Necrotising fasciitis is a life-threatening infection of the soft tissue which can be caused by different microorganisms, but infection caused by Aeromonas spp. or Vibrio spp. is frequently associated with higher mortality rate. Necrotising fasciitis progresses rapidly and often need aggressive surgical intervention. We present a rare case of necrotising fasciitis cause by Aeromonas sobria which mortality was successfully prevented by swift diagnosis and aggressive surgery.
Temporal bone carcinoma is a rare malignant tumor of the head and neck region. Its clinical presentations can mimic benign ear diseases, leading to inaccurate diagnosis and substandard management. We present the case of a 53-year-old female with a three-month history of progressive right otalgia, otorrhea, and hearing loss. Otoscopic examination revealed a mass occupying the right external auditory canal. However, the lesion was presumed to be an aural polyp by several clinicians previously. Multiple courses of oral antibiotics had been prescribed before she was referred to our clinic for the non-resolving aural polyp. Imaging studies showed an external auditory canal soft tissue mass with extradural and parotid extension. The mass was biopsied, and the result was reported as squamous cell carcinoma of the temporal bone. The patient was advised for a total temporal bone resection and parotidectomy; however, she declined the surgical intervention. Within a month, the tumor had metastasized to her lung, liver, and vertebral bodies. She was referred to the Oncology team for palliative chemo-radiotherapy. Temporal bone malignancy must be considered as a differential diagnosis in a middle-aged or elderly patient with a non-resolving aural polyp without a chronic discharging ear. Imaging studies and histopathological evaluation should be prompted to ascertain the diagnosis. Repeated course of oral antibiotic will delay treatment and subsequently may lead to poor prognosis.
Development of computer-based medical inference systems is always confronted with some difficulties. In this paper, difficulties of designing an inference system for the diagnosis of arthritic diseases are described, including variations of disease manifestations under various situations and conditions. Furthermore, the need for a huge knowledge base would result in low efficiency of the inference system. We proposed a hierarchical model of the fuzzy inference system as a possible solution. With such a model, the diagnostic process is divided into two levels. The first level of the diagnosis reduces the scope of diagnosis to be processed by the second level. This will reduce the amount of input and mapping for the whole diagnostic process. Fuzzy relational theory is the core of this system and it is used in both levels to improve the accuracy.
A 28-year old Malay man with evidence of an upper motor neuron cord lesion was diagnosed to have a C7 to T2 spinal arterio-venous malformation and associated cutaneous vascular lesion. He finally agreed for treatment after 5 years of progressive spastic right lower limb weakness leading to inability to mobilize. A two staged intravascular procedure was done followed by surgery with recovery of ASIA impairment scale grade B.
Thrombocytosis in children as well as in adult is defined as platelet count ≥ 450 × 109/L, and it is usually a reactive feature to various medical disorders. However, extreme thrombocytosis (platelet count ≥ 1000 × 109/L) is an uncommon finding among pediatric and adult patients, which may indicate more than a reactive phenomenon. We describe a case of a five-year-old boy who was admitted due to recurrent epistaxis. He had no history of allergic tendency or trauma. Physical examination was unremarkable except for shotty neck nodes. Laboratory results at presentation showed normal hemoglobin and total leukocyte count with eosinophilia (0.92 × 109/L), and extreme thrombocytosis. Other relevant investigations including coagulation profile, serum ferritin, liver, and renal function tests were all within normal ranges. Stool samples for ova and cysts were negative. The peripheral blood smear and bone marrow aspirate confirmed thrombocytosis with increased megakaryocytic proliferation and no artefactual reasons for the high platelets such as red blood cell fragments. Different causes of thrombocytosis in childhood were investigated after considering the possible differential diagnoses for extreme thrombocytosis.
Comment on: Singh B, Kim Sung L, Matusop A, Radhakrishnan A, Shamsul SS, Cox-Singh J, Thomas A, Conway DJ. A large focus of naturally acquired Plasmodium knowlesi infections in human beings. Lancet. 2004 Mar 27;363(9414):1017-24. PubMed PMID: 15051281.
Tumours that occur in the oral cavity may contain granular cells as a component of their pathology. A more common granular cell lesion occurring in the head and neck region is the granular cell tumour (GCT) that usually arises in the tongue or the buccal mucosa. Granular cell tumours are very rare in the parotid gland with only 11 cases previously reported in the English literature. We report a case of a benign tumour involving the parotid gland of a young female patient. The case was diagnostically challenging due to the large proportion of granular cells masking the underlying pathology. Histopathological features and immunohistochemical analysis favoured a diagnosis of a benign GCT. The present report provides an insight into the differential diagnosis and attempts to characterise the granular cells with the use of the wellestablished immunohistochemical markers and conventional histopathological techniques.
A 35-year-old man from Bangladesh, who had been in Malaysia for approximately a year, was extensively investigated for more than two months in a state hospital for pyrexia with hepatosplenomegaly. However, no obvious cause of his illness was found. He was treated with multiple antibiotics with no resolution of pyrexia and hepatosplenomegaly. He was later referred to the Haematology Unit, Universiti Kebangsaan Malaysia for further assessment as a case of lymphoma. On carefully reviewing his bone marrow aspirate smears, the diagnosis of leishmaniasis (kala-azar) was finally made. The patient responded to treatment with pentamidine.
