A 35-year-old Malaysian man presented with rapid onset of flaccid quadriparesis associated with nausea and vomiting. General blood tests revealed severe hypokalaemia (serum potassium 1.5 mmol/L) and hypophosphataemia (serum phosphate 0.29 mmol/L) as a potential cause of the flaccid paralysis. Arterial blood gases showed mixed acid base disturbance of respiratory alkalosis and metabolic acidosis with hyperlactataemia. Thyrotoxic periodic paralysis (TPP) was suspected as the underlying cause of this presentation and thyroid function tests showed severe hyperthyroid results (free T4 > 77.2 pmol/L, free T3 19.3 pmol/L, thyroid-stimulating hormone [TSH] < 0.05 mIU/L). Treatment with intravenous potassium and phosphate infusion and oral propranolol resulted in rapid resolution of his symptoms. A discussion of the clinical and pathophysiological features and treatment of TPP (a very rare encounter in UK clinical practice) is presented, and to our knowledge associated hyperlactataemia has not been previously described.
A case of Tracheoesophageal Fistula (TOF) was presented where the blind upper esophageal pouch was mistakenly intubated; in spite of this, adequate lung ventilation was possible for more than one hour. This was only noticed by the surgeon upon incision of the lower end of the pouch.
Meckel's diverticulitis or Meckel's associated pathology frequently presents in childhood with gastrointestinal bleeding. It is rarely seen in adults. It is a congenital abnormality that commonly goes undetected. We present a case of a perforated Meckel's diverticulum due to fishbone ingestion in an elderly gentleman. The aim of this case report is to highlight the rare presentation of a perforation in a Meckel's diverticulum due to an extrinsic pathology and to outline diagnostic and management options in cases of Meckel's diverticulum.
Pericardial effusion with cardiac tamponade is a rare and life-threatening complication of peripherally inserted central catheter (PICC) in a neonate. We report a 33-week preterm neonate who had sudden clinical deterioration at day seven of total parenteral nutrition regime via PICC. Recognition of pericardial effusion with cardiac tamponade in neonates with a PICC requires a high index of suspicion and steps in prevention include proper catheter tip placement and continuous monitoring of line position and function.
Rhabdomyolysis is a serious but rare side effect of Lamivudine treatment. Therefore, appropriate biochemical monitoring should be undertaken when it is used in the treatment of hepatitis B. This paper presents a case of Lamivudine-associated rhabdomyolysis in a 31-year-old man with congenital heart disease and hepatitis B. Three days after starting Lamivudine, the patient developed myalgia. Significant muscle tenderness and swelling of the upper and lower limbs was discovered during a physical examination. Creatine kinase was markedly raised. Lamivudine-induced rhabdomyolysis was suspected and the drug was discontinued. Symptoms and creatine kinase activity improved within four days of Lamivudine cessation and hydration. Early identification of Lamivudine-induced rhabdomyolysis is key in preventing this potentially fatal drug reaction; withdrawal of Lamivudine may contribute to complete remission of rhabdomyolysis.
Gram-negative endocarditis is rare and it has high mortality if there is a delay in diagnosis and treatment. Gram-negative organisms should be considered in the differential diagnosis of IE in hemodialysis patients. Central lineassociated bloodstream infections (CLABSIs) can be prevented by following sterile measures during catheter insertion and proper management of catheter site.
A 41 year-old Malay man had been treated by general practitioners for bilateral red eyes with profuse discharge of three weeks' duration with no improvement. He then presented to an ophthalmologist who noted profuse purulent discharge, bilateral corneal perforation, lid swelling and chemosis. Culture of the ocular discharge grew Neisseria gonorrhoeae. Treatment with systemic and topical antibiotics prevented microperforations in the right eye from progressing to overt perforation and was able to control disease in the left eye.
This case illustrates an 80-year-old lady who presented with acute low back pain and finally succumbed from complications of osteoporotic vertebral fracture. Among the contributing factors are delayed diagnosis and a lack of continuity of care. It reminds the practitioners of the importance to look out for red flag symptoms and to have a high index of suspicion for vertebral fracture in high risk patients presenting with low back pain.
