Depression is a curable debilitating illness that becomes a leading cause of morbidity and mortality globally. The prevalence of depression is underrecognized among adolescents. The study is conducted to determine the prevalence of depression among secondary school students of Kuantan Malaysia. Materials and method: We conduct a quantitative cross-sectional study. A population of 414 students from two urban schools, two rural schools, and one international school will participate in the study. The assessment tool used is the Malaysian version of Depression, Anxiety and Stress Scale 21 (DASS 21). Data will be analyzed using SPSS version 21 (SPSS IBM, New York, USA). Factors associated with depressive symptoms will be analyzed using multi Variate logistic regression analysis. Results: Prevalence of depression in Kuantan, Malaysia will be compared to the same international trends. Conclusion: Our study can determine and compare the prevalence of depression in different categories. Education and early interventions of depressed adolescents will add extra value of the project.
Good physical health or istitha’ah is one of the shariah requisite to perform hajj pilgrimage. Hence, passing the health screening is mandatory for the pilgrim to-be in Malaysia. The aim of this study is to describe the pilgrims’ health screening profile from a FELDA settlement in Pekan, Pahang. Materials and method: All 26 candidates from Chini’s FELDA cluster who were selected for hajj pilgrimage in 2017 underwent health screening at a nearby health clinic. Data from this health screening were analysed descriptively using SPSS software version 23.0. Results: Candidates consists of 11 men and 15 women aged between 48 to 86 years with the mean age of 61. Result showed that both sexes have comparable mean age and body mass index. Most of the candidates (88.5%) have at least 1 chronic medical problem (excluding overweight) while 54% have at least 2 or more medical problems. Women have higher prevalence of non-communicable disease (NCD) conditions namely obesity, hypertension, and diabetes (40%, 60%, and 40%) compared to men (27%, 45% and 36% respectively). This figure is higher than 2015 national figure for age specific: 50 years group (obesity 36.6%, hypertension 49.3%, diabetes 27%). In addition, 20% of the women also have anaemia while none in men. Conclusion: Majority of the candidates in this group are elderly and have at least two chronic medical problems. Women have higher prevalence of NCD and anaemia than men. Thus, based on the findings, early and focused pilgrims’ health screening especially among elderly female is essential and appropriate action should be taken in order to reduce risk for morbidity and mortality during hajj pilgrimage.
Melioidosis is endemic in Malaysia and an important cause of sepsis. Current gold standard for diagnosis is by culture method,but its long procedure will delay the treatment leading to hospital-related mortality.Thus,a good rapid test is needed to reduce its mortality burden. Recently, Active Melioidosis Detect (AMD) have been shown to be useful. Objectives: (1)To measure the sensitivity and specificity of AMD. (2)To study the sensitivity and specificity of early morning urine AMD compared to spot urine AMD. Materials and method: A prospective crosssectional study of clinically suspected melioidosis patients in HTAA and HSNZ from April until December 2018. Blood and urine samples were tested with AMD. Test results were analysed for sensitivity, specificity,positive predictive value and negative predictive value. Results: A total of 89 patients were included in this study.The mean age is 52 years old, and 56.3% were male gender.64% of patients have diabetes mellitus.11 patients have positive blood culture for Bukholderia pseudomallei, 4 of them were tested positive for AMD.3 of them presented with septic shock (3.4%), however none died.The sensitivity of the AMD was 36.4% ([95% CI 12.4 to 68.4]) and the specificity was 66.7% ( [95% CI 46.0 to 82.8]) in all samples, with positive predictive value of 30.7% and negative predictive value of 72%.Blood samples have lower sensitivity of 9.1% ([95% CI 4.8 to 42.9]) with high specificity of 100% ([95% CI 84.5 to 100]). Urine spot samples have higher sensitivity compared to serum and morning urine, with 36.4% ([95%CI 12.4 to 68.4]) and specificity of 88.9% ([95% CI 69.7 to 97.1]). Conclusion: From this pilot study, this test requires further evaluation before incorporating as point of care assay.
