Thirty-eight normal volunteers and 10 patients with untreated thyrotoxicosis were each given 0.5 ml of Lugol's solution daily for 10 days. On days 0, 5, 10, 15 and 20, serum levels of T4, free T4, T3 and TSH (by sensitive immunoradiometric assay) were measured. In normal subjects, the serum concentrations of free T4 declined significantly at day 10 while TSH levels were significantly increased at days 5, 10 and 15. Serum levels of T4 and T3 did not change significantly. All the observed changes took place within the limits of normal ranges for the hormones mentioned. In contrast, in the thyrotoxic subjects, both T4 and T3 were significantly decreased at days 5 and 10, while serum TSH remained below detection limit (0.14 mU/l) throughout the study. Short exposure to excessive iodide in normal subjects affects T4 and T3 release and this effect could be partially overcome by compensatory increase in TSH. In thyrotoxicosis, lack of compensatory increase in TSH results in rapid decreases in T4 and T3 levels. The integrity of the hypothalamo-pituitary-thyroidal axis may be effectively assessed by measuring TSH response to iodide suppression, using a highly sensitive immunoradiometric assay.
The prevalence of coinfection, superinfection and chronic infection with the hepatitis delta virus (HDV) was studied in 324 hepatitis B surface antigen (HBsAg)-positive Malaysians. Of these, 10.0% (5/50) had coinfection, 5.7% (11/194) had superinfection, but none of the 80 patients with chronic liver disease (CLD) or primary hepatocellular carcinoma (PHC) had chronic infection with HDV. The overall HDV infection was 4.9% (16/324). One of the coinfection cases acquired the HDV infection as early as 1982. HDV superinfection was detected mainly among IV drug abusers (20% or 7/35) and promiscuous males and females (13.6% or 3/22). They were all asymptomatic. Only 0.8% (1/125) apparently healthy blood donors was infected with HDV. None of the 12 multi-transfused patients examined were positive. Malaysia is the only Southeast Asian country examined so far in which HDV infection was detected. The reason could be that the IV drug abusers and the sexually promiscuous groups missed being examined in the other countries. Comparing the HDV infection rates in 4 categories of infected Malaysians (viz. acute hepatitis B patients, IV drug abusers, blood donors and CLD patients) with those of other countries, it was noted that the Malaysian rates were similar to the lowest in the range of prevalence rates of each category in the latter group. The rate of coinfection in a preliminary study in 1982-84 (9.0% or 1/11) was not very different from that obtained to date (10.0% or 5/50).(ABSTRACT TRUNCATED AT 250 WORDS)
Tatumella ptyseos, the type species for the genus Tatumella, is a newly established member of the Family Enterobacteriaceae. It is a Gram-negative, oxidase negative, fermentative rod that grows on Mac Conkey agar. This first isolate was obtained from the blood culture of a neonate having neonatal jaundice with presumed sepsis. The organism was in vitro sensitive to Gentamicin, Chloramphenicol, Cotrimoxazole and Ampicillin. The patient was treated with Ampicillin and Gentamicin and recovered uneventfully.
A simple adherence test to detect IgM antibodies in patients with typhoid is described. The test utilises the IgM-"capture" approach, in which the test serum is applied to microtitration plate wells previously coated with anti-human IgM, followed by application of a stained Salmonella typhi antigen suspension which shows adherence in positive cases. By this test, 58 (95%) of 61 sera from confirmed cases of typhoid possessed IgM antibodies to the H or O or both antigens of S. typhi. In patients for whom a diagnosis of typhoid was based only on a significant Widal-test titre, 31 (41%) of 76 sera had IgM antibodies to the H or O or both antigens of S. typhi. Some cross-reactivity of the IgM antibodies was detected, especially with the O antigens of S. paratyphi A and B. A total of 82 sera from non-typhoidal fevers (leptospirosis, typhus, dengue fever) showed no reactivity in this test. In normal sera there was no detectable IgM to the O antigen of S. typhi and only a small number (3.9%) had low levels of IgM to the H antigen. The significance and potential importance of this simple, sensitive, specific and economical test is discussed.
A review of rhabdomyosarcoma in childhood reveals that the pattern and results of treatment have changed with the introduction of multimodal therapy. Outcome in our series have been poor due to advanced disease, poor compliance to follow up resulting from poor socio-economics and educational levels of our patients and their faith in traditional medicine. Improvement in the prognosis can only be anticipated with earlier diagnosis and reduction in defaulter rate.
