798781 DOI: 10.1177/10105395211055545

Mental health in young people is a public health challenge worldwide, with around one-fifth of university students suffering from a 12-month mental disorder. In low- and middle-income countries (LMICs) of Southeastern Asia, resources for mental health are limited and counseling services are not regularly established at universities. This review aims to determine the prevalence of mental health problems among university students in 6 ASEAN (Association of Southeast Asian Nations) countries (Cambodia, Laos, Malaysia, Myanmar, Thailand, and Vietnam) and to identify the determinants of mental health. A systematic database search (PubMed, CINAHL, PsycINFO, PubPsych, and Scopus) for peer-reviewed, English language articles, published 2010-2020, reporting prevalence data based on standardized screening instruments resulted in 335 articles; 108 were eligible for full-text analysis, of which 34 could be included in the review. Median point prevalence was 29.4% for depression, 42.4% for anxiety, 16.4% for stress, and 13.9% for disordered eating. Current suicidality was present in 7% to 8% of students. There was a high rate of psychiatric comorbidity. Despite the high prevalence of mental health problems, the willingness to seek professional help was comparatively low. Implications for mental health promotion and prevention in university settings are discussed.
Fulltext α-Synuclein-mediated neurodegeneration in Dementia with Lewy bodies: the pathobiology of a paradox

Simon C, Soga T, Okano HJ, Parhar I

Cell Biosci, 2021 Nov 19;11(1):196.
PMID: 34798911 DOI: 10.1186/s13578-021-00709-y

Dementia with Lewy bodies (DLB) is epitomized by the pathognomonic manifestation of α-synuclein-laden Lewy bodies within selectively vulnerable neurons in the brain. By virtue of prion-like inheritance, the α-synuclein protein inexorably undergoes extensive conformational metamorphoses and culminate in the form of fibrillar polymorphs, instigating calamitous damage to the brain's neuropsychological networks. This epiphenomenon is nebulous, however, by lingering uncertainty over the quasi "pathogenic" behavior of α-synuclein conformers in DLB pathobiology. Despite numerous attempts, a monolithic "α-synuclein" paradigm that is able to untangle the enigma enshrouding the clinicopathological spectrum of DLB has failed to emanate. In this article, we review conceptual frameworks of α-synuclein dependent cell-autonomous and non-autonomous mechanisms that are likely to facilitate the transneuronal spread of degeneration through the neuraxis. In particular, we describe how the progressive demise of susceptible neurons may evolve from cellular derangements perpetrated by α-synuclein misfolding and aggregation. Where pertinent, we show how these bona fide mechanisms may mutually accentuate α-synuclein-mediated neurodegeneration in the DLB brain.
Isolation of new phytometabolites from Alpinia galanga willd rhizomes

Sharma PK, Fuloria S, Ali M, Singh A, Kushwaha SP, Sharma VK, et al.

Pak J Pharm Sci, 2021 Jul;34(4):1397-1401.
PMID: 34799313

The current research was aimed to isolate newer phyto-metabolites from rhizomes of Alpinia galanga plant. Study involved preparation of Alpinia galanga rhizome methanolic extract, followed by normal phase column chromatography assisted isolation of new phytometabolites (using different combinations of chloroform and methanol), and characterization (by UV, FTIR, 13C-NMR, 1H-NMR, COSY, DEPT and Mass spectrometry). The isolation and characterization experiment offered two phytometabolites: an ester (Ag-1) and tetrahydronapthalene type lactone (Ag-2). Present study concludes and reports the two phytometabolites, benzyl myristate (Ag-1) and 3-Methyl-6α, 8β-diol-7-carboxylic acid tetralin-11, 9β-olide (Ag-2) for the first time in Alpinia galanga rhizome. The study recommends that these phytometabolites Ag-1 and Ag-2 can be utilized as effective analytical biomarkers for identification, purity and quality control of this plant in future.
Optimization of empagliflozin immediate release tablets (10 mg) using central composite rotatable design with response surface methodology

M Hanif A, Bushra R, Iffat W, Ghayas S, Perveen S, Riaz H, et al.