Non Hodgkin lymphoma (NHL) is a malignant neoplasm affecting multiple systems in which extranodal NHL represents 10-20% of all NHL. Case report: This is a case of 45-year-old female with no known medical illness who presented with progressive numbness of bilateral lower limbs since March 2016 which subsequently progress to loss of motor power since November 2016. She initially was diagnosed as tuberculous (TB) spondylitis which then turned out to be B cell lymphoma of the thoracic vertebra. The diagnosis was confirmed on histopatological examination (HPE) after patient underwent laminectomy of T3-T7 vertebra bodies and excision biopsy with removal of the casseous material. Due to a lack of specific findings, the diagnosis of vertebral NHL is often missed or delayed. It warrants attention that NHL of thoracic vertebra may be misdiagnosed as TB spondylitis due to their similarities and sometimes the imaging features may simulate and overlap each other. The main treatment for vertebral NHL is chemotherapy, radiotherapy or both. Surgery maybe necessary if patient has story of neurological deficits. However patient was treated conservatively as she refused chemotherapy.
Prevalence of active smokers in Malaysia is remaining high (22.8%) despite the wide availability of quit-smoking services. Rather than look at the patients’ factors alone, the possible negative factors from health care providers should also be explored. Therefore, knowledge, attitude and practice of the healthcare professional on smoking cessation intervention needs to be assessed, especially among the primary care doctors. This can be done during national conference gathering all doctors from Malaysia. Materials and Method: A crosssectional study was conducted among medical doctors attending First East Coast Symposium on Specialized Care at Primary Care Level at Grand DarulMakmur, Kuantan on 1st to 2nd December 2019, using validated questionnaire of Knowledge, Attitude and Practice of Medical Doctors on Smoking Cessation Guidelines; consisting 17 questions to determine the KAP score. The difference between the median KAP scores between age, gender, ethnicity, religion, profession, location of clinic, availability of specialist at clinic, numbers of smokers seen and presence of smoking cessation training were assessed using Independent sample T-test and One-way ANOVA. Results: A total of 131 primary care doctors involved in the study. Majority were female (80.9%), Malay (96.2%), medical officers (74.8%), government doctors (90%) and haven’t undergone any kind of smoking cessation training (65.5%). The higher KAP score were statistically associated (p < 0.05) with history of attending training program (mean 35.7 score) and in charge of quit smoking clinic (mean 35.4 score). No significant difference of score between government (mean 32.0 score) and private doctors (mean 29.9 score). Conclusions : Majority of the involved primary care doctors had low KAP score. Being a family medicine specialist, in charge in stop smoking clinic and have attended smoking cessation training program were significantly associated with high KAP score. Therefore, more smoking cessation training should be provided for doctors.
Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids is a rare inflammatory Central Nervous System disorder prominently affecting the brainstem. We present an adolescent’s reflection on this condition complicated with Epstein-Barr virus induced CNS Lymphoma. Case report: A 16-year-old boy presented about 5 years ago with a balance problem. He was diagnosed by MRI after ongoing debate whether this is juvenile multiple sclerosis. He initially responded to methylprednisolone but developed acute deterioration requiring 8 cycles of Infliximab and Methylprednisolone. He then confirmed cerebellar lymphoma 2 years later hence commenced on chemotherapy and radiotherapy after posterior fossa decompression. He gradually losses his motor skills, left hemiparesis and spasticity. He needs tracheostomy and gastrostomy due to poor bulbar function. Now, he is fully dependent and requires chest physiotherapy and suctioning and cystostomy for urinary incontinence. He has multiple PICU admissions due to recurrent aspiration, acute cerebellar oedema and post posterior fossa decompression. He worries about family breakdown as mum is his sole carer and having regular nightmare. He changed school to meet his care demands and unsure how to adapt to new environment. Social experience makes him anxious due to lack of understanding about his condition. He is evidently having low self-esteem and confidence. Discussion: Children palliative care team has been involved since diagnosis to support him and family. He is understandably depressed and clinical psychologist input bear minimal impact. He is fully aware of the current situation and his wish to rap Eminem’s songs like he used to do it before. Conclusion: Early aggressive treatment in CLIPPERS aim to prevent neuroaxonal loss. However, due to bellicose nature of the condition, the prognosis is relatively poor. Managing adolescent expectation after gradual deterioration is challenging especially, he is aware that achieving ‘normality’ is impossible as the treatment advancement still in limbo.