The neuroleptic malignant syndrome (NMS) is a potentially fatal complication of antipsychotic therapy. A retrospective study of nine patients seen over six years at the University Hospital, Kuala Lumpur (UHKL), is described. The estimated annualised incidence was 1.2 per 1000 in-patients with psychosis. No ethnic difference was detected. Clinical features were similar to experiences elsewhere, with wide variability seen in the severity of illness. The neuroleptic drugs implicated were haloperidol, trifluoperazine, chlorpromazine, fluphenazine and clopenthixol. Treatment consisted of withdrawal of offending drugs and supportive measures. Specific therapy was given to five patients. There was one death. At follow-up no deterioration was detected. A different neuroleptic drug was successfully re-introduced in four patients. In view of the wide usage of major tranquillizers, a high degree of clinical awareness of this serious complication is necessary for early diagnosis to reduce morbidity and mortality.
Adrenal histoplasmosis in Cushing's syndrome of adrenal origin is rare. A patient with Cushing's disease with bilateral nodular hyperplasia and histoplasmosis of both the adrenal glands is described. The diagnosis of histoplasmosis was only made post operatively as the constitutional manifestations, besides being partially masked by hypercortisolism also resemble those of tuberculosis.
Serological markers were used to determine the infective agents causing acute viral hepatitis in 246 patients. The frequencies of the five viral infections investigated were: non-A, non-B hepatitis - 99 patients (40.2%); hepatitis A - 98 patients (39.8%); hepatitis B - 43 patients (17.5%); cytomegalovirus - 4 patients (1.6%); and Epstein-Barr virus - 2 patients (0.8%). The log mean ages of presentation for the three predominant infections were: hepatitis A - 18 years; hepatitis B - 25 years; and non-A, non-B hepatitis - 30 years (F = 18.8, p =< 0.001). 52% of all cases were Malays (expected 32. 7%); 32% Chinese (expected 54.6%); and 16% Indians (expected 1l.5%) (X2 = 53, p = < 0.001). Hepatitis A virus infection was more common amongst Malays whilst non-A, non-B hepatitis was more frequent amongst Chinese and Indians. 28% of children <16 years) and 50% of adults had serological markers of previous hepatitis B infection. The variation in frequency for the different forms of hepatitis amongst the three main ethnic groups would suggest that socioeconomic and/or cultural factors are important in the propagation of acute viral hepatitis in Malaysia. HBsAg-negative chronic liver disease in our community may be a product of the high incidence of non-A, non-B hepatitis.
Cytophagic histiocytic panniculitis (CHP) is a recently recognized entity that frequently poses a perplexing diagnostic problem. Although the classical case presents with a relapsing fever, subcutaneous nodules, pancytopenia and liver dysfunction, most patients have in addition a multitude of other manifestations which confuse the clinical picture. Notwithstanding the variable clinical course, the disease frequently terminates in fatal hemorrhage. Diagnosis is based on histological features. A lobular panniculitis with an infiltrate of cytologically benign cytophagocytic histiocytes in skin nodules is the sine qua non of CHP. Hence, a deep skin biopsy which includes subcutaneous fat is mandatory to establish the diagnosis. Published information regarding this newly described entity remains scarce and we report two cases of CHP, one occurring in a 30-year-old Kadazan man and another in a 17-year-old Chinese woman seen at the University Hospital, Kuala Lumpur. The latter case presented with exudative ascites, an unusual feature, possibly due to intra-abdominal panniculitis. In addition, we record the development of cirrhosis in the same patient.
