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The great masquerade: Empyema thoracis as an unusual presentation of primary lung malignancy

Nyanti LE, Kho SS, Tie ST

Med J Malaysia, 2019 02;74(1):79-81.
PMID: 30846667

Primary lung malignancy presenting as empyema is rare, with a reported incidence of 0.3%. We report a case of a 60- year-old man presenting with unilateral pleural effusion; diagnostic thoracocentesis confirmed Salmonella empyema. Post-drainage, chest radiograph showed persisting right hemithorax opacity; subsequent computed tomography revealed a right lung mass with right upper lobe bronchus obliteration. Percutaneous biopsy confirmed advanced stage lung adenocarcinoma. We discuss the mechanism of post-obstructive pneumonia in lung cancerassociated empyema and the utility of bedside ultrasound in diagnosis of lung masses. Clinicians are alerted to the possibility of lung malignancy in elderly patients presenting with empyema.
Fulltext Syndrome of inappropriate antidiuretic hormone secretion and Leser-Trélat syndrome as uncommon paraneoplastic manifestations of renal malignancy - a geriatric experience: a case report

Nyanti L, Samsudin A, Tiong IK

J Med Case Rep, 2019 Jun 21;13(1):188.
PMID: 31221202 DOI: 10.1186/s13256-019-2122-8

BACKGROUND: Leser-Trélat syndrome, which manifests as eruptive multiple seborrheic keratoses, is a rare paraneoplastic sign. Hyponatremia in the elderly population is an often overlooked but potentially sinister biochemical abnormality. Cancer-related causes of hyponatremia include syndrome of inappropriate antidiuretic hormone secretion, cerebral or renal salt wasting, and adrenal dysfunction. We report a case of an elderly man who presented with both syndrome of inappropriate antidiuretic hormone secretion and Leser-Trélat syndrome, and was eventually found to have renal malignancy.
CASE PRESENTATION: A 74-year-old indigenous Malaysian man with underlying chronic kidney disease presented with recurrent admissions for hyponatremia with parameters indicative of syndrome of inappropriate antidiuretic hormone secretion, constitutional symptoms, and diffuse skin lesions suggestive of multiple seborrheic keratoses. A radiological workup revealed metastatic renal cell carcinoma with evidence of metastasis to the brain, adrenal glands, bone, and lungs.
CONCLUSIONS: To the best of our knowledge, renal malignancy presenting as syndrome of inappropriate antidiuretic hormone secretion and Leser-Trélat concurrently is rare. The causes of hyponatremia in the elderly, approach to investigation, and value as a poor prognostic marker in malignancy are highlighted. We also discuss Leser-Trélat syndrome, its pathophysiology, and its possible implications on clinical practice.
Baseline trace metals in water and sediment of the Baleh River-a tropical river in Sarawak, Malaysia

Sim SF, Chai HP, Nyanti L, Ling TY, Grinang J

Environ Monit Assess, 2016 Sep;188(9):537.
PMID: 27573072 DOI: 10.1007/s10661-016-5553-3

Quantitative indices are classically employed to evaluate the contamination status of metals with reference to the baseline concentrations. The baselines vary considerably across different geographical zones. It is imperative to determine the local geochemical baseline to evaluate the contamination status. No study has been done to establish the background concentrations in tropical rivers of this region. This paper reports the background concentrations of metals in water and sediment of the Baleh River, Sarawak, derived based on the statistical methods where the areas possibly disturbed are distinguished from the undisturbed area. The baseline levels of six elements in water determined were Al (0.34 mg/L), Fe (0.51 mg/L), Mn (0.12 mg/L), Cu (0.01 mg/L), Pb (0.03 mg/L), and Zn (0.05 mg/L). Arsenic and selenium were below the detection limit. For sediment, the background values were established according to statistical methods including (mean + 2σ), iterative 2σ, cumulative distribution frequency, interquartile, and calculation distribution function. The background values derived using the iterative 2σ algorithm and calculated distribution function were relatively lower. The baseline levels calculated were within the range reported in the literatures mainly from tropical and sub-tropical regions. The upper limits proposed for nine elements in sediment were Al (100,879 mg/kg), Cr (75.45 mg/kg), Cu (34.59 mg/kg), Fe (37,823 mg/kg), Mn (793 mg/kg), Ni (22.88 mg/kg), Pb (27.26 mg/kg), Zn (70.64 mg/kg), and Hg (0.33 mg/kg). Quantitative indices calculated suggest low risk of contamination at the Baleh River.
Fulltext Adherence to the Malaysian clinical practice guideline for depression by general practitioners in private practice in Penang

Ho KC, Russell V, Nyanti L, Chan MW, Hassali MA, Dawood OT, et al.

