MyMedR

Case series: Fulminant community-acquired Acinetobacter pneumonia

Tonnii S, Chua HH

Med J Malaysia, 2020 03;75(2):186-188.

Acinetobacter infection, especially the drug-resistant strain, is a common cause of nosocomial infection. However, community-acquired Acinetobacter infection is uncommon. We reported three cases of community-acquired Acinetobacter pneumonia. All three cases had histories of regular home-brewed alcohol consumption presented with severe acute respiratory symptoms requiring ventilatory support and had low total white cell count. They succumbed to the illness within 2 to 10 days of admission. They had positive blood or endotracheal aspirate cultures of sensitive-strain Acinetobacter sp. which was only sensitive to high dose sulbactam. Early recognition and correct antibiotic can help reduce mortality.

Fulltext Outbreak of chikungunya in Johor Bahru, Malaysia: clinical and laboratory features of hospitalized patients

Chew LP, Chua HH

Med J Malaysia, 2009 Sep;64(3):220-2.

PMID: 20527272

In 2008, an outbreak of chikungunya infection occurred in Johor. We performed a retrospective review of all laboratory confirmed adult chikungunya cases admitted to Hospital Sultanah Aminah, Johor Bahru from April to August 2008, looking into clinical and laboratory features. A total of 18 laboratory confirmed cases of chikungunya were identified with patients presenting with fever, joint pain, rash and vomiting. Haemorrhagic signs were not seen. Lymphopenia, neutropenia, thrombocytopenia, raised liver enzymes and deranged coagulation profile were the prominent laboratory findings. We hope this study can help guide physician making a diagnosis of chikungunya against other arborviruses infection.

Fulltext Puffer fish poisoning: a family affair

Chua HH, Chew LP

Med J Malaysia, 2009 Jun;64(2):181-2.

PMID: 20058587 MyJurnal

Tetrodotoxin poisoning has been commonly reported in Japan due to consumption of contaminated fugu (puffer fish). Poisoning is possible when the fish is not cleansed and dressed properly. Puffer fish is considered a delicacy by the Japanese as the fish meat is very tender and tasty. A certified chef trained in ways of preparing this poisonous fish should only be allowed to serve this fish. Despite careful preparation, this fish remains a deadly meal for many as 50 deaths are reported annually1 . An outbreak of 34 cases of tetrodotoxin occurred in Johor in May 2008. Here, we would like to report three cases of tetrodotoxin poisoning in a family who consumed this deadly fish and was admitted to Hospital Sultanah Aminah Johor Bahru (HSAJB).

Fulltext Epidemiology of culture-positive infection in adult patients with haematological malignancies in Sarawak

Chew LP, Mohamad Adam B, Chua HH

Med J Malaysia, 2014 Apr;69(2):70-3.

PMID: 25241815 MyJurnal

No abstract available.

Fulltext Acute anuric renal failure following jering bean ingestion

Wong JS, Ong TA, Chua HH, Tan C

Asian J Surg, 2007 Jan;30(1):80-1.

PMID: 17337378

Djenkol beans or jering (Pithecellobium jeringa) is a traditional delicacy consumed by the local population in Malaysia. Jering poisoning or djenkolism is characterized by spasmodic pain, urinary obstruction and acute renal failure. The underlying pathology is an obstructive nephropathy, which is usually responsive to aggressive hydration and diuretic therapy. We present a case of djenkolism following ingestion of jering. The patient required urgent bilateral ureteric stenting following the failure of conservative therapy. Healthcare providers need to recognize djenkolism as a cause of acute renal failure and the public educated on this potential health hazard.

Fulltext Successful Non-surgical Treatment of an Acute Calculous Cholecystitis in a Myeloma Patient with Covid-19: Case Report

Tang ASO, Leong TS, Chew LP, Chua HH

SN Compr Clin Med, 2021;3(2):666-669.