Sera were obtained from 494 non-icteric patients admitted with illnesses other than overt hepatitis into the medical wards of the rural and urban hospitals in Malaysia. They were tested for HBsAg, HBeAg, and anti-HBs by enzyme immunoassay. The overall HBsAg carrier rate was 18.0% ranging from 9.6% in children, (10 years and under), to a maximum of 23.5% in the adolescents (11 to 20 years), the rates decreasing subsequently to 16.5% and 20.8% in the adult and middle-age groups, respectively. The Chinese (18.6%) and Malays (19.9%) had similar HBsAg carrier rates but the rate in the Indians (9.0%) was distinctly lower. Similar rates were observed in the males (16.5%) and the females (19.8%). The carrier rate was 17.1% in rural patients compared with 21.4% in the urban ones. The 'e' antigen was found in 14 of the 89 HBsAg carriers (15.7%). The overall prevalence was 14/494 (2.8%) rising sharply from childhood (2.9%) to adolescence (5.3%), subsequently declining with advancing age. The Chinese had the highest rate (6.2%) followed by the Indians (1.5%) and the Malays (1.1%). Males had a rate of 3.3% compared to the females with 2.3%. Anti-HBs was found in 33.8% of the patients, increasing steadily from childhood (18.3%) to middle-age (46.4%). The Chinese had a higher prevalence rate (41.6%) than the Indians (32.8%) and the Malays (29.3%). The rates were similar for the males (35.6%) and the females (31.5%). Rural patients (46.1%) had a higher rate than urban patients (35.7%). Both areas showed rising prevalence with increasing age.(ABSTRACT TRUNCATED AT 250 WORDS)
Continuous ambulatory peritoneal dialysis (CAPD), a widely used replacement therapy for end stage renal failure, is frequently complicated by bacterial peritonitis. The infecting organisms are mainly staphylococci and gram negative aerobes. Pefloxacin is a fluorinated quinolone with good in-vitro activity against these pathogens. The objective of this open non comparative study is to determine the effectiveness and safety of oral pefloxacin mesylate as a single first line antimicrobial treatment of CAPD peritonitis. 28 episodes of CAPD peritonitis were treated with a stat dose of pefloxacin 800 mg. followed by 400 mg. 12 hourly for about 15-18 days. A pefloxacin sensitive organism was isolated in 17 episodes. 11 episodes were culture negative. Treatment results showed a cure in seventeen (60.7%), no treatment response in seven (25%), and relapses in four (14.2%). Side effects encountered were not serious except for one incident of a generalized seizure. We conclude that oral pefloxacin is convenient, safe and effective enough as a single first line antimicrobial treatment for CAPD peritonitis.
The use of the colloidal-gold technique in electron microscopy immunocytochemistry has provided important information on the in situ localisation of intracellular antigens. We have developed a post-embedding technique for prolactin localisation on resin-embedded human pituitary tissue sections by the use of the protein-A gold conjugate. Human pituitary tissue obtained at autopsy was processed for electron microscopical study without post-osmication and then embedded in Epon. The indirect immunoperoxidase method was used for light microscopical targetting of lactotroph cells for subsequent electron microscopical antigen localisation. Ultra-thin sections were labelled with human anti-human prolactin followed by protein-A gold conjugate. Specific labelling was observed over secretory granules with a density of 15-30 particles per granule, as determined by the Quantimet 570 image analysis system. This technique provides a means of studying the pathophysiology of hormonal secretion at ultrastructural level and can be a useful tool in diagnostic and research investigations.
The outcome of 109 patients with severe head injury was studied in relation to clinical and computed tomographic (CT) criteria on admission, after resuscitation. Age, Glasgow Coma Score (GCS) and state of pupils strongly correlated with outcome. The presence of hypothalamic disturbances, hypoxia and hypotension were associated with an adverse outcome. The CT indicators associated with poor outcome were perimesencephalic cistern (PMC) obliteration, subarachnoid haemorrhage, diffuse axonal injury and acute subdural haematoma. The prognostic value of midline shift and mass effect were influenced by concomitant presence of diffuse brain injury. For the subset of patients aged < 20 years, with GCS 6-8 and patent PMC (n = 21), 71.4% correct predictions were made for a good outcome. For the subset of patients aged > 20 years, with GCS 3-5 and partial or complete obliteration of PMC (n = 28), 89.3% correct predictions were made for a poor outcome.
1. The vitamin A content of human liver tissue was determined in 363 autopsy samples. The sample comprised a total of 181 subjects dying after accidents and 182 dying from coronary heart disease among Singapore ethnic groups of both sexes. 2. The medium vitamin A reserve was 146 mg/kg in accident victims and 141 mg/kg in those who had died of coronary heart disease. Of all the samples 16% contained less than 40 mg/kg, 45% had 100-300 mg/kg, while 9% contained more than 500 mg/kg liver. 3. Among the accident victims, Indians had the lowest median liver vitamin A reserve (118 mg/kg) compared with that in other ethnic groups (137 mg/kg in Chinese, 191 mg/kg in Malays, 155 mg/kg in Caucasians). 4. The ethnic distribution of vitamin A reserve in coronary deaths was similar to that in accident victims. 5. There was no significant difference between the sexes in hepatic vitamin A reserve. 6. The distribution of vitamin A reserve in all the groups was skewed to the right.