Asian J Psychiatr, 2020 Feb;48:101899.
PMID: 31901584 DOI: 10.1016/j.ajp.2019.101899

INTRODUCTION: Most primary care in Malaysia is provided by general practitioners in private practice. To date, little is known about how Malaysian General Practitioners (GPs) manage patients with depression. We surveyed privately practising primary care physicians in the state of Penang, Malaysia, in relation to their experience of the Malaysian Clinical Practice Guideline (CPG) in Major Depressive Disorder, their current practice and perceived barriers in managing depression effectively.
MATERIAL AND METHODS: A questionnaire based on the study aims and previous literature was developed by the authors and mailed to all currently registered GPs in private clinics in Penang. Survey responses were analysed using SSPS version 21.
RESULTS: From a total of 386 questionnaires distributed, 112 (29%) were returned. Half of the respondents were unaware of the existence of any CPG for depression. One quarter reported not managing depression at all, while one third used anxiolytic monotherapy in moderate-severe depression. Almost 75 % of respondents reported making referrals to specialist psychiatric services for moderate-severe depression. Time constraints, patient non-adherence and a lack of depression management skills were perceived as the main barriers to depression care.
CONCLUSIONS: Our findings highlight the need to engage privately practising primary care physicians in Malaysia to improve their skills in the management of depression. Future revisions of the Malaysian Depression CPG should directly involve more GPs from private practices at the planning, development and implementation stages, in order to increase its impact.
Fulltext Water Quality Assessment of Tributaries of Batang Baleh in Sarawak Using Cluster Analysis

Ling TY, Soo CL, Heng TL, Nyanti L, Sim SF, Grinang J, et al.

ScientificWorldJournal, 2018;2018:8682951.
PMID: 30622445 DOI: 10.1155/2018/8682951

Assessment of river water quality is essential as it provides the knowledge required to make informed decisions. Therefore, water quality was determined at 15 tributary stations located along the Batang Baleh, Sarawak. Results of the study indicate that all tributaries were well-aerated (≈ 7.7 mg/L) with pH (≈ 7.3) and conductivity (≈ 37.3 μS/cm) values falling within acceptable ranges. However, there were tributaries that showed very high turbidity (> 1000 NTU) and suspended solids (> 800 mg/L) which were contributed by the soil erosion from logging activities in the watershed. Tributary stations associated with logging activities also showed significantly higher total phosphorus and organic nitrogen. Cluster analysis demonstrated that water quality at tributary stations along the Batang Baleh exhibited a longitudinal variation from upstream to downstream regions, particularly, dissolved oxygen, five-day biochemical oxygen demand, and nitrite-nitrate nitrogen, which were found higher in upstream region and steadily decreased towards the downstream region. Two stations located at Sg. Serani and Sg. Melatai were distinct from the other stations with the highest concentrations of turbidity, total suspended solids, organic nitrogen, and total phosphorus. Thus, there is an urgent need to reduce the pollutants in the tributaries of Batang Baleh for the health of the sensitive aquatic organisms.
Fulltext Fish biodiversity and assemblages along the altitudinal gradients of tropical mountainous forest streams

Soo CL, Nyanti L, Idris NE, Ling TY, Sim SF, Grinang J, et al.

