The estimation of age of human foetal remains is of great medico-legal importance. When the remains are intact and fresh, various morphological features such as crown-heel length, weight, appearance of ossification centres particularly around the ankles and knees and other parameters could be used to make a reasonable estimation of the period of gestation. In cases of criminal abortion, infanticide and child murder the question of age of the foetus, viability, live birth and a separate existence become very important. In practice, often at the time of detection, the remains are decomposed or skeletonised. In such a situation the examination of developing teeth will provide a reliable answer pertaining to the foetal age, the possibility of a separate existence and even the period of survival after birth. The.age determination from dental examination is possible from approximately 10 weeks intrauterine up to old age. The presence of neonatal line (birth line) in both dentine and enamel indicates live birth and a separate existence. It is possible that the time period of survival can be estimated by measuring postnatal deposition of these hard tissues. An intact human foetus that has undergone mild to moderate putrefaction was studied. The study of the morphological features and the ossification centres suggested that its approximate age was around nine months intrauterine. It was not possible to decide whether it was a live birth and had a separate existence. The examination of the developing first deciduous molar of the mandible suggested the approximate age was around 30-32 weeks intrauterine. The importance of examination of developing teeth in foetal remains (including neonates), particularly associated with putrefaction or skeletonisation is emphasized.
The evidence presented by the nine cases described in this paper indicates that primary arteritis of the aorta is a single clinico-pathological entity of which Takayashu's syndrome is a part. Different segments of the aorta may be affected resulting in a variety of symptom complexes. In this series, the mode of presentation was hypertension consequent on renal artery stenosis. Early diagnosis is important and surgical treatment is indicated to relieve the hypertension which carries an immediately serious prognosis.
We report a case of visceral leishmaniasis (kala azar) in a 28 year old Bangladeshi migrant. The patient had migrated to Malaysia 9 months prior to admission to our hospital. He was employed in a glove factory. His illness began one week prior to presentation with high swinging fever, chest pain and substantial weight loss. On examination, he was found to be cachetic, with cervical and inguinal lymphadenopathy and niassive hepatosplenomegaly. Investigations revealed a pancytopaenia with a Hb of 9.9 g/L, WBC 3.10 x 10^9/L and a platelet count of 29 x 10g/L. Liver function test revealed an elevated alkaline phosphatase 380 I.U./L and transanlinases AST 169 I.U/L and ALT 95 I.U./L. The serum albumin was 19 g/L. Blood for malaria parasite was negative. A bone marrow examination was performed to look for LD bodies and to exclude haematological malignancies. The bone marrow examination revealed multiple LD bodies. Serology for leishmania was strongly positive. The patient was heated with atnphotericin B to a total dose of 0.6 g. There was resolution of his fever and reduction in the size of the liver and spleen at the end of therapy. There was also a steady gain in his weight. The patient unfortunately failed to return for subsequent follow-ups
A 31-year-old woman presented with a one-week history of headache, generalised lethargy, weakness and poor appetite. Clinical examination showed that her blood pressure was 200/120 mmHg. On an earlier occasion, her blood pressure was found to be normal by a general practitioner whom she last visited three months earlier when she had an upper respiratory tract infection. Investigations showed hypokalaemia, suppressed serum renin and aldosterone. Further history was taken and revealed that she had been craving for guava fruits which she ate with flavoured "asam boi" (containing glycyrrhizic acid) at least three spoonfuls twice a day for the past six weeks. The hypertension and hypokalaemia resolved after two weeks of stopping the "asam boi". Her clinical picture was compatible with exogenously-induced hypermineralocortoidism.
Two of the four patients with tropical venereal diseases underwent incision and drainage of the inguinal bubo resulting in discharging sinus before they were referred to the Skin Clinic. Clinical diagnosis was made in all four but could not be confirmed. With appropriate therapy resolution was achieved without complications. The difficulties in arriving at and establishing the diagnosis are discussed.
Study site: Department of Dermatology
Sultanah Aminah General Hospital
Three cases of multiple drug resistant falciparum malaria in the same family are described. It is interesting to note that faIciparum malaria resistant to Fansidar has not as yet been reported in adults from West Malaysia up to the present time, although resistance to the drug in children is being encountered not infrequently. This presents a serious paediatric problem because malaria causes the highest incidence of mortality and morbidity in this age group in a proportion of the rural population.
A rare case of hepatic hydatidosis in non-endemic Malaysia is reported. It is important that clinicians treating the occasional patient be familiar with current diagnostic and therapeutic modalities.
Cardiomyopathy developed in the peripartum period in two healthy primigravida at 41 and 42 weeks of gestation are presented. In the first case, the patient presented with pulmonary oedema and had cardiac arrest immediately after admission. After resuscitation, a live baby was delivered by Caesarean section. Second cardiac arrest occurred after 12 hours of operation and the patient was resuscitated again. On the 8th post operative day, patient died of D.I.V.C. and renal failure. The second case was a twin pregnancy associated with pregnancy induced hypertension. Caesarean section was performed for foetal distress. She developed pulmonary oedema with left ventricular failure on the second post operative day, was resuscitated and discharged on the 15th day. These are the first two cases to be reported from Hospital University Sains Malaysia. Reference is made to three other cases in which a similar pathological process might have occurred.
