This was a prospective randomised study comparing carboxyhaemoglobin concentrations between low-flow anaesthesia (fresh gas flow 1.0 L/min) and minimal-flow anaesthesia (0.5 L/min) using desflurane. Sixty (ASA 1 or 2) adult patients undergoing elective surgery under general anaesthesia were randomly allocated to receive either low-flow (Group 1) or minimal flow anaesthesia (Group 2). Venous blood samples for carboxyhaemoglobin levels were taken at baseline and at 10 mins intervals for 40 mins. Both groups showed significant increase in carboxyhaemoglobin concentrations within the first 10 mins when fresh gas flow of 4.0 L/min was used. Reduction in carboxyhemoglobin levels was seen after 20 mins of minimal or low flow anaesthesia. However, there was no significant difference in the magnitude of reduction of carboxyhemoglobin concentrations between the groups. The fractional inspired of oxygen (FiO2) showed no significant changes in either group. In conclusion, desflurane usage in anaesthesia with either low-flow or minimal-flow was not associated with increased carboxyhaemoglobin concentrations.
Ocular inflammation from various causes may have similar clinical presentation thus careful clinical evaluations are mandatory particularly when the disease appear to be resistant to treatment. This paper reports a case of ocular lymphoma which was initially treated as Vogt Koyanagi Harada disease at a different centre. A 65-year-old Sudanese man complained of gradual worsening left eye vision. Careful ocular and slit lamp examination revealed a conjunctival lesion with choroidal infiltration as well as exudative retinal detachment. Computed tomography scan (CT scan) showed left eye axial proptosis, and a homogenous enhancing mass at the posterior coat of the globe. Tissue biopsy of the conjunctival lesion revealed marginal Zone B cell (MALT type), low grade, non-Hodgkin’s lymphoma. AS the ocular signs and symptoms progressed, chemotherapy was initiated. The proptosis, exudative retinal detachment, disc hyperemia and swelling improved after chemotherapy. The post treatment CT scan showed reduction of the posterior ocular coat mass. The possibility of malignant lymphoma should be considered in patients with resistant uveitis despite administration of corticosteroid. Ocular lymphoma is an indolent tumour with good prognosis. Careful ocular examination, adequate imaging studies followed by early surgical biopsy will contribute to early diagnosis.
Primary malignant melanoma of the vagina is rare but aggressive. Various treatment options include surgery and adjuvant therapy has been advocated but the outcome remained unpredictable. Standard treatment protocol is yet to be established. We report a case of 54-year-old, Para 4+1, with malignant melanoma of the vagina. She underwent wide local excision but the surgical margin was not clear of malignant cells, hence adjuvant radiotherapy was given. Combination chemotherapy was initiated subsequently as her disease disseminated. She succumbed later due to septicaemic shock. The treatment options for vaginal melanoma were reviewed.
First trimester placenta accreta is a rare occurrence but potential life threatening and catastrophic. Most of these
cases ended up with emergency hysterectomy. We report a case of incidental finding of placental accreta during
evacuation of retained product of conception (ERPOC) for missed miscarriage. A 33-year-old, Gravida 4 Para 2 + 1
at 15 weeks’ gestation admitted for missed miscarriage, failed medical evacuation requiring ERPOC. There was
excessive bleeding during the procedure and required hysterectomy and bilateral internal iliac artery ligation.
Histopathological examination confirmed products of conception with evidence of placenta accreta. This case
highlighted the diagnostic dilemma and importance of early accurate diagnosis of placental accreta prior to any
surgical intervention for miscarriage.
We report a case of dislodged Levornogestrel-intrauterine system (LNG-IUS, Mirena®) without evidence of uterine perforation. A 37-year-old Para 4+1presented with 3 months history of lower abdominal pain. Examination and imaging showed that the device was not present in the uterine cavity. She underwent laparoscopic retrieval of Mirena®. There was no evidence of uterine perforation intra-operatively. This case illustrated the rare possibility of dislodged Mirena®intra-abdominally without evidence of uterine perforation. The management for missing IUS was reviewed.
We report a case of rare, Mullerian vaginal cyst with intracystic haemorrhage in the absence of endometrial components. To date, this is the second case reported in the literature. A 51-year-old post-menopausal woman with history of anterior vaginal wall cyst was misdiagnosed to have cystocele. The cyst was excised and the content was old blood mixed with mucous. Histopathological examination revealed a Mullerian vaginal cyst without endometrial component. Thus, diagnosis and management of vaginal cyst was revisited and discussed.