Little is known about the association between actual and selfperceived oral health status among residents living in a care home. This study aimed to assess their oral health status and to determine its association with their selfperceived oral health satisfaction. Materials and method: A cross-sectional study was conducted from July to August 2018 among 75 residents of Rumah Ehsan, Terengganu (the largest care home in east coast Malaysia). The oral health status and oral hygiene of the participants were examined. Their sociodemographic profile and self-perceived oral health status were collected through structured interviews. Chi-square, Man-Whitney, and multiple logistic regression tests were used to test the factors associated with the self-perceived oral health satisfaction of the participants. Results: Unsurprisingly, the majority of the participants had poor oral health with high median DMF-T score of 29.0 (IQR=12) and majority (86.7%) had poor oral hygiene. It was intriguing to know that the majority of them (64%) perceived they have good oral health status with 68% satisfied with their current oral health status. There was no significant association between their actual oral health status and their perceived satisfaction. However, increasing age, Malay and those eating dependently were less likely to satisfy with their oral health status. Meanwhile, those who were dependent on the staff to brush their teeth were more likely satisfied with their oral health status. Conclusion: There was a wide discrepancy between the actual and self-perceived oral health status among residents in care homes. Hence, it is crucial to improving awareness and knowledge among them in order to improve their oral health. Factors contributed to their oral health satisfaction should be acknowledged by all dental practitioners.
Smartphones has now become a common and almost essential tool in our daily living activities. Students are among those who uses smartphones regularly which could lead to addiction if overused. This study aims to measure the prevalence of smartphone addiction and its relationship with psychological health among clinical year medical students in International Islamic University Malaysia (IIUM), Kuantan. Materials and method: A total of 203 Medical students in their clinical years were recruited via quota sampling method. The students filled in a four part online-based questionnaire consisted of questions on sociodemographic characteristics, smartphone usage information, Smartphone addiction scale-short version (SAS-SV) and WHOQOL-BREF. Data was analysed using IBM SPSS Statistics. Result: The prevalence of smartphone addiction among clinical year Medical students in IIUM was 51%. Bivariate analysis showed that majority of students chose social networking as their primary purpose of smartphone usage and this is significantly associated with smartphone addiction (p-value:0.037). Following multiple logistic regression analysis, students who had chosen games as their primary purpose of smartphone usage are 88% less likely to be related with smartphone addiction (p-value: 0.009, 95% CI: 0.025-0.595) compared to those who used it for academic performance tasks. Students who are not addicted to smartphones reported significantly better psychological quality of life compared to those who are addicted (p-value
Doctor-patient communication is a crucial, unique yet complex relationship in clinical practice due to its therapeutic qualities. With the current emphasis on patient-centred care and patient autonomy, medical practitioners are not only expected to possess clinical and biomedical knowledge but also the skills to develop a therapeutic doctor-patient relationship. Nevertheless, this expectation proves to be an uphill battle to physicians as evidenced from patient complaints which among others include lack of appropriate non-verbal behaviours, absence of paralinguistic elements, lack of trust and empathy. Moreover, unsatisfactory doctorpatient communication has been identified as one of the major elements in litigation cases in the medical field. One fundamental factor which leads to this predicament is the ineffective training of communication skills at the medical schools. Hence, this project aspires to develop a training model on doctor-patient communication skills based on patient-centred approach. The model will give more emphasis on the linguistics and psychosocial aspects of communication. Materials and method: Utilising both qualitative and quantitative approaches i.e. survey, observation, interview, psychological profiling, persona analysis and document analysis, the project aims to identify 1) the key communicative features and 2) the key clinical and psychosocial features to be incorporated in the model. It will then operationalise these features to conceptualise an expert assistance system which shall be used in the training of future physicians. The study will be conducted at the IIUM Kulliyyah of Medicine and it will involve medical students at the undergraduate level. Conclusion: The findings from this proposed research are significant in improvising and enhancing the current training on communication skills provided at the medical schools. With a more ‘humane’ approach to training, indirectly, it will increase the effectiveness in the delivery of health care and achieve sustainability in good health and well-being (SDG3) of the nation.
There was lack of local study assessing the oral health related quality of life (OHRQOL) of patients with periodontal diseases. Hence, this study aims to assess the OHRQOL and its associated factors in adult patients who were diagnosed with gingivitis and periodontitis. Material and method: This was a cross sectional study conducted from May to December 2018 among 100 participants attended Periodontal Clinic, Kulliyyah of Dentistry of International Islamic University of Malaysia (IIUM) using purposive sampling methods. Clinical parameters of participants were recorded by a single examiner then followed by a selfadministered questionnaire using the validated short version of Oral Health Impact Profile(S-OHIP) (Malay) to assess the OHRQOL and its associated factors. The OHRQOL of participants were reported using mean and standard deviation. The factors associated with OHRQOL were determined using independent t-test and Spearman correlation test. Results: The mean score for S-OHIP was 14.73 ± 9.24. Participants with periodontitis have higher S-OHIP score compared to those with gingivitis. There were significant association between OHRQOL and underlying diabetes mellitus, self-perceived oral health status and self-perceived oral health satisfaction with p value < 0.05. This shows that those with underlying diabetes mellitus have higher S-OHIP score indicated poorer OHRQOL. Meanwhile, those who perceived they have either good or very good oral hygiene and satisfied with their oral health have lower S-OHIP score indicated better OHRQOL. Conclusion: This study found that periodontal diseases have significant association with the OHRQOL. Therefore, reinforcement of oral health education by the dentists is crucial.
