We describe a Malay girl with disseminated cryptococcosis affecting the lungs, liver, lymph nodes and bones. The diagnosis was made by culture of the bone marrow. Tests of immune function showed that she was HIV-negative but the CD4 percentage was persistently low. Idiopathic CD4+ T-lymphocytopenia was diagnosed. The child died despite two courses of anti-fungal therapy.
A wide variety of skin disorders in children are encountered by doctors practising in tropical countries. While some of them are common and pose little difficulty in their management, a few are uncommon, run a protracted course and cause errors in diagnosis. Two patients--one with cutaneous tuberculosis and the other with chromomycosis--are described and illustrate the importance of early and prompt detection of disease in children.
Yaws was detected in a six-member family in the southern Malaysia state of Johor. This stresses the need to be vigilant against a long-forgotten disease of childhood which was of great public health concern in the past.
A hospital study was carried out to compare parenting stress among 87 Malaysian mothers of children with cerebral palsy and a control group (comprising 87 mothers of children without disability who attended the walk-in paediatric clinic), using the Parenting Stress Index (PSI) questionnaire. Multiple regression analysis was used to determine socio-demographic and medical factors associated with child-domain stress (CDS) and parent-domain stress (PDS). Mothers of children with cerebral palsy scored significantly higher than control subjects on all sub-scales of CDS and PDS (p < 0.01), except for the sub-scale of 'role restriction'. The presence of cerebral palsy (p < 0.001) and activities of daily living (ADL) scores (p < 0.001) were significantly associated with CDS. Factors predictive of PDS were ADL scores (p < 0.001), number of hospitalizations over the past year (p = 0.024), level of maternal education (p = 0.018) and Chinese mothers (p < 0.001). Although this study demonstrated that Malaysian mothers of children with cerebral palsy experienced higher levels of stress than controls, the impact of cerebral palsy per se on parenting stress was modified by other factors such as increased care-giving demands, low maternal education and ethnic background. Habilitation should be directed at easing the burden of daily care, minimizing hospital re-admissions and targeting appropriate psychosocial support at specific subgroups to change parental perception and expectations.
Study site: neurology clinics or physiotherapy department or inpatients, Paediatric Institute, Kuala Lumpur, Malaysia
A prospective study was carried out to (i) compare head growth patterns of 103 very low birthweight (VLBW, < 1500 g) Malaysian infants and 98 normal birthweight (NBW, 2500- < 4500 g) controls during the 1st year of life; and (ii) examine the relationship between neurodevelopmental outcome at 1 year of age and occipito-frontal head circumferences (OFC) at birth and at 1 year of age in VLBW babies. When compared with those of NBW infants at birth, mid-infancy and 1 year of age, the mean OFC ratios (observed/expected OFC at 50th percentile) of VLBW infants were significantly lower (p < 0.001). Small-for-gestational-age (SGA) VLBW babies had significantly lower mean OFC ratios than their appropriate-for-gestational-age (AGA) VLBW counterparts at birth (p < 0.001), but this difference was no longer seen at mid-infancy or at 1 year of age. Logistic regression analysis showed that abnormal late neonatal cranial ultrasound findings (odds ratio 8.5, 95% confidence interval 4.12-22.07; p < 0.001) and each additional day of oxygen therapy (odds ratio 1.15, 95% confidence interval 1.00-4.45; p = 0.045) were significant risk factors associated with neurodevelopmental disability at 1 year of age, while mean OFC ratios at birth or at 1 year of age were not. Poor postnatal head growth per se did not predict disability, but probably reflected the consequences of "brain injury" as evidenced by abnormal brain scans.
A 7-year-old boy, referred with lymphoma, presented with prolonged fever and intra-abdominal lymphadenopathy demonstrated on computed tomography (CT) of the abdomen. Blood culture isolated Penicillium marneffei. The patient was subsequently proven serologically to be positive for human immunodeficiency virus (HIV). Treatment with amphotericin B followed by itraconazole was successful. A high level of clinical suspicion and awareness is necessary for early diagnosis of penicilliosis, especially in an era of an increasing prevalence of HIV in this region.