A middle-aged gentleman with history of left penetrating keratoplatsy presented with left eye perforated corneal graft secondary to infective keratitis. The affected eye was blind from absolute steroid-induced glaucoma. In view of expected poor graft survival in a blind eye, globe removal was offered. However, the patient refused the treatment and request for another corneal graft. This case highlights both the possibility of good outcome of cornea graft in such a case, and also illustrates that patient’s autonomy to refuse treatment option outweighs beneficence.
Frontal mucocele is not commonly masked as upper lid abscess.A 72-year-old Chinese man with underlying hyperthyroidism complained of left upper eyelid swelling of 6 months duration. The swelling had persisted and worsen when intravenous antibiotic was changed oral type. Visual acuity on presentation was hand motion and reverse relative afferent pupillary defect was present. Because the swelling was large and resulted in mechanical ptosis and ophthalmoplegia, a CT imaging was performed, which showed huge left frontal mucocele eroding the supereromedial orbital rim. The left globe was displaced inferolaterally but there was no extension into brain parenchyma. Fundus examination showed pale optic disc with dull macula. Old laser marks were seen at peripheral fundus. Referral to ortholaryngologist was made and endoscopic sinus surgery and evacuation of mucopyocoele was done. Culture and sensitivity of the fluid showed no organism. He recovered well postoperatively with additional two weeks of antibiotics. We highlight the necessity of surgical drainage of mucocele, following a course of antibiotic.
Rapunzel syndrome, or generically known as trichobezoar, is a rare condition. It usually happens among teenage population. We are presenting a case report of Rapunzel syndrome that happened in a 4-year-old child. She was initially investigated for nephrotic syndrome, as she had high blood pressure and hypoalbuminaemia. However, it was later found out to be a trichobezoar, indirectly causing both hypertension and malnutrition. This condition demanded a combination of surgical and psychiatric discipline for diagnosis and its treatment.
Anaesthesiology is a specialty which is less well known and the public usually have little knowledge regarding anaesthesia and the roles of Anaesthesiologist. Many hospitals now use a single dedicated consent for anaesthesia. This study was conducted to compare the effectiveness of a single consent for anaesthesia with the combined surgical and anaesthetic consent. A total of 109 patients, scheduled for elective surgery requiring anaesthesia were interviewed with a standardised questionnaire. Patients were divided into two groups, where one group used a single anaesthetic consent while the other used a combined surgical and anaesthetic consent. A single consent for anaesthesia was found to be more effective than the current combined surgical and anaesthetic consent (p
Ectopic pregnancy in the interstitial part of the fallopian tube (cornual pregnancy) is a rare condition but can be fatal. Traditionally, the treatment had been cornual resection or hysterectomy. More conservative approaches had been advocated recently. There is no consensus on the dose or number of methotrexate injections that should be used in the treatment of interstitial pregnancies. Single dose intramuscular methotrexate is one of the treatment options. However, the failure rate is higher if the serum beta-hCG (beta-human chorionic gonadotrophin) level is more than 5000 IU/L. We report a case of cornual ectopic pregnancy with high initial serum beta-hCG level being successfully treated with multiple doses of systemic methotrexate. MRI was used to assess clinical resolution of cornual ectopic pregnancy.
We report a case of a 7-year-old girl who initially presented with painless right eyelid swelling with full extra-ocular movement (EOM). She was treated with intravenous broad-spectrum antibiotics for preseptal cellulitis but her condition worsened. An urgent magnetic resonance imaging (MRI) of the brain and orbit showed orbital abscess, subperiosteal abscess in the medial orbital wall and evidence of sinusitis in the anterior ethmoidal air cells. She underwent Endoscopic Orbital Decompression (EOD) surgery on day 4 of presentation and her condition improved remarkably. We report a case of orbital abscess with subperiosteal abscess in the medial orbital wall. This case highlights the possibility of progression of orbital cellulitis despite administration of a broad-spectrum antibiotic.
Retinal detachment is one of the common complications of pathological myopia due to presence of retinal break.
However, retinal break commonly occurs in the peripheral retina. This case report illustrates the rare incidence of
retinal break adjacent to the optic disc, highlights the possible causes of poor visual outcome following surgical
repair as well as the possible measures to treat the complications.