PMID: 33554049 DOI: 10.1007/s42399-021-00785-8

COVID-19 has a wide spectrum of clinical phenotypes. While fever and cough are the most common symptoms, abdominal pain is rarely reported. We report the first case of COVID-19 pneumonia in an elderly patient with multiple myeloma (MM), complicated by acute calculous cholecystitis (ACC). A 73-year-old gentleman with underlying IgG kappa MM, presented with fever, cough and dyspnoea. His nasopharyngeal swab was positive for SARS-CoV-2. Piperacillin/tazobactam and oral hydroxychloroquine were started in addition to granulocyte colony-stimulating factor (GCSF) support due to neutropenia. Patient deteriorated on day 5, requiring high flow oxygen support. Dexamethasone, low molecular weight heparin prophylaxis and one dose of intravenous immunoglobulin were given. Despite negative swab on day 10, he developed ACC on day 17. With antibiotics and supportive care, patient showed full recovery without any surgical intervention. It remains elusive whether the gallbladder might be vulnerable to COVID-19, necessitating further validation via prospective studies.

Fulltext A fatal case of chikungunya virus infection with liver involvement

Chua HH, Abdul Rashid K, Law WC, Hamizah A, Chem YK, Khairul AH, et al.

Med J Malaysia, 2010 Mar;65(1):83-4.

PMID: 21265260 MyJurnal

Recovery from chikungunya is previously considered universal and mortality due to the virus is rare and unusual. Findings from recent chikungunya outbreaks occurred in Reunion Island and India have since challenged the conventional view on the benign nature of the illness. Malaysia has experienced at least of 4 outbreaks of chikungunya since 1998. In the present on-going large outbreak due to chikungunya virus of Central/East African genotype, a previous healthy sixty six years gentleman without co-morbidity was noted to have severe systemic infection by the virus and involvement of his liver. He subsequently passed away due to cardiovascular collapse after 5 days of illness.

Fulltext Miscarriage Risk in COVID-19 Infection

Wong TC, Lee ZY, Sia TLL, Chang AKW, Chua HH

SN Compr Clin Med, 2020 Aug 15.

PMID: 32838193 DOI: 10.1007/s42399-020-00443-5

Diagnostic and Treatment Challenges in Cerebral Tuberculoma in a Patient with Morbid Obesity

Wong QY, Tang ASO, Loh WH, Yong XM, Samuel D, Law WC, et al.

Am J Case Rep, 2021 Jul 10;22:e932852.

PMID: 34244464 DOI: 10.12659/AJCR.932852

BACKGROUND Tuberculosis is prevalent, especially in low-income countries. The most devastating manifestation of tuberculosis is central nervous system (CNS) involvement, albeit rare. CASE REPORT We report a rare case of a 26-year-old woman with morbid obesity and hepatitis C who had cerebral tuberculoma and was treated with an extended duration of anti-tuberculosis multi-drug therapy. This patient was initially diagnosed with disseminated tuberculosis of the lungs, liver, and peritoneum. After 4 months of anti-tuberculosis treatment, she developed new right temporal hemianopia and new cerebral tuberculoma, which was identified on repeated magnetic resonance imaging (MRI) and was attributed to tuberculosis-immune reconstitution inflammatory syndrome. The anti-tuberculosis treatment was continued; however, she gained large amounts of weight, which resulted in the failure of the anti-tuberculosis treatment of the cerebral tuberculoma. We decided to adjust the anti-tuberculosis drug dosage using her total body weight, and she responded well, with a decrease in size of the cerebral tuberculoma. The anti-tuberculosis treatment was subsequently stopped after 3 years because of clinical and imaging improvement. CONCLUSIONS This case illustrates the challenges faced in the treatment of cerebral tuberculoma, which, in this case, included a high body mass index affecting drug dosage and confounding an inadequate treatment response as seen on interim MRI, resulting in prolonged duration of anti-tuberculosis treatment. Persistent enhancement seen on brain MRI does not equate to treatment failure.

Subcutaneous mycosis presenting as a non- healing left calf ulcer in an immunocompromised patient

Tang ASO, Yong KY, Wong J, Chua HH, Chew LP

Med J Malaysia, 2017 04;72(2):122-123.

