Ocular tuberculosis is an ocular infection caused by Mycobacterium tuberculosis (TB). About 5-10% of ocular inflammation cases are caused by ocular TB. Spectrum of ocular TB is diverse, affecting any part of the adnexa, different layers and structures of the globe, orbital contents, optic nerve to the orbital apex posteriorly. It can be associated with or without systemic manifestation. Posterior uveitis is the most common presentation of ocular tuberculosis. Subretinal haemorrhage secondary to choroidal neovascularization (CNV) is a rare complication in ocular tuberculosis. We report a rare case of secondary choroidal neovascularization in a 9-year-old boy with bilateral eye choroidal tuberculoma with underlying miliary tuberculosis. He was treated with intravitreal ranibizumab and intravitreal recombinant-tissue plasminogen activator (r-TPA) injection. The CNV resolved, however, vision was poor due to atrophic fovea.
Case of co-existence of twin pregnancy of complete hydatidiform molar with viable intrauterine pregnancy is extremely rare with low incidence of 1 case for 20,000 – 100,000. It is associated with high risk of spontaneous abortion, preterm delivery, intrauterine death, bleeding, pre-eclampsia, and persistence trophoblastic disease (PTD). It may associate with biochemical derangement that may induce symptomatic manifestation to the mother. There are few cases reported in Asia population with significant clinical dilemma and management to the maternal and foetus. Here, we report a case of a young woman with previous bad obstetric history who presented with antepartum per-vaginal bleeding and was noted to have a twin pregnancy with complete hydatidiform molar and viable foetus. It was complicated with markedly elevated human chorionic gonadotropin (hCG) and hyperthyroidism. Postpartumly, her hCG level was persistently high and her condition progressed into gestational trophoblastic neoplasm.
Warfarin is an anticoagulant that is commonly used as thrombo-prophylaxis in patients at risk of thrombo-embolic events. However, the use of warfarin is known to cause hemorrhage due to its anticoagulation effect. Although the common sites of hemorrhage are gastrointestinal and genitourinary tract, it can also occur in the least expected location. We report a rare case of spinal cord compression secondary to intraspinal epidural hematoma as a result of overwarfarinization in a patient who had undergone liver transplant. The patient underwent emergency decompression laminectomy of spinal cord and hematoma evacuation after the reversal of overwarfarinization to normal levels.
Electrocardiographic abnormalities can be associated with acute pancreatitis. However, data regarding the actual causative factor still remains elusive. Many previous cases were reported on non-specific ST and T wave abnormalities concurrent with acute pancreatitis but rarely with an increasing trend of cardiac markers. We describe the case of a 70-year-old female who presented with one such conundrum. Our patient had typical presentation of acute pancreatitis but had dynamic ECG changes with markedly increased cardiac markers. Subsequently after initiation of treatment for acute pancreatitis and observation for the course of several days, the ECG returned to the baseline as pre admission. This substantiates the fact that acute pancreatitis can mimic both biochemical and electrical manifestation of an acute coronary syndrome. Thus, Emergency Physicians should consider acute pancreatitis as a possible diagnosis in patients who present with abnormal electrocardiograms.
Trauma is thought to complicate 1 in 12 pregnancies. The management of trauma during pregnancy requires special consideration because pregnancy alters maternal physiology and the foetus is a potential collateral victim. The approach of these cases in the setting of the Emergency Department should not only be diagnostic for any foetal injuries but also prognostic for any future undue outcome. Antenatal traumatic brain injury is a rare but real complication of maternal blunt force trauma. Our case involves a 22-year-old primigravida who suffered a motor vehicle accident and on initial assessment revealed normal foetal assessment but subsequently after premature labour revealed a new born with traumatic brain injury. Early ultrasonographic evaluation and observational period with continuous electronic foetal monitoring may improve the detection and emergent treatment in these cases.
Infective endocarditis (IE) is a potentially life-threatening disease which carries high risk of morbidity and mortality. The variability of clinical presentation of infective IE remains a diagnostic challenge for the Emergency Physicians. The clinical manifestation may present as an acute, rapidly progressive infection with the absence of classical immunological vascular phenomenon or as subacute or chronic disease with vague constitutional symptoms that may mislead initial assessment and mimic other conditions. Symptoms may also manifest as a result of systemic embolization which can be catastrophic and life-threatening especially if it ends up in the cerebral circulation. IE complicated by cerebral mycotic aneurysm (CMA) is the worst neurological sequalae and can be misdiagnosed as a primary intracranial infection such as meningoencephalitis. Here, we report a case of neurological emergency secondary to systemic embolization of IE with a devastating diagnosis of CMA. History of prolonged fever associated with headache and focal neurological deficit led to the initial diagnosis of meningoencephalitis due to a low clinical suspicion of the disease in the Emergency Department. In emergency setting, a combination of high degree of clinical suspicion together with thorough history, physical examination and diagnostic imaging are crucial in order to guide and establish the diagnosis of this potentially devastating disease. Early recognition and initiation of aggressive treatment is crucial to provide better prognosis and higher survival rate for patients with CMA.
