Congenital absence of lacrimal puncta may be an isolated finding or associated with other developmental abnormality. Nasolacrirnal ducts can be absent thus predisposing to the formation of a congenital lacrimal mucocele. Punctal and canalicular agenesis is very rare. Four percent of new patients attending the lacrimal clinic at Moorfields Eye Hospital, London, UK. from 1981 to 1990 inclusive were diagnosed to have this condition. We describe a case of bilateral congenital absence of lacrimal puncta with lacrimal mucocele. Combined surgery was carried out by Ophthalmologist and Otolaryngologist with successful results.
The accuracy of multi-detector computed tomographic (MDCI) coronary angiography (CTA) is dependant on image quality as well as the experience of the operator. Established centers have reported negative predictive values of over 95%. The aim of our study was to investigate the accuracy and feasibility of CTA for the assessment of haemodynamically significant coronary stenosis in a center with very early experience (<6 months) utilizing the improved spatial and temporal resolutions of the latest generation 64-row MDCI scanner. One hundred and twenty eight patients (93 male, 35 female; mean age 56.2 +/- 9.5 years) with suspected or known coronary artery disease underwent both CIA and conventional coronary angiographv (CCA). The sensitivity, specificity, positive (PPV) and negative (NPV) predictive values for stenoses > or =50% by CIA compared to CCA were 70%, 97%, 70% and 97% respectively. Evaluation of main and proximal segments in patients with good quality images (78% of patients) produced values of 94%, 95%, 74% and 99% respectively. The improved spatial and temporal resolutions of 64-row MJ) CT provided a high negative predictive value in assessing significant coronary artery stenosis even in a centre with very early experience. However, new centers embarking on CTA might not be able to reproduce the results reported by more experienced centers.
Nasopharyngeal carcinoma (NPC) is a common cancer in Malaysia. The clinical presentation in Sarawak has not been well documented. A retrospective review of 213 selected NPC cases was undertaken on the clinical records in Sarawak General Hospital, Sarawak, from June 1999 to June 2003. There were 116 patients in Kuching and 97 in Serian. There were twice as many males as females. The youngest patient was 16 and the oldest 88 years old with a mean age of 51 years. The four most common symptoms in order of frequencies were cervical lymphadenopathy, epistaxis, hearing loss and diplopia. 80.8% of the patients presented with cervical lymphadenopathy and about 85% of the patients presented in the advanced stages. Very small percentages of the patients were found to have single presenting symptoms of epistaxis (2.4%) and hearing loss (0.5%).
One hundred patients (101 eyes) with culture-proven bacterial keratitis were treated in the Department of Ophthalmology, Hospital Sultanah Aminah, Johor Bahru, over a 4-year period. The majority of patients was male (63%), Malay (60%), from the Johor Bahru district (62%) and aged between 41 to 50 years (20%). The ocular predisposing factors were ocular trauma (41 eyes), ocular surface disease (28 eyes) and contact lens wear (26 eyes). The corneal ulcers were mainly large (50.5%), central (59.4%) and colonized by Gram-negative bacteria (78.1%). The most frequently isolated microorganisms were Pseudomonas aeruginosa (67 eyes), Staphylococcus aureus (12 eyes), Acinetobacter baumanii (6 eyes), Klebsiella pneumoniae (5 eyes), Corynebacterium sp. (3 eyes:) and Streptococcus pneumonliae (3 eyes). Twelve eyes (11.8%) had polymicrobial infection. A good visual outcome occurred in 52.5% of eyes analysed. Prognostic factors for visual outcome include presenting Snellen visual acuity, time to presentation after onset of ocular symptoms, ocular predisposing factor, corneal ulcer location and corneal ulcer size.
We conducted a retrospective review of 135 patients with melioidosis in Pahang from January 2000 to June 2003. Patients were mostly male (78.5%) and Malay (83%) with a median age of 51 years. Seventy four percent of patients were diabetic. Common presentations were pneumonia (40.7%), septicaemic without obvious source of infection (19.3%) and multiple organ involvement (15.6%). Only 32.7% were given appropriate antibiotics empirically. The overall mortality was 54% with most deaths (65%) occurring within 48 hours of admission. Patients with pneumonia, multiple organ involvement and septicaemic of unknown source had higher mortality as compared to patients with subcutaneous, musculoskeletal or single internal organ involvement without pneumonia (p < 0.001). The relapse rate was 19.2%.