Myomectomy is rarely performed in pregnancy due to risk of miscarriage or pregnancy loss, bleeding and possible
hysterectomy. Myomectomy is mainly reserved for unavoidable indications such as rapidly growing fibroid or severe
pain with possiblity of red degeneration for which medical treatment failed. However, good outcome had been
reported in selective second trimester myomectomies.
Breast carcinoma to the colon and rectum is rare type of metastatic spread. We report a case of colonic metastasis
from a lobular carcinoma of the breast twelve years after the initial diagnosis. Accurate diagnosis and early treatment
of systemic therapy can be done if awareness is increased.
During induction of general anaesthesia, the act of laryngoscopy and tracheal intubation stimulates the sympathetic
nervous system resulting in an increase in blood pressure and heart rate which may be harmful especially in elderly
patients with pre-existing ischaemic heart disease. Several drugs have therefore been used to obtund this increase
including esmolol, nicardipine, magnesium sulphate and lignocaine. This prospective, double blind randomised
clinical trial compared the efficacy of magnesium sulphate and esmolol in attenuating haemodynamic responses to
laryngoscopy and tracheal intubation. One hundred and twenty six ASA I-II patients scheduled for elective surgery
requiring general anaesthesia with tracheal intubation were enrolled and randomised into two groups: Group 1 (n =
67) received MgSO4 40 mg/kg diluted in 100 ml normal saline administered over ten minutes, whereas Group 2 (n =
59) received a bolus of esmolol 1.0 mg/kg diluted to 10 ml. Systolic and diastolic blood pressures and heart rate were
recorded every minute for subsequent 10 minutes following laryngoscopy and tracheal intubation. Attenuation of the
mean systolic and diastolic blood pressures following laryngoscopy and tracheal intubation was significantly larger
in Group 2 compared to Group 1. Patients in Group 2 had significantly better suppression of heart rate response
compared to Group 1 during the first four minutes after laryngoscopy and tracheal intubation (p
Mycobacterium tuberculosis (MTB) is a rare cause of prosthetic joint infection. The diagnosis is challenging
especially in cases of latent tuberculosis. QuantiFERON-TB Gold (QFT®) is an interferon-gamma relative assay
(IGRA) which is highly specific and sensitive for detection of MTB infection. We report a case of 76-year-old lady
diagnosed with tuberculous prosthetic joint infection following total knee replacement. Histological examination of
abnormal synovial tissue taken intraoperatively reveals chronic granulomatous lesion and raised suspicion of
tuberculous infection in otherwise asymptomatic patient. The tuberculin skin test, MTB acid-fast stain and
tuberculosis polymerase chain reaction were negative. The diagnosis dilemma was solved with positive result of
QuantiFERON TB Gold Test. The patient was treated with anti-tuberculous drug without any surgical intervention.
At five months follow-up, patient was clinically well with no symptoms and signs of infection.
Eccrine spiradenoma is a benign tumour of the sweat gland. Eccrine glands can be found almost everywhere but are mostly concentrated on the palms, soles and the axillae. Lesions involving the breast are rare. We present a case of a 13-years-old Malay girl with eccrine spiradenoma of the breast. The clinical presentation and histological features are being described.
A 24-year-old Chinese gentleman presented with two weeks history of sudden floaters in his right temporal visual field associated with blurring of vision. This ex-smoker also reported chronic, bloody cough for two years and recent pleuritic chest pain. Examination revealed a thin patient with right eye visual acuity of 6/18 associated with optic nerve dysfunction, optic disc swelling and macula star, retinal vasculitis and retinitis. Despite anti-tuberculosis medication and corticosteroids, he developed neovascularisation. Subsequent vitreous haemorrhage necessitated trans pars plana vitrectomy, membrane peeling, endolaser and silicone oil injection. Final visual acuity was 6/9 with quiescent retinopathy.
Pyogenic granuloma of the eyes usually occurs after ocular surgery or inflammation related to the eyes, itself. This lesion is commonly related to procedures associated with chalazia, strabismus, or even enucleation. However, the incidence of pyogenic granuloma that arises directly from the lower canaliculi of the nasolacrimal system is rare and not being extensively reported. We report a case of an elderly lady who presented with pyogenic granuloma post EDCR with silicone stenting for left nasolacrimal duct obstruction. She presented with persistent left eye epiphora following procedure. The unusual site for pyogenic granuloma and it occurrence after EDCR raise the possibility that the condition is related to previous procedure and the material being used.