Knowledge on under-five childhood immunization has been identified as a key factor in determining understanding and compliance to the schedule. Understanding the current levels of knowledge and introducing a health intervention to improve the level will benefit the population to be healthier and reduce morbidity. Materials and Method: A quasi-experimental study was conducted in nurseries in Putrajaya and Cyberjaya, Malaysia from January 2016 to January 2018. 98 respondents from Putrajaya were given the technology based intervention and 98 from Cyberjaya were the wait-listed control group. Respondents answered a validated, self-administered questionnaire at baseline, immediate post-intervention and 3 months post-intervention that were specifically targeted to examine their levels of knowledge on under five childhood intervention. Results: Data was analysed using Statistical Package for Social Science (SPSS) Version 23. The level of knowledge at baseline was 58.9% for the intervention group and 61.7% for the control group with no significant difference between both groups (p=0.651). Immediate post intervention showed a significant difference (p
Nursing students are subjected to a variety of stressors during their study. Severe and prolonged stressors may affect the psychological well-being in the form of depression, anxiety and stress which may affect students’ academic performance, physical health and quality of life. Therefore, this study aimed to determine the rate and severity of depression, anxiety and stress symptoms and also to assess the relationship between these symptoms with stressors faced by the students. Materials and method: A sample of 174 nursing students from International Islamic University Malaysia participated in this study. Depression Anxiety, Stress Scale (DASS-21) was used to assess the psychological well-being by determining the prevalence and severity of depression, anxiety and stress (DAS) symptoms. The sources of stressors were identified by giving the students a list of the most possible source of stressors which were chosen depending on previous studies, and then the severity of stressors and their relationship with these symptoms were assessed. Results: The overall prevalence of depression, anxiety and stress symptoms was 51.7%, 81.6% and 43.1% respectively but it was found that 13.2%, 44.3% and 10.3% of nursing students have clinically significant depression, anxiety and stress respectively. No significant differences between the gender and age of students in relation to DAS symptoms. Regarding the source of stressors, the top five stressors decided by the students were fear of failing, examination and grades, study pressure and obligations, fear of unemployment after graduation and academic overload. Conclusion: Depression, anxiety and stress symptoms are present among nursing students which require early intervention. Academic factors can be considered as sources of stressors that may precipitate emotional disturbances among the nursing students.
Huntington's disease (HD) is an inherited progressive neurodegenerative disorder which affects motor function, cognition and the psychological state of HD patients. Its triad of unique symptoms compared to other neurodegenerative disorders might give rise to a higher level of burden for their carers. The aim of this study was to explore factors associated with the quality of life in patients with HD. Materials and Method: Eighty-one HD patients and their carers participated in this study. Cognitive impairment was assessed with the Neuropsychiatry Unit Cognitive Assessment Tool (NUCOG), motor disturbances was scored using the Unified Huntington's Disease Rating Scale (UHDRS) motor scale, psychological status of both patient and carer were assessed using the Depression Anxiety Stress scale (DASS21), behavior of the patient was assessed using Revised Cambridge Behavioural Inventory (CBI-r) and patient's quality of life was assessed with WHOQOL-BREF questionnaire. Results: Patients' psychological conditions, motor disturbances and behavior of the patient are correlated with low QOL in HD patient. Conclusion: Other than regular motor symptoms, psychological and behaviour of HD assessment should be assessed regularly to ensure the patients having good quality of life.