Pak J Pharm Sci, 2021 Jul;34(4(Supplementary)):1519-1525.
PMID: 34799327

Empagliflozin is a selective inhibitor of sodium glucose co-transporter II, given as mono therapy or an add-on treatment to reduce the glycated hemoglobin levels in type 2 diabetes. This work deals with designing, formulating and optimizing empagliflozin (10mg) immediate release (IR) tablets by direct compression technique using different excipients. Through central composite rotatable design (CCRD), total nine formulations (EF1-EF9) were generated by changing the composition of binder avicel PH 102® (X1) and superdisintegrant acdisol⌖ (X2). Formulation runs with in suitable weight range and powder properties were subjected to compression. The influence of interaction of excipients on friability (Y1), hardness (Y2) and disintegration (Y3) were analyzed by fitting the polynomial quadratic model with response surface methodology (RSM). Trials EF2, EF7, EF8 and EF9 exhibited acceptable tablet attributes upon physico-chemical testing. Different dissolution models were applied to observe the in vitro drug release pattern in phosphate buffer of pH 6.8. The cumulative drug release of IR tablet batches followed the Weibull kinetics with regression coefficient (r2) values of 0.983-0.992. Empagliflozin trials were exposed to accelerated storage conditions (40±2°C/ 75±5% RH) for stability testing. Shelf life period of exposed formulations were computed in range of 22 to 25 months. Keeping in view of the results, it is concluded that the employed technique of preparation and optimization are observed to be excellent for developing immediate release empagliflozin (10mg) tablets.
Fulltext Humanistic and socioeconomic burden of COPD patients and their caregivers in Malaysia

Rehman AU, Muhammad SA, Tasleem Z, Alsaedi A, Dar M, Iqbal MO, et al.

Sci Rep, 2021 11 19;11(1):22598.
PMID: 34799609 DOI: 10.1038/s41598-021-01551-5

Chronic obstructive pulmonary disease (COPD) is associated with substantial humanistic and socioeconomic burden on patients and their caregivers. COPD is expected to be 7th leading cause of disease burden till 2030. The objective of the current study was to assess the humanistic and socioeconomic burden of COPD patients and their caregivers in Malaysia. The burden includes the cost of management of COPD, QOL of COPD patients and their caregivers, work productivity and activity impairment of COPD patients and their caregivers due to COPD. One hundred and fifty COPD patients and their caregivers from the chest clinic of Penang Hospital were included in the study from August 2018 to August 2019. Caregiving cost was estimated using the replacement cost approach, while humanistic and social burden was assessed with the help of health status questionnaires. Overall, 64.66% and 7.1% of COPD patients reported to depend on informal caregivers and professional caregivers respectively. COPD patients reported dyspnoea score as 2.31 (1.31), EQ-5D-5L utility index 0.57 (0.23), CCI 2.3 (1.4), SGRQ-C 49.23 (18.61), productivity loss 31.87% and activity impairment 17.42%. Caregivers reported dyspnoea score as 0.72 (0.14), EQ-5D-5L utility index 0.57 (0.23), productivity loss 7.19% and social activity limitation as 21.63% due to taking care of COPD patients. In addition to the huge direct cost of management, COPD is also associated with substantial burden on society in terms of compromised quality of life, reduced efficiency at the workplace, activity impairment and caregiver burden.
Budget Impact of Emicizumab for Routine Prophylaxis of Bleeding Episodes in Patients With Hemophilia A With Inhibitors

Watanabe AH, Lee SWH, Chai-Adisaksopha C, Lim MY, Chaiyakunapruk N

Value Health Reg Issues, 2021 Nov 17;28:7-13.
PMID: 34800834 DOI: 10.1016/j.vhri.2021.07.003

OBJECTIVES: To examine the budget impact of emicizumab as prophylactic therapy in reducing the frequency of bleeding episodes in patients with hemophilia A with inhibitors in Malaysia.
METHODS: A budget impact model was built to assess the cost implication of introducing emicizumab for routine prophylaxis of bleeding episodes in people with hemophilia A with inhibitors. It was based on the public healthcare system in Malaysia over a 5-year duration. The primary analysis computed healthcare costs for emicizumab compared with no prophylactic regimen to calculate the budget needed to treat all patients with hemophilia A with inhibitors.
RESULTS: The introduction of emicizumab resulted in a total incremental budget of Malaysian Ringgit (RM) 20 356 897 ($4 917 125) during the first year. The total cost for the current situation (no prophylaxis) was RM13 425 941 ($3 242 981), whereas the total cost for the new situation (prophylaxis with emicizumab) was RM33 782 838 ($8 160 106). The 5-year cumulative incremental budget impact from 2021 to 2025 was RM97 205 459 ($23 479 579) with an uncertainty range from -RM4 869 886 (-$1 176 301) to RM138 035 597 ($33 341 932) and a total of 72 patients treated with emicizumab. In a sensitivity analysis, the use of emicizumab was cost saving if the annual bleeding rate was greater than 16 instead of 6 times per year.
CONCLUSION: The 5-year budget impact might be considered reasonable and possibly cost saving. The model and approach used in this study to obtain relevant parameters where scarce data exist may help other jurisdictions with future adaptation.

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