MyMedR

Although Corynebacterium urealyticum has rarely been isolated in diagnostic laboratories, this bacterium can be a significant uropathogen causing significant complications. It causes cystitis and alkaline encrusted cystitis, commonly involved in patients who need prolonged hospitalization and bladder catheterisation. We report here a case of a 19-yearold young man who was diagnosed with N-Methyl Daspartate receptor (NMDAR) encephalitis that requires hospitalization for optimization of rehabilitation treatment in Hospital Kuala Lumpur, Malaysia. His urine culture isolated slow growing gram-positive pleomorphic rods subsequently identified as C. urealyticum. Based on the risk factors, the isolation of C. urealyticum could not be simply dismissed as contaminants. The patient was treated successfully with vancomycin for two weeks.

First toddler mesenteric lymphatic malformation in Malaysia - A case report

Soh CH, Emmanuel J, Rahizan MI, Azmi MA, Thillainayagam SD, Nurdaliza MB, et al.

Med J Malaysia, 2022 Jan;77(1):104-106.

PMID: 35087006

This is the first reported case of a mesenteric lymphatic malformation in a toddler in Malaysia. It is a rare benign condition with incidence of 1 in 250,000 populations. Our patient presented to us at 2 years 11months old complaining of abdominal distension for 6 months without obstructive symptoms. Clinically there was a vague soft central abdominal mass. CT abdomen done revealed a large multiloculated intraperitoneal mesentery cystic mass within the central abdomen extending to pelvis. A semi-emergency laparotomy was performed. Intra-operatively the multiloculated mesenteric cyst measured 20cm x 30cm, adherent to the small bowel beginning at 12cm from duodeno-jejunal junction. Resection of the mesenteric cyst with adherent small bowel and primary anastomosis was done. Histopathological examination revealed multiple large lymphatic channels of various sizes in the mucosa and submucosa. Our patient has no signs of recurrence and remains symptom-free after 1 year since his surgery. Surgery with clear margins of resection is the recommended gold standard based on available literature. Type of surgical resection required will depend on the type of mesenteric lymphatic malformation. An awareness of this rare pathology is required to ensure proper management is given to these patients.

An exposed Cardiovascular Implantable Electronic Device (CIED) complicated with infection: A case report of unconventional experience with 'Sealed CIED'

Mohd Said MR, Gian Singh SS, Chea CY, Mohd Firdaus MAB, Narasamuloo KR, Krishinan S

Med J Malaysia, 2022 Jan;77(1):119-120.

PMID: 35087011

The rate of infected Cardiovascular Implantable Electronic Device is alarming and causes substantial socio-economic burden. A common approach involves immediate extraction of the infected device. Here, we report an unorthodox approach to this problem by 'sealing' the generator inside a sterile container as a temporary permanent pacemaker while waiting for implantation of another device. We report a 66 years old emaciated lady with underlying Sick Sinus Syndrome, who had an implanted single chamber pacemaker and presented with partial protrusion of her device. She underwent sub-pectoral implantation of the new device but subsequently re-presented with pocket site infection after a month. A decision was made to extract the infected generator from the sub-pectoral pocket and it was sealed inside a sterile container as 'bridging therapy' while awaiting arrival of a leadless pacemaker for implantation together with total extraction of the old infected device. Our clinical vignette demonstrated the difficulties we encountered and influenced on our decision for this unconventional approach despite limited supporting evidence.

Jejunal gastrointestinal stromal tumour masquerading as an ovarian cancer: A case report

Sohail M, Chua RHB, Sim SK, Nik Azim NA

Med J Malaysia, 2022 Jan;77(1):125-127.

PMID: 35087013

A 60-year-old lady presented with lower abdominal discomfort and a huge palpable intra-abdominal mass for 4 months, with significant weight loss over half a year. Transvaginal ultrasonography and computed tomography (CT) abdomen showed a large right solid cystic mass likely ovarian in origin. The CA-125 was raised. With the provisional diagnosis of ovarian cancer patient underwent laparotomy at Hospital Umum Sarawak, Malaysia. However intraoperative findings showed that uterus and both ovaries were normal. The tumour was arising from the jejunum and adherent to the dome of the urinary bladder and right broad ligament. The tumour was resected and final diagnosis was jejunal gastrointestinal stromal tumour (GIST). We described this case which was misinterpreted as an ovarian cancer.

A child with unique skin pattern: A case report of Tinea imbricata

Roslan SR, Abdul Hadi A

Med J Malaysia, 2022 Jan;77(1):113-115.