Sci Rep, 2021 Aug 19;11(1):16922.
PMID: 34413385 DOI: 10.1038/s41598-021-96253-3

Knowledge of the fundamental aspects of ecology such as the patterns of fish species distribution and biodiversity in the forest streams is the first and basic step to develop effective conservation strategies. Yet, studies on altitudinal changes of fish composition and assemblages in Bornean forest streams are scarce despite being one of the hotspots of biodiversity conservation. Hence, surveys on freshwater fish composition along the altitudinal gradients of the Baleh River Basin in Sarawak, Borneo were conducted from April 2014 to August 2015. The Baleh River Basin was divided into seven altitudinal groups with a total of 72 stations. Group elevation ranged from 53 to 269 m above sea level. The fish samples and environmental parameters were taken concurrently during samplings. A total of 3565 specimens belonging to six orders, 14 families, and 76 species were found in the present study. The most dominant family in the Baleh River Basin was Cyprinidae (74.4%), followed by Gastromyzontidae (16.2%) while the most dominant species was Tor tambra (12.9%), followed by Lobocheilos ovalis (12.3%). Fish abundance significantly higher at high altitude sites than those at low altitude sites except for Mengiong River which has the lowest fish abundance despite with high elevation. Species richness was found significantly lower in midstream segment. Noticeable altitudinal gradient of fish assemblages was observed along the Baleh River except a discontinuity at the midstream segment which is attributable to the poorer quality inflow from the Mengiong River coupled with the meandering feature of the segment. Fish abundance was significantly and positively correlated with elevation, water pH and conductivity while negatively correlated with turbidity. Anthropogenic activities in the Baleh River Basin had altered the environmental variables thus disrupted the altitudinal gradient of fish assemblages. This phenomenon is apparent when the Canonical Correspondence Analysis (CCA) revealed that the first axis (CCA1) explained 42.5% of the variation and has positive loading on dissolved oxygen (DO) and negative loading on water conductivity; whereas CCA2 explained 37.5% of the variation and positively loaded on elevation, water pH, and DO. The results demonstrated that Gastromyzon fasciatus preferred more oxygenated water than Protomyzon sp., G. sp 1, and G. punctulatus although they are all from Gastromyzontidae family that inhabiting high altitude sites. Barbonymus schwanenfeldii was also found most abundant with elevated dissolved oxygen value. On the other hand, Rasbora volzii and R. hosii inhabiting lower altitude sites with less oxygenated and more acidic water.
Fulltext Clinical-radiological features and diagnostic modalities for mediastinal melioidosis

Nyanti LE, Lee SSY, Shanmugam V, Muien MZBA, Othman AA, Chia YL, et al.

Int J Tuberc Lung Dis, 2023 Oct 01;27(10):724-728.
PMID: 37749834 DOI: 10.5588/ijtld.23.0079

Melioidosis is a potentially life-threatening infection caused by the Gram-negative bacillus Burkholderia pseudomallei. Mediastinal melioidosis has a range of clinical presentations, making it difficult to diagnose: we therefore reviewed the evidence on the clinical characteristics, radiological features and invasive diagnostic modalities or interventions. An electronic search was conducted on three databases (PubMed, SCOPUS, Google Scholar) from November to December 2022. The initial search yielded 120 results, of which 34 studies met the inclusion criteria, but only 31 full-texts were retrievable. Among these, 4 were cohort studies, 26 case reports or series and 1 a conference abstract. The four main themes covered were mediastinal melioidosis as a diagnostic dilemma, unexpected complications, invasive interventions or an accompanying thoracic feature. Radiological manifestations included matting, necrosis and abscess-like collection. Severe presentations of mediastinal melioidosis included superior vena cava obstruction, sinus tract formation and pericardial tamponade. Transbronchial needle aspiration was the most common invasive diagnostic modality. Further research is needed to understand the relationship between the thoracic features of melioidosis on patient prognosis, its relationship to melioidosis transmission and potential preventive measures.
Pleural fluid residue as a diagnostic tool for cytology-negative malignant pleural effusion: A proof-of-concept study

Nyanti LE, Huan NC, Ramarmurty HY, Renganathan T, Bin Abdul Aziz MA, Low JL, et al.

Afr J Thorac Crit Care Med, 2023;29(4):e1149.
PMID: 38239775 DOI: 10.7196/AJTCCM.2023.v29i4.1149

BACKGROUND: Pleural fluid residue, or macroscopic tissue, circulating freely in the pleural fluid obtained through direct filtration, may carry diagnostic histopathological information. We aimed to determine the histopathological concordance of pleural fluid residue in diagnosing TPE and MPE, compared with conventional pleural biopsy. This was a prospective cohort study of consecutive inpatients with cytology-negative exudative effusion who underwent pleuroscopy and had their initial suctioned pleural fluid filtered for residue samples. Pleural fluid residue demonstrated malignant cells in four out of seven cases of pleural biopsy-confirmed malignancy. Pleural fluid residue has comparable cytomorphology but reduced cellularity compared with pleural biopsy. No tuberculous histological features were present in the pleural fluid residue samples. In this preliminary study pleural fluid residue provided histopathological information for malignant pleural effusion, but no incremental diagnostic information for tuberculous effusion. However larger and more definitive studies are required to clarify these findings, and to explore the utility and suitability of pleural fluid residue for mutational analysis.
WHAT THE STUDY ADDS: This study demonstrates the potential of pleural fluid residue as a non-invasive diagnostic method for confirming malignancy in cytology-negative exudative effusion.
WHAT ARE THE IMPLICATIONS OF THE FINDINGS: In resource-limited settings or patients contraindicated for pleural biopsy, pleural fluid residue may provide a viable diagnostic alternative; however, this observation needs further validation.