Local anaesthesia systemic toxicity (LAST) is an uncommon and a potentially life-threatening event that develops after peripheral nerve block. The cause may be multifactorial and may include the choice of drug, technique of block and individual patient risk factors. We report a case of a 55-year-old female who developed slurring of speech and quadriplegia after receiving a mixture of lignocaine and hydrocortisone through an intra-articular injection to the right shoulder. Neurological examination revealed hypotonia and absence of power (0/5) in all limbs. These toxic events may have resulted from an accidental intra-arterial or dural cuff injection of local anaesthesia or absorption from surrounding tissues. This case report demonstrated that an intra-articular injection in the shoulder may cause LAST and may be under-recognized as it can mimic stroke.
Proximal femur fracture in paediatric patients are very rare and can easily be missed especially when the history of trauma is so trivial, and associated with pathological fracture. We report a case of 6-year-old girl with a history of left knee pain following a fall from a height of 2 feet. She was treated as a soft tissue injury of the left knee as the left knee radiograph was normal. She was reassessed at day 3 of injury with worsening symptoms. Radiograph of the pelvis and left knee revealed a comminuted intertrochanteric fracture of left femur with an underlying bone cyst. We would like to highlight this case report to avoid missing a proximal femur fracture where a trivial trauma resulted In the presentation of a non-specific knee pain. Femur fracture in peadiatric age group can result in the significant complication of growth such as osteoporosis.
Paediatric hand fractures are common and prompt management is mandatory to achieve a good functional outcome. However many fail to realize that treating a fracture does not only involve bones but the soft tissues, as well. K-wiring itself can be difficult with multiple attempts inadvertently injuring the flexor or extensor tendons and resulting in adhesions. We highlight this possible complication of K-wiring which we believe is under reported due to the perception that K-wiring is a simple procedure. We present a case of a 9-year-old child, who sustained a closed displaced fracture of the base of the proximal phalanx (Salter Harris type 2) of the left index finger. He underwent percutaneous K-wiring but was complicated with severe adhesions of the flexor digitorum profundus (FDP) and flexor digitorum superficialis tendons (FDS). He was unable to flex the proximal and distal interphalangeal joints of the affected finger. We subsequently performed tendon adhesiolysis twice together with A2 pulley reconstruction, to restore movement of the finger. K-wiring of the fingers are not just simple bony procedures but also involve soft tissue components which can be prone to adhesions.
Individuals with disabilities have different needs and concerns at different stages of life. The arrival of puberty brings about new challenges especially for females with issues related to menstrual care involving both the patient and their caregivers. This case report is about a 13-year-old girl with Down syndrome who was cared for by her widowed father since the age of six. She was suffering from severe mental disability. Her father was concerned, because she was unable to maintain personal hygiene during menses such as changing sanitary napkins and managing stains, hence requested for menstrual manipulation. Options for menstrual manipulation for individuals with disabilities include both medical and surgical interventions. Hormonal therapy options include oral contraceptive pills, depo-provera, progestin implants and progesterone release intra-uterine contraceptive devices. Surgical options such as hysterectomy or endometrial ablation may be considered as a last resort as it is more invasive and irreversible, involving ethical and legal implications. Selection of the suitable therapy involves shared decision making between health care provider and caregiver taking into consideration the patient’s best interest. This case report also highlights the role of family physicians in managing and coordinating care on delicate issues related to menstrual care for people with disabilities. This case report may serve as a guide to physicians and families with special needs children, while approaching issues on menstrual care.
Rhabdomyosarcoma (RMS) is the most common soft tissue malignancy in children and adolescents. The rarity of its occurrence in infant poses a great difficulty in terms of diagnosis and management. Here, we report an aggressive case of alveolar rhabdomyosarcoma in an infant who presented with neck swelling and neurological complications. The Magnetic Resonance Imaging (MRI) revealed a soft tissue swelling of the neck with intraspinal extension and spinal cord compression, raising the possibility of a neurogenic or malignant nerve sheath tumour. Histopathological examination revealed a primitive, small round cell tumour with no rhabdoid differentiation. The clinical presentation, neurological symptoms, tumor location and the histopathologic features were highly suggestive of neuroblastoma. However, the tumour cells were positive for desmin with focal and weak nuclear positivity for myogenin and MyoD1; immunoexpressions which were in favour of rhabdomyosarcoma. Fluorescent in situ hybridization (FISH) confirmed the presence of a translocation t(2;13)(q35;q14), supporting the diagnosis of alveolar rhabdomyosarcoma. Despite chemotherapy, patient succumbed to death after two months due to septic shock. Rhabdomyosarcoma is highly aggressive mesenchymal neoplasm which may present with diagnostic difficulty. This case highlights the importance of molecular studies in making an accurate diagnosis so that appropriate chemotherapy may be instituted.