In this paper, we report three cases of orbital rhabdomyosarcoma in different age groups with different histopathologic types. Case 1 is a 10-year old Malay boy who presented with painless proptosis of the left eye. Magnetic resonance imaging (MRI) showed soft tissue mass arising from the lateral rectus muscle. Tissue biopsy revealed rhabdomyosarcoma of embryonal type. Case 2 is a 32-year old Malay man who presented with a progressive left eye proptosis associated with pain and redness. Computed Tomography (CT) scan showed a retrobulbar mass extending medially in the left orbit. Meanwhile, biopsy showed rhabdomyosarcoma of pleomorphic type. Case 3 is a 67-year old Malay woman who presented with proptosis and fungating growth of left orbital region, epistaxis and nasal blockage. CT scan revealed an ill-defined mass filling up the left orbital cavity. Biopsy showed rhabdomyosarcoma of alveolar type. Rhabdomyosarcoma is the most common in childhood but it should be considered as a differential diagnosis of orbital tumours irrespective of age.
We describe a case of a giant thrombosed intrasellar internal carotid artery aneurysm initially diagnosed as pituitary macroadenoma. The differentiating neuroimaging features were discussed.
In spite of the efforts and interventions by the Government of Pakistan and The World Health Organization, the neonatal mortality in Pakistan has declined by only 0.9% as compared to the global average decline of 2.1% between 2000 and 2010. This has resulted in failure to achieve the global Millennium Development Goal 4. Hypoxic-ischaemic encephalopathy, still birth, sepsis, pneumonia, diarrhoea and birth defects are commonly attributed as leading causes of neonatal mortality in Pakistan. Inherited metabolic disorders often present at the time of birth or the first few days of life. The clinical presentation of the inherited metabolic disorders including hypotonia, seizure and lactic acidosis overlap with clinical features of hypoxic-ischaemic encephalopathy and sepsis. Thus, these disorders are often either missed or wrongly diagnosed as hypoxicischaemic encephalopathy or sepsis unless the physicians actively investigate for the underlying inherited metabolic disorders. We present 4 neonates who had received the diagnosis of hypoxic-ischaemic encephalopathy and eventually were diagnosed to have various inherited metabolic disorders. Neonates with sepsis and hypoxic-ischaemic encephalopathy-like clinical presentation should be evaluated for inherited metabolic disorders.
A 13-year-old boy presented with a 2 weeks history of tearfulness, childish behaviour, separation anxiety, hypersomnia, hyperphagia and sexual disinhibition following a brief episode of fever. He had been experiencing the episodes since he was seven. The episodes lasted from a few days to 3 weeks and would normally occur once in a year. Most of the time it started with fever and resolved spontaneously. In the past he described auditory hallucination but not this time. Examination revealed a slightly overweight adolescent male appearing appropriate to his age. During the session he was restless, sleepy and burst into tears frequently. He constantly asked his mother when he could go home to sleep. He was very childish and clung to his mother. He was given a trial of risperidone 1 mg to be taken once a day for 3 days. On follow-up he had completely recovered.
Intramuscular shoulder angiomyolipomas are very rare. We report a case in a 22-year-old male with a well circumscribed lesion located on the back of the shoulder. This lesion, differs from renal angiomyolipoma in terms of non-association with tuberous sclerosis, circumscription and male predominance. Another characteristic feature is the absence of epithelioid cells. Differential diagnosis includes lipoma, angiolipoma, angioleiomyoma, hemangioma, myolipoma and liposarcoma. It is distinguished from the above mentioned entities by the presence of a combination of thick-walled blood vessels, smooth muscle and fat.
Intramuscular shoulder angiomyolipomas are very rare. We report a case in a 22-year-old male with a well circumscribed lesion located on the back of the shoulder. This lesion, differs from renal angiomyolipoma in terms of non-association with tuberous sclerosis, circumscription and male predominance. Another characteristic feature is the absence of epithelioid cells. Differential diagnosis includes lipoma, angiolipoma, angioleiomyoma, hemangioma, myolipoma and liposarcoma. It is distinguished from the above mentioned entities by the presence of a combination of thick-walled blood vessels, smooth muscle and fat.
A 45-year-old Malay lady developed brisk vesicular, plaque-like reaction to a Mantoux test concomitant with a diagnosis of acute myeloid leukaemia (AML). The lesion resolved one month after chemotherapy. Similar lesions developed later after she was bitten by mosquitoes on the forearms. She also had the lesions over her cheek. A skin biopsy showed infiltration of the dermis with neutrophils and some monocytoid cells. The lesion resolved one week after prednisolone therapy.
Ossifying fibromyxoid tumor (OFMT) is a rare benign tumor, most of which occurs in adults with localization in the subcutaneous tissue or muscle of the extremities. A five-year-old girl presented with a mass in her right upper thigh. Due to the large size of the mass (10 x 7 cm), our provisional diagnosis was a soft tissue sarcoma. A tru-cut biopsy showed that the lesion was benign. The mass was excised and has not recurred since. To the best of our knowledge, this patient is the youngest case of OFMT reported in the English literature.