Necrotizing fasciitis is an aggressive infection involving fascia and subcutaneous tissue thus causing infectious thrombosis of the nutrient vessels to the overlying skin ultimately leading to extensive necrosis. Although necrotizing fasciitis is common in the perineum, abdominal wall and extremities it is relatively uncommon in the head and neck region. This is a case report of a 65 year old female visiting from India who presented with diabetic ketoacidosis precipitated by cervical necrotizing fasciitis. Computed tomography imaging showed involvement of the left parapharyngeal space and there was soft tissue gas present. This patient subsequently underwent an emergency neck exploration and desloughing. Repeated pus culture studies isolated Klebsiella species as the sole pathogen. Our case illustrates that prompt diagnosis and treatment of cervical necrotizing fasciitis can ensure a good outcome.
We report a 40-year-old man who has Marfan's syndrome and was recently diagnosed to have pulmonary tuberculosis when he presented with chronic cough. He was admitted with bilateral lower limb weakness which was ascending in nature. He eventually required ventilation. It was initially thought to be isoniazid-neuropathy. However, stopping the drug did not improve the condition and the patient developed bilateral lower motor neuron 7th cranial nerve palsy. Nerve conduction, MRI and CSF studies were done to confirm a first case report of AMSAN variant progressing to CIDP in a patient with Marfan's syndrome and pulmonary tuberculosis.
Thyroid hormone resistance (RTH) is a rare autosomal dominant disorder, characterized clinically by goiter and biochemically by elevated circulating free thyroid hormone levels in the presence of measurable serum thyroid-stimulating hormone (TSH) concentrations. About 85% of patients with RTH harbor mutations in thyroid hormone receptor [beta] (TR[beta]). Even rarer is pituitary thyroid resistance syndrome. We report a case of a 35-year-old man who presented with hypermetabolic symptoms with elevated levels of thyroid hormones, associated with nonsuppressed thyrotropin (TSH). When treated with anti-thyroid drugs, his thyroid hormone levels normalized and TSH increased, suggesting thyroid resistance at the pituitary level.
This was an open-label, uncontrolled study with the aim of assessing the efficacy and safety of pegylated interferon alfa-2b plus ribavirin in the treatment of chronic hepatitis C. The study was conducted in Island Hospital, Penang beween January 2002 and December 2003. Thirty-three patients were enrolled in this study with ten defaulters. The overall sustained virological response (SVR) (Intention-To-Treat analysis) in naïve patients was 39.10%. However, when the study was adjusted to only include those who completed treatment and follow-up, overall SVR as 52.9%. Side-effects were tolerable in most patients with anaemia occurring in 22 patients (66.7%), leukopenia 23 patients (69.7%) and thrombocytopenia in 15 patients (45.5%). This study showed that pegylated interferon alfa-2b 1.5 mcg/kg/week plus ribavirin > 10.6 mg/kg/day is efficacious and safe to be used in the treatment of: chronic hepatitis C.
A 5 year retrospective review of cases of melioidosis was carried out in Sultanah Aminah Hospital, Johor Bahru. There were 44 new cases of melioidosis which was proven by either blood or pus culture growing Burkholderia pseudomallei from the period between January 1999 and December 2003. Of these, 38 (86.4%) were males compared to only 6 (13.6%) females. Thirty-one (70.5%) were Malays, 7 (15.9%) were Chinese, 5 (11.4%) were Indians and 1 (2.2%) was a Sarawakian. The peak age group was between 50 and 59 years (31.8%). Out of these 44 new cases, only 32 medical records could be retrieved and analysed. Twenty-four out of 32 patients (75%) analysed had diabetes mellitus, 4 had chronic or end stage renal failure (CRF/ESRF) and only 1 had Human Immunodeficiency Virus (HIV). One case of "near drowning" was also recorded. Twenty-one out of 44 patients or 47.7% died, of which 8 (38.1%) died within 24 hours of admission. Pulmonary involvement was recorded in 62.6% of the patients but many had signs and symptoms of multiorgan involvement.
Surgical biopsies of lymphnodes of 315 patients (273 adult and 42 children) were reviewed microscopically and analysed. The sex ratio was similar in adults but in children males were twice than female (2:1). Ethnically Malay patients predominated in both the groups. The commonest cause of biopsied lymphadenopathy in adults were malignancy (47%) followed by chronic nonspecific lymphadenitis (20%) and granulomatous lymphadenitis (9%) while in children chronic nonspecific lymphadenitis was the commonest (46%) followed by granulomatous lymphadentitis (21%) and malignancy (14%). Twenty percent of adults and 4% of children had normal lymphnodes. Secondary deposits in adult males and females were of squamous cell carcinoma and adenocarcinoma type respectively. In our study 100% of clildren and 96% of adults with granulomatous lymphadenitis had tubercular lesions.