Individuals with double aneuploidy of Down-Turner syndrome are very rare and to date, fewer than 50 cases have been reported, worlwide. We report a case of a male infant who presented with dysmorphic features of upslanting eyes, flat nasal bridge, wide spaced nipples and macroglossia. Based on the clinical features, he was diagnosed with Down syndrome. His peripheral blood sample was taken and sent for cytogenetic analysis for confirmation. Chromosome analysis of his lymphocyte cell culture revealed a mosaic pattern of double aneuploidy with monosomy X identified in 31 metaphases and trisomy 21 in 14 metaphases: (45,X[31]/47,XY,+21[14]). Further analysis with fluorescence in situ hybridization (FISH) using Vysis LSI SRY Spectrum Orange/CEP X Spectrum Green Probe and Vysis CEP Y Spectrum Aqua Probe and Vysis LSI 21 Spectrum Orange Probe performed on the cells (nuclei and metaphases) has confirmed the presence of the abnormal two cell lines (81% monosomy X and 19% trisomy 21) in the patient. Ultrasound investigations of his pelvic region showed normal testes and no evidence of uterus, ovary or vagina. To the best of our knowledge, this is the first Down-Turner syndrome reported in Malaysia. In conclusion, this case demonstrates the importance of Giemsa-banded karyotype and FISH analyses as diagnostic tools in identifying the chromosomal abnormality and determining the ratio of the normal:abnormal cells present in the patient. An annotated bibliography of earlier reported cases of Down-Turner with documented karyotyping is also included in this report.
In trauma, a systematic approach has been developed to assist physician and surgeon in identifying immediate life-threatening injuries so that prompt intervention can save lives and reduce mortality. This approach also called for a head-to-toe examination so that other injuries are not missed out. Sacral fracture, although rare, but could have serious complications. The present case discusses about a trauma patient who presented with complain of genitalia pain with normal genitalia examination. Sacral fracture was not suspected and was only detected when a pelvic radiograph was ordered as part of the trauma survey. Fortunately, the patient had no complications resulting from the injury itself. The aim of the present case is to discuss the importance of investigating beyond patient’s complaint, as in this case the patient only complained of genitalia pain which ended up as a sacral fracture.
Major depressive disorder is an important psychiatric illness that can be a life-threatening condition when it presents with suicidality. This case report describes an adolescent who presented with major depressive disorder but with an underlying undiagnosed attention deficit hyperactive disorder (ADHD). The 17-year-old male adolescent presented with psychosomatic complaint of non-resolving left sided chest pain. He also had major depressive symptoms and suicidal ideation. His ADHD was being missed. This case highlights the difficulty of diagnosing ADHD during adolescence as the presentation may not be as typical as during early-childhood years.
Aneurysm and pseudoaneurysm of the dorsalis pedis artery remains to be rare vascular entities with a reported incidence of 0.5% of peripheral arterial aneurysms. Only, few cases were reported. The formation of pseudoaneurysm is commonly associated with fracture, laceration wound or iatrogenic arterial injury. An arterial injury that coincides with pseudoaneurysm can initially be missed due to lack of clinical findings. Prompt recognition remains paramount to reduce morbidity and mortality. Here, we present a rare complication of a commonly performed orthopaedic procedure in a young male who presented with painful swelling over left foot after he was involved in an industrial injury. He presented again with a pulsating mass over his left foot after 2 months post fixation surgery of a Lisfranc injury. He was treated conservatively with compression bandage and able to regain to his normal activity after the treatment initiated.
Endogenous endophthalmitis is a devastating intraocular infection. Finding the primary infection and directed treatment is life-saving. We describe a 47-year-old man, with uncontrolled diabetes mellitus, who presented with two weeks history of progressive reduced vision and redness of the left eye (LE). He was generally unwell since a month, previously. Examination showed relative afferent pupillary defect (RAPD) in the affected eye and visual acuity was hand movement. There was moderate anterior chamber and vitreous reaction. Fundus examination showed a huge dome-shaped choroidal mass covering the entire macula. Diagnosis of severe endogenous endophthalmitis was made, with isolation of Enterobacter sp. from his blood culture. Meanwhile, he also had elevated inflammatory markers with presence of leucocytosis, neutrophilia and elevated erythrocyte sedimentation rate (ESR) as well as C-reactive protein (CRP). Vitreous tap and aqueous tap had no growth, He improved with combination of intravitreal and systemic antibiotic, as shown by the resolved fever and reduced inflammatory markers but progressive inflammation occluded the fundus details and the LE vision eventually became no projection of light despite treatment. Subsequently, he developed rubeotic glaucoma and was treated conservatively because the LE was painless with poor vision. The repeated blood culture and urine was normal. In conclusion, endogenous endophthalmitis with eventual panophthalmitis is difficult to treat and has very poor visual prognosis. Our case highlights the challenges faced in the management of vision-threatening endophthalmitis and panophthalmitis in this patient.
