Phasic ECG voltage changes or electrical alternans is a well-described ECG changes seen in the pericardial effusion and cardiac tamponade. Popular as once believed, this ECG features are no longer considered pathognomonic for pericardial effusion and cardiac tamponade. Electric alternans is observed in pneumothorax especially left-sided pneumothorax. This is a case of a 41-year-old man who presented with chest pain and breathlessness to the emergency department. Assessment in the emergency unit revealed an obvious distress man with a respiratory rate of 60 breaths/min with cyanosis There were generalised rhonchi and prolonged expiratory breath sound appreciated. Chest X-ray (CXR) was done and diagnosed to have left tension pneumothorax. Initial electrocardiogram (ECG) showed electrical alternans in all leads. He was intubated for respiratory distress followed by chest tube insertion. His initial ECG findings resolved after treatment of the tension pneumothorax. Doctors need to evaluate the cardiac findings along with respiratory findings.
Myasthenia gravis, the most common autoimmune
neuromuscular disorder, is characterised by
muscle weakness and fatigability. A 23-yearold-lady
with background history of breathing
and swallowing difficulty for six months was
presented with respiratory distress to the hospital
which is without an in-house neurology service.
Her diagnosis remained a challenge as patient
presented as an emergency without detailed
medical history. She was subjected to bedside ice
pack testing and subsequently managed along the
diagnosis of myasthenia crisis. She responded to
the treatment and survived the critical period. So,
diagnosis of myasthenia gravis by ice pack test
and managing a case of myasthenic crisis would
be possible in limited heath care setting.
Trimethoprim-Sulfamethoxazole (TMP-SMX)
or Co-Trimazole is the treatment of choice for
meliodosis. A 52-year-old man presented with
generalized body weakness with reduced appetite.
He had bradycardia on examination. After
investigations, he was diagnosed as hyperkalaemia.
He had life-threatening hyperkalaemia treated
with Trimethoprim-Sulfamethoxazole (TMPSMX)
as part of the eradication therapy for
Meliodosis. Urgent haemodialysis was done. There
were changes done for his meliodosis treatment.
This case wished to highlight the importance of
considering hyperkalemia in patient treated with
Trimethoprim-Sulfamethoxazole especially when
risk factor for hyperkalaemia is present.
Trigeminal schwannoma is a rare cause of
cerebellopontine angle tumour. This case report
of a 65-year-old lady presented with ipsilateral
facial numbness and instability. She was finally
diagnosed to have trigeminal schwannoma after
seeking multiple medical consultations with her
doctors. This case report highlights a rare cause
of cerebellopontine angle tumour.
Wegener’s granulomatosis (WG) is a necrotizing
granulomatous inflammation. A 40-year-old lady
of Malay descent presented with unresolving
bilateral painful red eyes for three weeks. Clinical
examination revealed that best corrected vision
acuity of 6/9 for both eyes. Slit lamp examination
revealed diffuse scleritis. Other Investigations
result like UFEME blood cell: 2+, C-reactive
protein 70.06 mg/L and ESR of 125 mm/h
suggestive on acute inflammations. Connective
tissue screening revealed cytoplasmic ANCA
was positive and was supported by Anti-Serine
Protease3 (PR3) 68. All the investigation results
revealed that she had Wegener’s granulomatosis
with ophthalmology manifestation in the
form scleritis. Patient was treated with guttae
Maxidex QID to reduce cells that present in
anterior chamber and oral ibuprofen 400 mg
thrice daily. Subsequently, oral prednisolone
and oral cyclophosphamide with oral Bactrim
were commenced. Patient responded well and
redness resolved. There are many differential
diagnoses for chronic conjunctivitis but to rule
out connective tissue disease should be one of the
primary differential diagnoses in young female.
Oral immunosuppressive and Trimethoprim/
Sufmethoxazole (Bactrim) were been found
beneficial and symptoms were resolved. Wegener’s
granulomatosis is a great mimicker as exemplified
in this case. This disease can be misdiagnosed and
maltreated as conjunctivitis. Thus, the authors
wish to emphasize that WG is one the differential
diagnoses that need to be considered in a person
with bilateral scleritis.
Bilateral medial medullary stroke is a rare stroke syndrome. The clinical presentation of bilateral medial medullary stroke is heterogenous and often overlaps with other non-stroke neurology emergencies such as Guillain-Barrésyndrome, myasthenic crisis and acute vestibular syndrome, leading to misdiagnosis. We wish to present a case of a young lady with type 1 diabetes mellitus, who had presented with subacute neuromuscular weakness which was erroneously treated as myasthenic crisis. Her case was subsequently diagnosed as bilateral medial medullary stroke, following evolving clinical signs and magnetic resonance imaging (MRI) findings of a heart-shaped abnormality at the rostral medulla. This rare stroke syndrome represented a diagnostic challenge which necessitated a strong clinical suspicion and an urgent MRI scan of the brain for prompt diagnosis to enable appropriate treatment initiation.