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.
A 55-year-old woman presented with sudden onset of left-sided body weakness and numbness, which was diagnosed as multifocal cerebral infarct with right thalamic bleed. She had concurrent hypertension, diabetes mellitus and chronic kidney disease. She suffered from central poststroke pain and reactive depression as poststroke complications, for which amitriptyline was prescribed. Unfortunately, she developed symptoms suggestive of mania and psychosis upon initiation of medications, which resolved upon withdrawal of amitriptyline. Amitriptyline is effective for treatment of poststroke pain and particularly useful in concomitant depression. Unexpectedly, this patient developed new psychopathologies after initiation of this medication. This case highlights the development of new psychopathologies that could be due to the antidepressant, underlying bipolar disorder or a complication of the stroke itself. Primary care providers need to actively enquire regarding neuropsychiatric symptoms because they can adversely affect the patient's quality of life as well as impede rehabilitation efforts.
A 35-year-old Malaysian man presented with rapid onset of flaccid quadriparesis associated with nausea and vomiting. General blood tests revealed severe hypokalaemia (serum potassium 1.5 mmol/L) and hypophosphataemia (serum phosphate 0.29 mmol/L) as a potential cause of the flaccid paralysis. Arterial blood gases showed mixed acid base disturbance of respiratory alkalosis and metabolic acidosis with hyperlactataemia. Thyrotoxic periodic paralysis (TPP) was suspected as the underlying cause of this presentation and thyroid function tests showed severe hyperthyroid results (free T4 > 77.2 pmol/L, free T3 19.3 pmol/L, thyroid-stimulating hormone [TSH] < 0.05 mIU/L). Treatment with intravenous potassium and phosphate infusion and oral propranolol resulted in rapid resolution of his symptoms. A discussion of the clinical and pathophysiological features and treatment of TPP (a very rare encounter in UK clinical practice) is presented, and to our knowledge associated hyperlactataemia has not been previously described.
A patient with severe hyponatreamia secondary to chronic renal failure was treated with peritoneal dialysis (PD). On the third day of admission, she developed progressive obtundation. Neurological examination showed bilateral brisk reflexes with intact brain stem reflexes. Magnetic resonance imaging demonstrated patchy demyelination of the pontine area indicating central pontine myelinolysis (CPM). Despite supportive measures, the patient died on the fifteenth day of admission. The rate of correction of hyponatraemia with peritoneal dialysis can be rapid and detrimental to hyponatraemic chronic renal failure patients and careful monitoring of serum sodium level is advocated.
This paper deals with two patients on warfarin in whom the use of topical methylsalicylate preparations led to clinically significant bleeding problems. The first patient required fresh frozen plasma to tide over the crisis while the second patient recovered spontaneously on stopping the warfarin temporarily. The possible mechanisms by which salicylates potentiate the anticoagulant effect of warfarin are briefly outlined.
Primary thyroid lymphoma (PTL) is a rare form of thyroid cancer that is known to be associated with Hashimoto thyroiditis. This association is supported by the presence of elevated titres of both antithyroglobulin and antimicrosomal antibodies in up to 95 percent of patients with PTL. Most patients with PTL present with a rapidly enlarging neck mass and compressive symptoms. The majority of thyroid cancer patients have normal levels of thyroid hormones; they are rarely hyperthyroid, with no obvious clinical features of thyrotoxicosis. We describe a patient who presented with minimal clinical features of thyrotoxicosis despite having markedly elevated serum free thyroxine and suppressed serum thyroid-stimulating hormone levels.
An immunocompetent 5 year-old girl presented with pyrexia of unknown origin associated with headache. Initial investigations showed leukocytosis and an increased erythrocyte sedimentation rate. A Widal-Weil Felix test, blood film for malarial parasites, mycoplasma IgM antibody, cultures from blood and urine, full blood picture, Mantoux test, and chest x-ray were all negative. A lumbar puncture was done as part of a work-up for pyrexia of unknown origin. Cryptococcus neoformans was seen on India ink examination and confirmed on culture. She was treated with 10 weeks of intravenous amphotericin B and 8 weeks of fluconazole. Further immunological tests did not reveal any defect in the cell-mediated immune system. C. neoformans meningitis may present with non-specific symptoms and should be considered in a work-up for pyrexia of unknown origin.