Spinal tuberculosis in children is an established preventable disease in developing countries. Complications are devastating due to its aptitude to cause bone destruction, spinal deformity and paraplegia. Case report: We present an eight-month old girl with isolated gross motor regression and evolving spastic paraplegia. It highlights the challenge we encountered due to delay in garnering the pertinent investigation. She presented to clinic with history of legs weakness and loss of rolling after a period of prolonged febrile illness. Both parents are medical practitioners. Mother had history of SVT during pregnancy in spite on anti-arrhythmic treatments. Her father is a thalassaemia carrier. A thorough examination revealed gross motor delay and upper motor neuron signs. She had raised inflammatory markers, anaemia and thrombocytosis with persistent low-grade temperature. CT brain with contrast showed meningeal enhancement. Full septic work up revealed the CSF result reflecting partially treated meningitis. She was treated with third generation cephalosporin and acyclovir. Mother claimed exposure to TB patients hence Mantoux test was recommended which came positive. Her chest x-ray, sputum culture, CSF culture and NAA studies came non-conclusive for pulmonary tuberculosis. MRI for brain and spine showed features of tuberculous spondylodiscitis of T4-T5 vertebrae with associated subligamentous paravertebral spread and epidural extension causing spinal cord compression and T3-T6 hydro-syringomyelia. After multidisciplinary team discussion, patient started on intensive antituberculosis regimen with good initial response. Discussion: Clinically lower limbs power improved with good antigravity movement. Laboratory and radiological investigations have improved inflammatory markers and dropping trend thrombocytosis, and spinal gibbous stay stationary with improvement in plain radiology. She is under regular follow up awaiting serial MRI. Conclusion: The challenge in diagnosis of extra pulmonary tuberculosis in infants is getting them excluded early. High index of suspicion along with radiological investigation is vital to aid the diagnosis and establishment of treatment to expect a good outcome.
Diagnostic challenge is seen in Systemic Lupus Erythematosus (SLE) due to insidious onset, unpredictable course, broad spectrum of clinical presentation that mimic other diseases manifestation and possibility not fulfilling the classification criteria at the earlier course of the disease. Case report: We highlighted a case of a man, lived with diagnosis of Schizophrenia for almost 15 years subsequently revealed him suffered from neuropsychiatric lupus as he fulfilled the SLE classification criteria. His initial presentation was altered sensorium treated as acute psychosis-the tip of an iceberg to the underlying disease. His multiple admissions to psychiatric ward were believed contributed by episode of lupus flare. Necessary investigation is important to exclude another medical condition before make a diagnosis of Schizophrenia using DSM-V criteria. The misdiagnosis has significantly impaired his social life and untreated disease had leads to morbidity and severe organ damage. This case emphasizes on the crucial aspect of assessing patient as a whole, follow-up the progression and re-evaluates patient’s condition for a new hint. Even though there is no cure yet for SLE, correct and early diagnosis is able to guide for individualized treatment and thus helping in good disease control that warrant better outcome.
In Malaysia, a course of vaccination DTaP/IPV/Hib was introduced in 2008, replacing the 2006 DwPT-HBV/Hib+OPV vaccines. Severe systemic adverse reactions after diphtheria, tetanus and pertussis vaccination are uncommon. Cardiac complications are rarely reported and is most probably implicated to the pertussis component. We describe a rare case of acute myocarditis that developed 60 hours after DTaP/IPV/Hib vaccination. Case report: A 2-month old infant presented to emergency department after her first diphtheria, tetanus and pertussis vaccination due to severe respiratory distress and cyanosis. She had her BCG and two Hepatitis B vaccinations previously with no major side effects. Parents reported that she was feverish for 48 hours post vaccination with no other associated symptoms. Prior to presentation, she went floppy and was immediately brought to hospital. On arrival, she was tachypnoeic and cyanotic with hypoperfusion and hypotensive. She was also noted to have hepatomegaly. She was grunting and her level of consciousness deteriorated. She was immediately intubated and her first blood gas showed profound metabolic acidosis with pH 6.6, base excess -24mmol/L, lactate 14mmol/L and bicarbonate 4mmol/L. She required fluid boluses and inotrope infusion was commenced. She received antibiotics and sodium bicarbonate to correct her acidosis. Her echocardiography showed global hypokinesia, CK 3018 and positive Troponin. She was treated with immunoglobulin for myocarditis and on high frequency oscillation for 4 days before being extubated on day 11 of admission. All her viral serology and cultures came back negative. Discussion: Cardiac complications after diphtheria, tetanus and pertussis and other vaccinations are exceptionally uncommon. This patient developed sudden onset cardiogenic deterioration after an expected fever-like illness post vaccination. Given her viral screening and cultures were negative, this make acute myocarditis post vaccination a remote possibility. We concur that evaluation of cardiac state should be considered in recently vaccinated infants who manifest with cyanosis, hypoperfusion and drowsiness.
