Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a rare inherited cardiomyopathy characterised by right ventricular dysfunction, ventricular arrhythmias and increased risk of sudden cardiac death. Due to the replacement of myocardium with fibro-fatty and fibrous tissue, patients with ARVC are prone to develop ventricular tachycardia. Histologically, it is often reported as the 'triangle of dysplasia' involving the inflow tract, outflow tract and apex of the right ventricle.2 We describe a 20-years-old patient who collapsed during a futsal match and was subsequently diagnosed to have ARVC with a right ventricular thrombus from cardiac magnetic resonance imaging.
Nasopharyngeal mass in paediatric population is usually benign and malignant nasopharyngeal tumours such as carcinoma is rare. We report a case of nasopharyngeal carcinoma (NPC) in an adolescent with atypical imaging findings that mimicked a benign mass. This highlights the importance of a comprehensive review on the distinctive radiographic features of paediatric nasopharyngeal mass. We discuss the imaging features of NPC in the paediatric group, which differ from the elderly patients. By recognising these distinctive imaging features, it may help in diagnosing typical case. This case report serves as a reminder that NPC, despite being uncommon, should be considered in the differential diagnosis of a juvenile nasopharyngeal mass.
Chronic Myeloid Leukaemia (CML) is a disease characterised by a distinctive marker that is the Philadelphia Chromosome and an ability to transform into blast phase, which confers a poor prognosis. The median survival was reported to be between three to six months in correlation to blast phase. Extramedullary involvement with CML to sites such as pleural, meningeal and bones have been reported. We report a case of 41-year-old man who was diagnosed with CML in blast phase and presented with ascites. Ultrasound of abdomen showed coarse echotexture of liver suggestive leukaemic infiltration to the liver. The liver profile was severely deranged and associated with coagulopathy. Flow cytometry analysis of the peritoneal fluid revealed presence of myeloblasts consistent with CML in blast crisis with leukaemic ascites. Bone marrow biopsy also confirmed disease transformation. He received standard induction chemotherapy for acute myeloid leukaemia with dose modifications based on liver enzymes performance. Our case highlights an unusual presentation of CML in blast crisis with leukaemic ascites and the challenges in managing cytotoxic treatments due to the liver infiltration.
We report a rare case of severe Plasmodium knowlesi malaria and dengue co-infection in a 36-year-old lady with hyperparasitaemia, metabolic acidosis, haemolysis and acute kidney injury. She was in shock requiring inotropic support and elective intubation. She had pericardial tamponade which necessitate pericardiocentesis to allow for haemodynamic stability during haemodialysis. She underwent haemodialysis, was ventilated for six days and stayed in hospital for 29 days. She was discharged home well with almost complete renal recovery. Physicians must have a high degree of suspicion for dengue co-infection in malaria patients with plasma leakage such as pericardial effusion to allow for prompt management.
Coughing is an important reflex mechanism which enhances the clearance of secretions and particulates from the airways, however repetitive muscle strain due to prolonged coughing may cause the uncommon complication of stress fracture of the ribs. The following is an unusual case of cough induced multiple rib fractures associated with subcutaneous emphysema and pneumothorax which was missed in the emergency setting. Delayed diagnosis and treatment would have been avoided if this uncommon condition was considered as a possibility.
Despite being a common skin dermatosis in the tropics, physicians in the tropics may miss the diagnosis of cutaneous larva migrans for other pruritic skin manifestation. This is especially in those who live in urban housing with no history of travel. Cutaneous larva migrans, an intensely pruritic skin pathology is mainly contracted by people with history of beach holiday or contact with moist soft sand which had been contaminated with dog or cat faeces. This article reports a patient who presented with intensely itchy papular spots over the dorsum of his foot after walking barefooted in an urban toilet soiled with cat faeces. The patient had initially seen an urban general practitioner who diagnosed the papular skin lesion as an allergic reaction, and prescribed antihistamines. The patient subsequently developed creeping skin lesions and was seen by the author who prescribed albendazole 400 mg twice daily for three days. The patient reported reduction in itching after two days of albendazole treatment and a follow up at ten days revealed a healed infection.
Melanoma of the ear canal is extremely rare; due to its hidden area, most would present late in their history. We present the first case reported, of a black pigment foreign body mimicking a melanoma in the external auditory canal. A 14 year old Chinese male presented with right sided otalgia and itch. Otoscopic examination revealed an irregular black naevus in the right auditory canal. An intraoperative excision showed a black pigment foreign body giant cell reaction. Clinicians should be aware of the possibility of a foreign body granuloma of the ear canal that might mimic a melanoma.