PMID: 35087009

This paper reports a case of Tinea imbricata in a young Orang Asli boy which was noted during his admission for severe symptomatic anemia. Upon discharge, he was started on syrup Griseofulvin 10mg/kg daily and Whitfield cream for 4 weeks. The Department of Orang Asli Development (JAKOA) and the local Health Clinic were contacted before discharge to facilitate patient's follow-up and monitoring. Outbreaks of Tinea imbricata among the Orang Asli have been known to happen from time to time. Although this dermatophyte infection is rare in the urban population, transmission among travelers has been reported. This case report highlights its unique presentation and treatment approach.

Left aorto-ventricular tunnel: A differential diagnosis to aortic regurgitation

Wong AR, Amelia A, Mohd Zain MR, Sayuti KA

Med J Malaysia, 2022 Jan;77(1):101-103.

PMID: 35087005

Left aorto-ventricular tunnel is a rare congenital heart disorder. A then 19-year-old young lady was referred to our clinic for chronic rheumatic heart disease with aortic regurgitation. However, because of an almost continuous murmur, and an unusual transthoracic echo, she underwent various investigations, finally revealing a rare type 2 left aorto-ventricular tunnel. She had been variously diagnosed as chronic rheumatic heart disease with aortic regurgitation, bicuspid aortic valve with aortic regurgitation, and then possibly coronary arterial (cameral) fistula (based on 2D transthoracic echo) and finally left aorto-ventricular tunnel. This is the first case described in South East Asia who is asymptomatic, apart from a murmur, and her long journey to this final diagnosis illustrates the need to "chase shadows" on echoes, to come to a proper conclusion for the patient.

Intravascular ultrasound guided treatment of severe coronary artery calcification with Shockwave Intravascular Lithotripsy

Yap LB, Choy CN, Balachandran K

Med J Malaysia, 2022 Jan;77(1):116-118.

PMID: 35087010

Coronary artery calcification is a pathological deposition of calcium in the intimal and medial layer of the arterial wall. Shockwave intravascular lithotripsy (IVL) has evolved as a new modality to treat heavily calcified coronary arteries. IVL involves using a percutaneous device to produce acoustic pressure waves resulting in the delivery of sufficient energy to break up superficial and deep calcium deposits. We present a case where highly dense coronary calcium was successfully treated with intravascular ultrasound (IVUS) guided coronary angioplasty and IVL treatment. IVUS demonstrated heavy calcification at the proximal LAD with a 360° calcium arc. Post procedure, IVUS demonstrated multiple fractures of coronary calcium. Stent deployment was done successfully with good stent strut apposition. There was no procedure related complication. The case demonstrates an example where IVL is an important adjunctive tool in the cardiac catheterization laboratory for lesion preparation and optimal percutaneous coronary intervention.

Milk-alkali syndrome: The forgotten diagnosis for altered sensorium

Yap WL, Rahman A, Baharuddin KA

Med J Malaysia, 2022 Jan;77(1):107-109.

PMID: 35087007

Milk-alkali syndrome (MAS) is one of the causes of hypercalcaemia. We report a case of a 75-year-old lady with a history of thyroidectomy, presented with an altered mental state and had an extremely high calcium concentration of 4.96mmol/L. The hypercalcemia was attributed to the ingestion of large doses of calcium supplements, including calcium carbonate and calcium lactate, leading to MAS. She was managed with intravenous fluids, diuretics and withdrawal of calcium supplements. The patient responded well to treatment and regained consciousness. Details of the case including clinical presentations, electrocardiogram (ECG) findings and treatment plan, are discussed in this article.

A nationwide survey on awareness and knowledge about Bronchial Provocation Test amongst doctors in Malaysia

Ng KL, Huan NC, Mohammad FA, Mohd Aminudin NH, Mohammad FA, Abdul Rahaman JA

Med J Malaysia, 2022 Jan;77(1):33-40.

PMID: 35086992

BACKGROUND: Bronchial provocation test (BPT) is widely used internationally not only to evaluate bronchial responsiveness in conditions especially asthma, but is also utilized as a marker of control, severity and prognosis for asthma. However, the uptake of BPT in certain countries including Malaysia remains low. We aimed to explore this lack of knowledge by assessing the current level of awareness and knowledge on BPT amongst doctors in Malaysia.

MATERIALS AND METHODS: A nationwide web-based questionnaire targeting doctors was sent through social media (Facebook, WhatsApp and Telegram) and Malaysian Medical Association (MMA) mailing lists between 1 October 2020 - 5 February 2021.