Several new concepts are used to describe contraceptive use histories for nearly 1200 women in Peninsular Malaysia. These histories are summarized by 81 episode histories. Transition matrices provide useful summaries of the changes women make in their contraceptive practice from one pregnancy interval to the next. Data from the mid-1940s to mid-1970s, during which period there was a dramatic increase in contraceptive use, reveal considerable inertia in individual couples' contraceptive practice. Persistence with a method was greater the less effective the method: while 86% of couples using no method in one interval used no method in the next, only 56% of couples using the pill in one interval also used it in the next. Virtually all transitions are of three types: continuation with the same method, a change from no method to some method, or a change from some method to no method. For only 1% of all pregnancies did couples use one contraceptive method before a pregnancy and a different method after the pregnancy. Differences are examined by calendar year and education.
13 patients with the amenorrhoea-galactorrhoea syndrome who conceived during treatment with bromocriptine were reported. Mean period of amenorrhoea was 3.0 years. In ten patients galactorrhoea was noted for a mean period of 4.2 years while in three it was discovered during examination. Seven patients presented with primary infertility. Menses returned in all cases after a mean duration of 2 months of treatment with bromocriptine at an average dose of 5. 86 mg daily. Mean serum prolactin was 4344 mUll (range 750 mU/l to 23,000 mU/l) before treatment and this declined to 186 mU/l with treatment. Seven patients became pregnant 5 to 25 months of treatment while six conceived after first menses. 21 pregnancies resulted from the thirteen patients. There was one spontaneous abortion and one premature delivery in which the baby died. Of the 16 live- births, there were twelve girls and four boys and their mean birth-weight was 2932 g. All were normal at birth and during subsequent developments except one with congenital dislocation of hip. It is concluded that bromocriptine is effective in restoring menstrual cycles and fertility by lowering serum prolactin in patients with the amenorrhoea-galactorrhoea syndrome. Bromocriptine may be safe for use during pregnancy, but it is suggested that the medication should be stopped immediately after conception unless tumour growth is apparent.
62 cases of polycystic ovary syndrome (PCO) were reviewed with regards to their clinical and endocrine features. The subgroup of patients with acanthosis nigricans (AN) was further studied in detail. The prevalence of the syndrome was significantly higher in the Indian (35.5% of cases). Obesity, AN, hirsutism, non-insulin dependent diabetes mellitus (NIDDM) and raised level of serum testosterone were present in 77.1%, 74%, 79%, 21% and 48% of the cases respectively. Patients with AN was associated with higher body mass index, serum testosterone level, and prevalence of hirsutism and NIDDM than patients without AN. These observations are in keeping with the hypothesis that hyperinsulinemia may be of importance in the pathogenesis of a sub-group of PCO associated with insulin resistant states.
A 44 year old lady with primary hypothyroidism presented with massive pericardial effusion without cardiac tamponade. Pericardial tap was done twice and the effusion resolved as the hypothyroid state improved. She remained hypertensive despite the euthyroid state. She was discharged well with L-thyroxine and anti-hypertensive therapy.
The clinical, biochemical and immunological features of 180 patients with hyperthyroid Graves' disease managed at the Universiti Kebangsaan Malaysia (UKM) Endocrine Clinic from 1983 to 1987 were examined. The prevalence of the disease is highest in Chinese and lowest in Indians. The female: male ratio is 2.8:1. Hypokalaemic periodic paralysis and hypercalcaemia were present in 5.0% and 1.7% of the cases respectively. Pretibial myxoedema was extremely rare. Thyrotropin - binding inhibitory immunoglobulins, anti-thyroglobulin and anti-microsome antibodies were positive in 61.5%, 25.8% and 42.3% of the patients respectively. A eumetabolic state could be achieved in the majority of patients with antithyroid drugs alone. Definitive therapy with subtotal thyroidectomy or radioiodine were needed in 31.3% of cases.