Study site: Accident and Emergency Unit, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
This case reports a 57-year-old lady presented with cough of two months duration despite repeated treatments from multiple general practitioners. It took her another two months to know her diagnoses and a further couple of months to be relieved of her cough and became asymptomatic. Chronic cough management in primary care often needs an empiric integrative approach and requires good doctor-patient rapport with informed follow ups and continuity of care to be successful.
Primary bone tumours, even in very advanced stages, rarely exhibit transarticular spread. We present a case of chondrosarcoma of the ilium with destruction of the sacroiliac joint, the ipsilateral sacral ala and with sacral nerve involvement.
Subtalar coalition is an uncommon condition that usually manifests in early adolescence(1). Frequently, this condition is missed. Delayed diagnosis may result in osteoarthritis requiring triple arthrodesis. Here, we report two patients with subtalar coalition. The first patient is a 12 year old boy who presented with right ankle pain for one year and was treated with excision of the coalition and bone wax insertion at the excision site. We followed up the patient for two years and the result was excellent with full range of movement of his right ankle and subtalar joint attained within two months. He returned to athletic activity by six months and was discharged with no complications after two years. The second patient is a 15 year old girl who presented with bilateral ankle pain and swelling for three years and was treated with excision of the coalition and subtalar interpositional arthroplasty bilaterally. She defaulted follow up after seven months as she was very satisfied with the result. We wish to highlight this condition which may be misdiagnosed as flexible flat foot or ankle sprain.
The evidence presented by the nine cases described in this paper indicates that primary arteritis of the aorta is a single clinico-pathological entity of which Takayashu's syndrome is a part. Different segments of the aorta may be affected resulting in a variety of symptom complexes. In this series, the mode of presentation was hypertension consequent on renal artery stenosis. Early diagnosis is important and surgical treatment is indicated to relieve the hypertension which carries an immediately serious prognosis.
Hypokalemic thyrotoxic periodic paralysis is a potentially life-threatening complication of hyperthyroidism, defined by 3 characteristic features: thyrotoxicosis, hypokalemia, and acute painless muscle weakness. In this case, a 25-year-old Malaysian man presented with acute, painless lower extremity weakness immediately after a meal. His associated symptoms included palpitations, tremor, and anxiety. He also reported a 30-pound unintentional weight loss over the previous 18 months, dyspnea on exertion, and insomnia.
Chronic discharging ear, mostly due to middle or external ear infection, is one of the leading causes for seeking healthcare among the paediatric population in a developing country. However, a long-standing forgotten middle ear foreign body forms a rare cause for such presentation demanding a high index of suspicion from the clinicians. Most of them are iatrogenic or accidental, and are removed by conventional permeatal approach; need for tympanotomy is rarely documented in the recent literature. We report the first case where a large stone was introduced into the middle ear through a pre-existing tympanic membrane perforation by the child himself, and only the second documentation of removal of a middle ear foreign body by tympanotomy in a child.
A common practice in psychiatry when treating patients is the concurrent administration of anticholinergics along with antipsychotics, either to prevent or treat extrapyramidal syndrome reactions from occurring. However, most antipsychotics have inherent anticholinergic properties themselves. Therefore, this subtype of these patients have a higher than usual risk of developing anticholinergic side-effects, of which the central nervous manifestations can mimic psychosis, and may cloud judgement on patients’ progress towards their treatment.
A common practice in psychiatry when treating patients is the concurrent administration of anticholinergics along with antipsychotics, either to prevent or treat extrapyramidal syndrome reactions from occurring. However, most antipsychotics have inherent anticholinergic properties themselves. Therefore, this subtype of these patients have a higher than usual risk of developing anticholinergic side-effects, of which the central nervous manifestations can mimic psychosis, and may cloud judgement on patients' progress towards their treatment. KEYWORDS: Anticholinergics, anticholinergig toxicity, antipsychotics