RESULTS: In all 415 survey responses were analysed from doctors of various grades namely medical officers to consultants. A total of 404 (97.35%) encountered patients with asthma in their daily practice. According to specialty: 169 (40.72%) were from primary care, 121 (29.16%) internal medicine, 50 (12.05%) pulmonary medicine and 75 (18.07%) others. Only 163 (39.28%) were aware of BPT as a tool to diagnose asthma. 232 (55.90%) and 124 (29.88%) regarded BPT as an important test and felt confident to refer patients for BPT respectively. Of those participants who were not confident to refer: 35.17% were unsure of BPT indications, 33.21% were unsure of centres providing BPT, 8.17% cited logistic reasons, 6.04% were concerned of possible BPT side effects. 387 (93.25%) wanted more training in BPT. The median BPT knowledge score was 20% (1 out of 5). Awareness and knowledge were affected by specialty but not by: region of practice, gender, age and grade from logistic regression analysis.

CONCLUSION: Various national level programs and targeted local interventions are much needed to increase the awareness, knowledge and uptake of BPT in Malaysia.

Factors associated with unsuccessful quitters in stop smoking services in Perlis, Malaysia

Ikhwan MI, Hamid NA, Nor Izwana H

Med J Malaysia, 2022 Jan;77(1):47-52.

PMID: 35086994

INTRODUCTION: Tobacco smoking is one of major risk factor of non-communicable disease worldwide. As a prevention strategy, stop smoking services has been advocated at primary care. However, evidence suggests that worldwide there is high rate of unsuccessful quitters. In Malaysia, such evidence has come from small studies or single site study, and evidence on factors associated with failure to quit is scarce. This study aimed to identify the factors associated with unsuccessful quitters among smokers in Stop Smoking Services provided by government health clinics at North Peninsular of Malaysia.

MATERIALS AND METHODS: This was a retrospective study record review using data from the Stop Smoking Services registry and patient file card between January 2017 and Jun 2019. Independent variables included in this analysis are sociodemographic data, comorbidity, number appointments attended, duration of smoking, age of starting smoking, previous attempt to quit, fagerstrom score and type of treatment. The outcome of interest, is unsuccessful quitters defined as those who continued to smoke at 6 months after attending the service. A total of 427 sample randomly cases selected from 490 eligible sample was analysed. Logistic regression was used to model factors associated with unsuccessful quitters.

RESULTS: The study suggested that clients who attended 0-3 clinic sessions (AdjOR 6.57; 95% CI: 4.14, 10.43) and being single, unmarried (AdjOR: 2.78; 95%CI: 1.07, 7.18) was associated with increased risk of being unsuccessful quitters among smokers in Northern state of Malaysia CONCLUSION: The number of clinic sessions attended and marital status were factors associated with unsuccessful quitters among smokers in the State of Perlis, of Malaysia.

Ocular co-morbidities in patients with atopic dermatitis - a cross-sectional study from a tertiary referral hospital, Malaysia

Gan TS, Juares Rizal A, Salim NL, Lau LL, Voo SYM

Med J Malaysia, 2022 Jan;77(1):6-11.

PMID: 35086988

INTRODUCTION: Atopic dermatitis (AD) is a chronic relapsing pruritic inflammatory skin disease that commonly occurs among children as well as adults. AD patients were reported to have high prevalence of ocular manifestations, which may be due to the disease nature or drug complications. This study aimed to determine the prevalence of ocular manifestations in patients with AD.

MATERIALS AND METHODS: Eighty patients who fulfilled the UK Working Party's Diagnostic Criteria for Atopic Dermatitis were included in the cross-sectional study. A standardized case report form was formulated to collect the demographic data and disease profile of the participants. AD severity was evaluated using the EASI and SCORAD score. All patients underwent a complete ophthalmological evaluation.

RESULTS: The prevalence of ocular manifestations among the patients with AD was 48.8%. Fifty-four (67.5%) patients had facial dermatitis and 37 (46.2%) showed periorbital signs. The mean AD disease duration was 10.99 ± 11.20 years. Majority of the patients had mild to moderate AD. The most frequent ocular manifestation was allergic conjunctivitis (18.75%) followed by cataract (8.75%) and ocular hypertension (8.75%). Among the patients with ocular manifestations, 27 (69.2%) patients regularly applied topical corticosteroids on the face. The use of systemic corticosteroids was seen in 19 (42.2%) patients. Prolonged AD duration was significantly associated with the development of ocular manifestations.

CONCLUSIONS: Nearly half of the patients with AD were complicated with ocular disease regardless of the AD severity, facial dermatitis and presence of periorbital signs. Long disease duration is associated with ocular manifestations, especially steroid related complications.