Tropical pulmonary eosinophilia (TPE) is considered to be a variant of human filarial infection. The pulmonary manifestations of TPE have been well described. Extra-pulmonary features of the disease, although not commonly seen, have been reported previously. A 9-year-old Malay girl with a history of recurrent cough and wheezing was admitted because of cardiac failure. Physical examination revealed a very sick girl with tachypnoea, central cyanosis, finger clubbing, elevated jugular venous pulse, generalized crackles and rhonchi in the chest, a loud second heart sound and hepatosplenomegaly. A chest radiograph showed cardiomegaly and right pleural effusion. Laboratory investigations revealed hypochromic, microcytic anaemia with persistent blood eosinophilia (absolute eosinophil counts varied from 1.9 to 5.5 x 10(9)/1). The ELISA test for antifilarial IgG antibodies was strongly positive. She responded promptly to treatment with diethylcarbamazine. In summary, this is a patient with TPE who presented with cor pulmonale, probably due to late-stage interstitial pulmonary fibrosis. In order to prevent the long term morbidity of cardiorespiratory disability, the early signs of TPE should be recognized and the infection treated.
A study of race-related distribution of hepatitis B markers was conducted in 458 children admitted consecutively to Singapore General Hospital. The positive rates for hepatitis B surface antigen (HBsAg) in Chinese, Malays and Indians were 11.2, 8.0 and 12.2% respectively and the corresponding figures for anti-HBs were 30.2, 12.0 and 14.6%. In Chinese children HBsAg prevalence was shown to be sex-related, being higher in males than females. The percentages of Chinese children positive for anti-HBs and anti-HBc were also higher than those of the Indians. This study confirmed that Singapore children were exposed to hepatitis B infection from early life. All three races were equally susceptible to this infection.
There are few data on paediatric melioidosis in endemic areas outside rural north-eastern Thailand and northern Australia. This study reports 16 culture-confirmed cases of melioidosis in children aged < or = 15 years seen between 1976 and 2005 at an urban teaching hospital in Kuala Lumpur, Malaysia. Seven (43.8%) patients had septicaemic melioidosis (with three known deaths) and nine (56.2%) had localised disease (one death). Eleven (68.8%) patients had underlying diseases, including five with haematological malignancies. Skin, soft tissue and lymph nodes were most commonly affected. There were no cases of parotitis or pharyngocervical disease (seen in Thailand), or encephalomyelitis (seen in Australia). The differences in disease seen in this study compared with the mostly rural patients described in previous studies might be owing to a different patient population in an urban environment. Septicaemic melioidosis has a high mortality, but localised disease has a good prognosis, and selected cases may be cured without the full recommended treatment regimen.
All post-neonatal children with acute non-traumatic coma admitted over an 8-month period were analysed and followed up for 18-24 months to determine the aetiology and outcome of their coma. One hundred and sixteen children, 72 boys and 44 girls, were recruited. Half the children were under 1 year of age and only 16 (14%) were more than 6 years of age. Eighty cases (69%) were due to infection, 15 (13%) to toxic metabolic causes, six (5%) to hypoxic ischaemic insults, four (3.5%) had intracranial haemorrhage, nine (7.8%) were due to miscellaneous causes and in two (1.7%) the cause was unknown. Seven cases were lost to follow-up. Of the remainder, 39 (35.7%) died, 32 (29.3%) developed permanent neurological deficit, and 38 (35%) were discharged well. The outcome was worst in the infectious group. Age of onset and sex did not significantly affect outcome. Our findings are similar to experience in Japan, where infection accounts for 74% of non-traumatic coma, but differ considerably from Western data on childhood coma where only a third of cases are due to infection.