Pediculosis capitis is a worldwide problem which carries significant consequences among the school children and caregivers. This study aims to investigate the prevalence and predictors of Pediculosis capitis among primary school children in Kuantan, Pahang. Materials and method: An analytical crosssectional study using two-stage cluster random sampling was carried out among 1,365 primary school children in seven schools in Kuantan, Pahang. A selfadministered validated questionnaire was used followed by hair and scalp examination. Results: The median age of the respondents was 8.0 years. Majority of them were males (53.41%), Malays (60.29%), household income between RM1000RM2999 (31.87%) and from urban school location (98.68%). The overall prevalence of Pediculosis capitis was 9.6% (n=131). Multivariate logistic regression analysis showed that predictors for Pediculosis capitis were female (Odds ratio (OR)=8.571, 95% Confidence interval (CI)=5.024-14.620), Indian (OR=5.560, 95% CI=3.384-9.136), those with siblings more than five (OR=2.644, 95% CI=1.044-6.700), history of contact with infested person (OR=2.445, 95% CI=1.619-3.691) and urban school location (OR=0.030, 95% CI=0.284-0.091). Conclusion: Pediculosis capitis is a common public health problem affecting primary schoolchildren in Kuantan, Pahang and those levels are of epidemic importance. Hence, preventive measures are necessary to reduce the transmission of head lice among school children.
APDE is an acquired, transient bleeding disorder characterised by normal platelet counts with eosinophilia. It was previously known as ‘nonthrombocytopenic purpura with eosinophilia’. We report a case of a 3-year-old boy with prolonged history of spontaneous unexplained bruising which was initially investigated by SCAN team for non-accidental injury (NAI). Case report: A 3-yearold boy attended clinic with a 4-month history of recurrent bruising. Parents were unsure of preceded illness, but he remained well with no history of trauma. He has unremarkable medical history and father is a thalassaemia carrier. Upon assessment in clinic, he was subsequently referred for suspected NAI and SCAN team led to a police report with a plan to review in 2-months. Parents later decided to bring the child for further medical assessments which revealed multiple bruises over both thighs, back of shoulder, loin and trunk with varying sizes and ages. They were all non-tender on palpation with no recognisable shapes or patterns. Blood results showed normal liver functions with slightly prolonged APTT 39.8 secs. He has normal platelet count with significant eosinophilia 2.2 x 10^9/L and occasional reactive lymphocytes. Reflecting this result, plan for platelet functions and von Willebrand tests were made. However, due to costs, we decided to treat the child with antihelminthic agent for possible parasitic infestation. He had 3 days course of albendazole and no further bruises appeared after 5 days of completing treatment. Discussion: The clinical presentation of APDE can mimic Idiopathic Thrombocytopenic Purpura in many ways yet normal platelet counts often leads to a delay in diagnosis. Reassuringly, the course of APDE is benign and no treatment is often required. Conclusion: Investigations however are costly, therefore treatment with anti-helminthic agent would be an alternative option in providing assurance to family and medical practitioners dealing with suspected cases.
Acute onset quadriparesis can be a manifestation of a variety of neurological, metabolic or autoimmune conditions. Rarely, it could be one of many clinical presentations of juvenile dermatomyositis which belongs to the group of idiopathic inflammatory myopathies of childhood. We report the case of a 9-year old girl who presented with global myopathy over a two-month period. Case report: A 9-year-old girl referred with a 2 months history of generalised muscular pain and weakness. There were no significant history of preceded illness, trauma or excessive strenuous exercises. She had no other systemic complaints such as fever or skin rash. Past medical history was unremarkable except for recurrent tonsillitis. Physical examination revealed a child with normal alertness and behaviour. She has notable generalised swelling of all four limbs. Her neurological examination revealed normal tone however her power was definitely reduced in all four limbs (Graded 3/5). She demonstrated signs of proximal myopathy. Subsequent investigations revealed high Creatinine Kinase (CK) levels of 6470U/L, ESR 84mm/hr with deranged transaminases and positive serum mycoplasma and CMV IgM. Her MRI brain and spine along with lumbar puncture results were normal. She was referred to tertiary centre for further evaluation as her weakness progressed. An MRI muscle demonstrated marked inflammation in all four limbs including paravertebral muscles. Her muscle biopsy showed inflammatory myopathy leading to a diagnosis of juvenile dermatomyositis (JDM). She is now showing sustained clinical improvements following a course of immunoglobulin and corticosteroids therapy. Discussion: The diagnosis of JDM is generally considered in patients with rash-associated muscle weakness. Essentially, it involves assessment of muscle, skin, lung and cardiac involvement on top of baseline list of investigations that has been outline by Single Hub and Access point for pediatric Rheumatology in Europe (SHARE). This case reflects that JDM is possible despite non-existent of skin involvement.