Factors associated with severe envenomation of snakebite cases at emergency department, Hospital Sultan Abdul Halim, Kedah, Malaysia

Mhd Nizar MNF, Rahman A, Baharuddin KA, Ahmad MZ, Mohamed Ismail M

Med J Malaysia, 2022 Jan;77(1):20-25.

PMID: 35086990

INTRODUCTION: Snakebite envenomation is a medical emergency and cases continue to be encountered in Malaysian hospitals. This study aims to determine the prevalence of snakebite presentations and the associated factors with severe envenomation of snakebite in Sungai Petani, Kedah, Malaysia.

MATERIALS AND METHODS: This was a retrospective, crosssectional study involving snakebite patients presented at the Emergency Department (ED), Hospital Sultan Abdul Halim (HSAH), Kedah from 1 July 2015 to 30 June 2019. The cases were extracted from the computerized system and the case records of patients were retrieved from the Medical Record Unit. Patients that met the study criteria were included and their sociodemographic features, clinical presentations including use of anti-venom were collected. Logistic regression analysis was performed to determine the factors associated with severe envenomation.

RESULTS: A total of 220 snakebite cases with the mean age of patients was 39.66 (SD±21.79) years old. Majority of them were Malay and males. 41.4% of snakebite cases occurred in late evenings and the mean time-lapsed to arrive at HSAH was 108.6 minutes. 81.4% of snakebite cases occurred while engaging in outdoor activities and 43.6% of the snakebite cases involved work-related incidents. 58.2% of the patients were bitten in the lower limb. 78.6% of patients were bitten by the identified snake species, predominantly from Viperidae family. The prevalence of severe envenomation was 50.9%. Malay ethnicity (adj. OR =2.549, 95% CI =1.277,5.089), bite to the upper limb (adj. OR =2.125, 95% CI =1.192, 3.790), and bite by snakes from Viperidae family (adj. OR =3.017, 95% CI =1.613, 5.642) were found to have significant associations with severe envenomation of snakebite.

CONCLUSION: The prevalence of severe envenomation was more than 50% of snakebite cases. Malay ethnicity, upper limb snake bites, and snakebite from a Viperidae family had a higher chance of severe envenomation.

Achalasia cardia: A five-year review in Hospital Tuanku Ja'afar, Seremban

Chin DHJ, Lim KG, Peh HS, Burud IAS, Tata MD, Zakaria J

Med J Malaysia, 2022 Jan;77(1):41-46.

PMID: 35086993

INTRODUCTION: Achalasia cardia is an oesophageal motility disorder that affects various age groups. This study focused on the epidemiological features of achalasia, its risk factors, treatment modalities offered and the clinical outcomes in a tertiary hospital.

MATERIALS AND METHODS: A retrospective search was carried out on all patients with a diagnosis of achalasia cardia in Hospital Tuanku Ja'afar (HTJ), Seremban, Malaysia between 2014 and 2018. Demographic data, patient symptomatology, and definitive management options were determined from the records. Telephone interviews were conducted to evaluate patient satisfaction with the outcome of treatment.

RESULTS: There were 30 patients with a newly diagnosed achalasia cardia in that 5-year period, with an equal incidence among men and women. The mean age of presentation was 44.63 ± 18.21 years. Malays formed the largest group. The mean weight and body mass index were 46.8 ± 10.4 kg and 18.0 ± 4.4 kg/m2 respectively. There was a wide range of duration of symptoms at presentation with a mean of 30.11 ± 35.29 months. Almost all patients presented with dysphagia (96.7%) while 70% also noted loss of weight. All patients underwent oesophagogastroduodenoscopy (OGDS) and 26 patients (86.7%) had barium swallow as part of diagnostic workup. A total of 18 patients underwent a laparoscopic Heller myotomy with or without Dor Fundoplication and/or cruroplasty while two patients (6.7%) underwent pneumatic dilatation as first treatment. Iatrogenic mucosal perforations were detected in 8 patients who underwent myotomy and fundoplication and were repaired intraoperatively. Of the patients who underwent myotomy and fundoplication, the mean weight increase was 15.6kg, increasing from 43.0 ± 8.4 kg to 58.6 ± 13.7 kg. All the patients who underwent treatment were satisfied with their treatment outcomes.

CONCLUSION: Most patients with achalasia cardia deemed suitable for surgery and counselled accordingly accept surgery resulting in high levels of satisfaction and weight gain in almost all these patients. A small minority who opt for pneumatic dilatation may also achieve satisfactory outcomes comparable to surgery in the short term. Although rare, clinicians should be able to recognise this disease early as early intervention often leads to satisfactory longterm outcomes.

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