Anaesthetizing patients with Long QT Syndrome is a major challenge, as the potential for sudden catastrophic cardiovascular collapse is well known. We present a 15-year-old boy with Long QT Syndrome who presented for an elective renal transplant. All electrolyte concentration abnormalities were corrected preoperative and adequate beta-blockade was maintained. The patient was given a target controlled infusion of propofol, together with opioids and atracurium. Anaesthesia was uneventful and the patient was extubated at the end of the surgical procedure.
Parotid swelling is a common presentation in ENT clinic. Most of the cases involve pathology of the gland. There are not many reported cases about parotid duct pathology. We describe a case of a large parotid duct mucocele with a calculus. Excision of the mucocele and superficial parotidectomy was performed. The post-operative recovery was uneventful.
Allergic rhinitis is a global health issue and its prevalence is increasing. Allergic rhinitis and asthma coexist in many patients. Allergic rhinitis is an Ig E mediated reaction. Prostaglandins and Leukotriens do not play a significant role in the pathogenesis of allergic rhinitis. Skin prick test and Enzyme linked immunosorbent assays (ELISA) are useful as diagnostic tests. The three major modalities of treatment for allergic rhinitis are allergen avoidance, pharmacotherapy and immunotherapy.
An eight-year-old boy admitted for acute abdominal pain was diagnosed to have torsion of the spleen (TS) based on contrast enhanced computerised tomography (CECT) of the abdomen. CECT showed whorled appearance in the splenic hilum. Whorl sign' refers to the presence of a twisted splenic pedicle intermingled with fat, resulting in alternating circular bands of radiodensity and radiolucency and is considered diagnostic of TS. This is the fourth reported case of whorl sign in children with TS and the first from Malaysia.
This is a case of a 25 year old lady whose eye had been infected by cysticercosis. This case highlighted that the inflammation was due to host immune response. She was treated with oral corticosteroid and the lesions regressed.
We report on our early experiences with the Press Fit Condylar Rotating Platform (PFC-RP) total knee replacement prosthesis at University Malaya Medical Centre. This new prosthesis was introduced to Malaysia in 2001. It combines the rotating platform technology of Low Contact Stress (LCS) and the modularity of Press Fit Condylar (PFC) system. We performed 18 knee replacements using cruciate retaining prosthesis without patellar resurfacing in 10 patients and followed them up over a period of 16-month. A new operative strategy was developed to match the flexion and extension gaps. The pre- and post-operative assessments were made according to the American Knee Society Scores (AKSS). Post-operative pain relief, range of motion, knee score and functional score showed promising early results. The average knee rating improved from 28 to 91 (range 75-94). Average functional assessment improved from 26 to 82 (range 75-90). The radiographic assessments show correction of an average pre-operative varus of 140 to post-operative valgus of 50 (range 4-70). Early infection occurred in two knees. Both responded to aggressive debridement and antibiotics. Stiffness was encountered in one patient. There were no spinouts of the insert. We are satisfied that the implants are performing well at the one-year mark and will continue monitor this cohort.
Revision surgery following failed open reduction for developmental dysplasia of the hip (DDH) is technically demanding. We reviewed 12 patients in our institution that required a revision surgery between January 1994 and December 2003. The aims of this study are to identify the causes of redislocation after the primary open reduction and to determine the clinical and radiological outcome after the revision surgery. The mean age at presentation for DDH was 31 months (range 1-84) and the mean age at primary open reduction surgery was 38 months (range 15-84) and the mean age at revision surgery was 69 months (range 21-180). The mean follow-up period after revision surgery was 20 months (range 3-84). All the revision surgery was performed via an anterior Smith Peterson approach. The most common cause for redislocation was inadequate exposure and failure to release the obstructing soft tissues around the hip. The bony factors for redislocation included failure to perform a femoral shortening and excessive derotation of an anteverted femoral head combined with a Salter osteotomy. Three cases with posterior acetabular wall deficiency needed immobilization of the hip in extension as the hip tended to dislocate in flexion. Six patients had limb length discrepancy ranging from 1 cm to 4 cm and 50% developed avascular necrosis. Only 2 patients were asymptomatic and the majority had a limp and limitation of motion. All were pain free except one. In view of the technically demanding surgery and poor results after revision, the surgeon should recognize the pathology and ensure that the primary procedure achieves a stable and concentric reduction.
We studied the factors influencing the mid-term outcomes of tibial plateau fractures treated conservatively (n=21) and surgically (n=27) from December 1994 to December 1997. Joint stability was an important prognostic determinant. In the surgical group, the most important factor was good anatomical reduction. Functional outcomes were comparable between the conservative and surgical groups. We concluded that conservative treatment is a valid option for fractures with minimal displacement and surgical treatment is justified for severely displaced or depressed fractures. Attention must be paid to the recognition and restoration of joint stability and articular surface congruency for a satisfactory outcome.