Post-infectious bronchiolitis obliterans is a rare disease that may occur following a microbiological insult towards the lower respiratory tract causing a severe form of chronic obstructive airway disease. Subpleural lung cyst may occur in 20-36% of Down syndrome. We report a case of a 30-month-old Down syndrome child who had interesting radiological concurrent findings of bronchiolitis obliterans with subpleural cysts on High Resolution Computed Tomography (HRCT) thorax. This patient was born premature and had early onset pneumonia during the neonatal period. Subsequently, he had three episodes of pneumonias at 18, 19 and 26 months. He presented with recurrent symptoms of cough, wheeze, rapid breathing and had features of persistent airway obstruction characterized by chest hyperinflation, persistent tachypnoea with crepitations and rhonchi despite on regular bronchodilators. The only positive culture was Influenza B from his nasopharyneal aspirate culture. To our knowledge, this is the first reported case with both radiological entities in a child with Down syndrome.
Posterior Polymorphous Dystrophy (PPD) is a rare, innocuous and asymptomatic condition in which corneal endothelial cells display characteristics similar to epithelium. It is often bilateral and frequently asymmetric. We report a case of a 10-year-old girl with a family history of glaucoma who presented with right eye blurring of vision since few years. She had frequent spectacle-prescription changing due to unimproved visual acuity. Cycloplegic refraction revealed high astigmatism and moderate amblyopia over the right eye. Her best corrected vision was 6/9 for the right and left eyes. Slit-lamp examination showed a vesicular-like lesion at the periphery of corneal endothelial layers in both eyes. Endothelial cell density was much reduced on the right eye compared to the left, with more severe astigmatism. Other ocular examinations were unremarkable. Patient was instructed to patch her better left eye periodically. Although patients with Posterior Polymorphous Dystrophy (PPD) present at the age of adulthood, the age at diagnosis is highly variable. It is rare and inherited through an autosomal dominant pattern. PPD may rarely lead to astigmatism, by which was present in the patient due to the features of non-keratoconic and keratoconic cornea on the right and left eye, respectively. Endothelial cell counts were reduced more on the right eye compared to the left, which later may worsen her visual acuity thus indicating corneal transplant in the future. Patient also had a strong family history of glaucoma. Hence, screening of associated disease of corneal endothelial dystrophy in the family may be necessary.
Many anatomical variations exist in and around the carpal tunnel. However, symptomatic anomalies causing carpal tunnel syndrome is rare. Additionally, carpal tunnel surgery is considered a simple operation commonly done by junior surgeons who are usually unaware of variations resulting in unfavorable surgical outcomes. We highlight a case of lumbrical muscle variation causing carpal tunnel syndrome. A 73-year-old male presented with numbness and pain of both hands associated with abnormal fullness over both wrists and distal forearms. Initially the right hand was numb and subsequently a year later, the left hand became numb. Physical examination was positive for Durkan, Phalen and Tinel signs at the carpal tunnel. Magnetic Resonance Imaging (MRI) showed abnormal muscle tissues in the carpal tunnel. During the carpal tunnel release and exploratory surgery, we noted an abnormally proximal origin of the lumbrical muscles in the forearm rather than the typical palmar origin. He also had lumbrical muscle hypertrophy in the left side. These two factors resulted in overcrowding within the carpal tunnel. Post-operatively the patient recovered well with pain relief and gradual improvement of his numbness. Variations in the anatomy of the lumbrical muscles is not uncommon and may result in carpal tunnel syndrome. Hence, carpal tunnel release surgeries may not be as straight forward as expected and surgeons should be aware of this possibility.
Traditional and Complimentary Medicines (TCMs) can potentially cause Adverse Cutaneous Drug Reactions (ACDRs). The aim of this study was to describe the characteristics of ACDRs due to TCMs and compare with those due to conventional medicine. This was a retrospective study with 134 cases being diagnosed with ACDR at the Dermatology Clinic of a tertiary hospital in Kuala Lumpur. Most (82.1%) ACDRs were caused by conventional drugs, while 17.9% were due to TCMs. Majority (70-75%) of the ACDRs were of mild to moderate severity. The most common ACDR to TCM was Exfoliative Dermatitis (ED) and Acute Generalized Exanthematous Pustulosis (AGEP) (both 16.7%) while maculopapular rash was the most common reaction for conventional medications (25.5%). The onset of adverse reaction to TCM was about 4 weeks (60.2%) while reactions due to conventional medication was earlier (1 to 6 days, 65.4%; p