A female patient who presented with left empyema thoracis caused by Actinomyces odontolyticus is reported. She responded to treatment with penicillin and metronidazole but after 3 weeks developed leucopenia complicated by gram-negative septicaemia. Leucopenia improved rapidly on withdrawal of metronidazole. Treatment was continued with a prolonged course of penicillin and she made an uneventful recovery.
Focal eventration of the diaphragm with transthoracic kidney is a very rare condition. It is usually asymptomatic and often revealed as an incidental finding on imaging studies. We presented a case of previously undiagnosed focal eventration of left hemidiaphragm with transthoracic left kidney confused with traumatic diaphragmatic hernia. Differentiation of these two conditions is important as each were managed differently. A traumatic diaphragmatic hernia needs early surgical intervention whereas no treatment was required for focal diaphragmatic eventration in most cases. Diagnostic laparoscopy confirmed the findings in this case and the patient was managed conservatively.
We report the case of a 23-year-old woman who presented with prolonged menstruation and multiple bruises on the limbs and trunk. Investigations revealed severe thrombocytopenia and deranged coagulation profile with markedly prolonged activated partial thromboplastin time (aPTT). Lupus anticoagulant, anti-cardiolipin antibody and anti-beta-2-glycoprotein 1 antibody were positive. She was diagnosed with Immune Thrombocytopenic Purpura (ITP) with positive antiphospholipid antibody serology and given a course of intravenous methylprednisolone and tapering doses of oral prednisolone. She was steroid free and had no bleeding or thrombotic event over two years follow up.
Primary omental liposarcoma is a rare clinical entity with less than 20 cases being reported in the literature. Laparotomy has been the traditional approach for resection, with no reports of laparoscopic resection. A 39-year-old lady presented at the Sarawak General Hospital, Kuching, Malaysia with a history of a progressive, painless left upper quadrant abdominal swelling for a year. CT scan showed a well-defined heterogeneously enhancing cystic mass measuring 7.5x7.5x8.1cm with a poor plane with the adjacent greater curvature of stomach and transverse colon. Upper and lower endoscopy was normal. The tumour was completely dissected from the adjacent transverse colon and removed laparoscopically. Histopathological examination of the resected specimen revealed a myxoid liposarcoma. She had an uneventful recovery and was discharged well on the third postoperative day. She subsequently underwent adjuvant chemotherapy and was well at 1-year follow-up with PET CT showing no evidence of recurrence or metastases.
Left atrial myxoma almost always arises in the inter-atrial septum. A case is described where it arose from the posterior wall of the left atrium. Clinical presentation was suggestive of mitral stenosis and sub-acute bacterial endocarditis and diagnosis was arrived at necropsy.
Cases of lingual thyroid are rare. The Johns Hopkins Hospital, New York, reported three cases of lingual thyroid in 800,000 admissions. We report here a case of lingual thyroid associated with hypothyroidism. The embryology, clinical features and principals of management are discussed.
The novel Coronavirus disease 2019 (COVID-19) had rapidly spread and became a worldwide pandemic since its detection in Wuhan, China. The disease has caused significant morbidity and mortality, particularly among patients with comorbidities. The current treatment involves supportive management alongside antiviral therapy and immunosuppressant therapy in severely affected patients. We describe a case of a patient with underlying lupus nephritis (LN) who presented with severe COVID-19 infection and concomitant LN flare with acute kidney injury (AKI). The patient was treated with antiviral therapy, Favipiravir, considering his risk of developing severe COVID-19 infection. As the patients would usually have AKI alongside LN flare, we administered initial steroid therapy at a lower dose (Methylprednisolone 50mg daily) and oral hydroxychloroquine despite the initial concerns on immunosuppressant usage in COVID-19 infections. Although our patient recovered relatively well from COVID- 19 infection, he continued to have positive reverse transcriptase-polymerase chain reaction (RT-PCR) nasopharyngeal swab for COVID-19 up to 29 days of illness. His kidney function stabilised despite having persistent nephrotic range proteinuria. Hence, the attending team decided to pulse the patient with a high dose steroid (IV Methylprednisolone 250mg OD for three days) after two weeks of illness despite the persistent positive swab. The patient's condition continued to improve, and this case illustrates an approach in treating COVID-19 with concomitant active immune-mediated glomerulonephritis. We find that it is safe to institute high dose immunosuppressant in recovered COVID-19 patients two weeks after the illness.
We are reporting a case of missed blunt traumatic aortic injury (BTAI). A 28 year male presented with chest pain following a motor vehicle accident. He was discharged following normal clinical signs and chest radiograph. The following day he complained of lower limb weakness. Traumatic aortic dissection was revealed via computer tomography (CT) of the thorax. BTAI cannot be ruled out with normal clinical signs and chest radiograph alone. CT thorax is mandatory to rule out BTAI in high impact chest injury.