An Indian family with all 3 sons having the fragile X syndrome is reported. The frequency of fragile X cells observed ranged from 4·16%. The phenotypically normal mother, although an obligate carrier, did not express any fragile X chromosomes in her Iymphocyte cultures. The range of mental retardation in affected
hemizygous males and heterozygous females as well as the significance of the fragile X chromosome in prenatal diagnosis are discussed.
In patients with thyroid disease, ocular involvement or thyroid ophthalmopathy is common, irrespective of their thyroid status. A common feature of thyroid eye disease is eyelid retraction, which leads to a classical starry gaze (Kocher sign). Treatment with radioactive iodine (RAI) is a known therapy for hyperthyroidism. However, this treatment may lead to or worsen thyroid ophthalmopathy. We report a case series of two patients with thyrotoxicosis, who presented with an atypical and subtle occurrence of thyroid eye disease (TED) soon after RAI therapy. One of the patients was initially diagnosed and treated for dry eyes; however, over a period of time, the patient's vision progressively deteriorated. Clinical and radiological investigations confirmed thyroid ophthalmopathy with low serum thyroid hormone levels. Both patients recovered well after immediate intensive intravenous steroid treatment. These cases highlight the importance of recognizing partial ptosis as one of the presenting signs of active TED among general practitioners and physicians.
Emergency lung resection for chest trauma is a rare event with a reported incidence of 0.08-1.3% but is associated with a high morbidity and mortality especially if a pneumonectomy is required, if due to blunt chest trauma or when concomitant injuries are present. We report three cases of young adult males with penetrating chest injuries that required emergency thoracotomy (ET) and anatomical lung resection to achieve definitive control of life threatening pulmonary haemorrhage. All patients survived to hospital discharge and remained well on follow-up. Indications for an ET and what constitutes the optimal operative management of such patients is discussed.
Intraorbital foreign bodies (IOrbFB) are associated with both sight and life threatening injuries. We report a case of an IOrbFB associated with retrobulbar hemorrhage and injury of the frontal sinus in an 11 year-old boy, after history of fall from the tree. Imaging studies revealed a metallic foreign body (FB) in the orbit and fracture of the walls of the frontal sinus. The usual entry route of an IOrbFB is either through the eye or orbital walls and extremely rare through the paranasal sinuses. This is the first reported case of a FB entering the orbit through the frontal sinus.
Tracheal agenesis is a rare congenital airway anomaly that usually results in a fatal outcome. The diagnosis is usually made through post-mortem examination. In the current literature, there has been no reported long-term survival although a few reports claimed prolongation of life of several hours to days. This condition is commonly associated with premature birth, polyhydramnios and a male predominance. In 90% of the cases, it is associated with multiple cardiovascular, gastrointestinal and genitourinary tract anomalies which are incompatible with life. We report a case of a premature newborn with severe respiratory distress, absent cry and cyanosis soon after birth. Attempts at endotracheal intubation failed as it was no possible to negotiate the tube beyond the vocal cords. Needle cricothyrotomy and attempted tracheostomy also failed to secure the airway. The diagnosis was confirmed at post-mortem examination.
Traditional Malay herbal medicine is still used in Malaysia especially in rural areas, instead of using modern medicine. Datura or "kecubung" has been used to treat allergic rhinitis in certain places. Inaccurate doses can potentially cause severe or fatal neurologic anti-cholinergic toxidromes. A good knowledge of toxidromes with optimization of supportive care can prevent fatal complications and lead to a more speedy recovery. We present a case of kecubung poisoning.
This case history illustrates the real life experience and dilemma of an 80-year-old woman in pursuit of medical care for her left shoulder pain. Points for discussion range from clinical features of Pancoast tumor, importance of pain management, good principles of Family Medicine and Palliative care to ethical issues of conspiracy of silence, limited treatment plan and palliative versus curative radiotherapy treatment without a known biopsy report. This paper provides opportunity for analysis of a real complex clinical situation, application of medical knowledge to problem solving in clinical practice and relevant topics for discussions. (For anonymity sake, the names of patient, doctors, general and private hospitals are not mentioned. The aim of this paper is solely for continuous medical education without any intention to ridicule any party).
This case illustrates an 80-year-old lady who presented with acute low back pain and finally succumbed from complications of osteoporotic vertebral fracture. Among the contributing factors are delayed diagnosis and a lack of continuity of care. It reminds the practitioners of the importance to look out for red flag symptoms and to have a high index of suspicion for vertebral fracture in high risk patients presenting with low back pain.
Study site: Accident and Emergency Unit, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
A 41 year-old Malay man had been treated by general practitioners for bilateral red eyes with profuse discharge of three weeks' duration with no improvement. He then presented to an ophthalmologist who noted profuse purulent discharge, bilateral corneal perforation, lid swelling and chemosis. Culture of the ocular discharge grew Neisseria gonorrhoeae. Treatment with systemic and topical antibiotics prevented microperforations in the right eye from progressing to overt perforation and was able to control disease in the left eye.
Catheter knotting is a rare complication of bladder catheterisation. Retention of catheter parts resulting in calculus formation is even rarer. We report a case of a vesical calculus formed over a broken and retained supra-pubic catheter which to the best of our knowledge has yet to be reported, along with three other cases of bladder catheter knotting.