PMID: 28473676

This is a case report of subcutaneous mycosis presenting as a non-healing left calf ulcer in an immunocompromised patient. Traumatic inoculation of the causative agent is the most likely route of infection. The diagnosis requires a detailed history and high clinical suspicion, confirmed by histopathological examination. The management requires a multidisciplinary team approach involving surgeon, pathologist, physician sub-specialised in infectious disease, wound care nursing team as well as social support services. The literature review recommended that the treatment of choice for such infection is surgical debridement in addition to optimal antifungal therapy.

Thrombotic thrombocytopenic purpura-like syndrome associated with arcanobacterium pyogenes endocarditis in a post-transplant patient: A case report

Andy Tang SO, Leong TS, Ruixin T, Chua HH, Chew LP

Med J Malaysia, 2018 10;73(5):344-346.

PMID: 30350823 MyJurnal

Systemic Arcanobacterium pyogenes is a rare bacterial infection in humans.1The diagnosis of thrombotic thrombocytopenic purpura (TTP)-like syndrome and infective endocarditis (IE) is often elusive. We report a case of TTP-like syndrome associated with A. pyogenes endocarditis in a post-allogenic transplant patient.

Fulltext Mammary Paget's Disease of the Nipple: Relatively Common but Still Unknown to Many

Ooi PS, Draman N, Yusoff SSM, Zain WZW, Ganasagaran D, Chua HH

Korean J Fam Med, 2019 Jul;40(4):269-272.

PMID: 30486607 DOI: 10.4082/kjfm.17.0143

Mammary Paget's disease is clinically defined as skin inflammation of the nipple area and is an adenocarcinoma of the epidermis of the nipple. The pathogenesis of mammary Paget's disease is relatively unknown; nonetheless, there are two popular theories that support the underlying carcinoma and de novo carcinogenesis. For the attending medical practitioner, mammary Paget's disease poses a diagnostic and therapeutic dilemma, especially in the absence of a clinically palpable breast mass. We report a rare case of a 48-year-old Malay woman who presented at Hospital Universiti Sains Malaysia, Kelantan, Malaysia with the symptom of skin erosion on the left nipple and unresponsiveness to multiple topical treatments. A full evaluation and assessment of the patient were conducted, and mammary Paget's disease was diagnosed.

Fulltext Disseminated AIDS-related Kaposi's sarcoma

Tang ASO, Teh YC, Chea CY, Yeo ST, Chua HH

Oxf Med Case Reports, 2018 Dec;2018(12):omy107.

PMID: 30487992 DOI: 10.1093/omcr/omy107

We present a case of disseminated Kaposi's sarcoma with both cutaneous and extracutaneous involvement in an HIV-infected patient with a relatively high CD4 count of 369 cell/mm3. He developed chronic diarrhea, constitutional symptoms, worsening bilateral pleural effusion with respiratory distress, and progression of skin lesions distributed over his chest and extremities. The temporal relationship between rapid clinical progression and initiation of HAART suggested the possibility of Kaposi's sarcoma-associated immune reconstitution inflammatory syndrome, which eventually resulted in the death of this patient.

Fulltext Correction to: Thrombosis and Bleeding as Presentation of COVID-19 Infection with Polycythemia Vera: a Case Report

Chow LC, Chew LP, Leong TS, Mohamad Tazuddin EE, Chua HH

SN Compr Clin Med, 2020;2(11):2508.

PMID: 33134841 DOI: 10.1007/s42399-020-00604-6

[This corrects the article DOI: 10.1007/s42399-020-00537-0.].

Fulltext Thrombosis and Bleeding as Presentation of COVID-19 Infection with Polycythemia Vera. A Case Report

Chow LC, Chew LP, Leong TS, Mohamad Tazuddin EE, Chua HH

SN Compr Clin Med, 2020;2(11):2406-2410.

PMID: 33043250 DOI: 10.1007/s42399-020-00537-0

Coronavirus disease (COVID-19) has a wide spectrum of clinical manifestations. In this case report, we describe our first case of COVID-19 pneumonia that was complicated by cerebral venous thrombosis and bleeding in a patient with polycythemia vera. Madam A, a 72-year-old lady with polycythemia vera, ischemic stroke, hemorrhoids, diabetes mellitus, hypertension, and dyslipidemia was admitted to the hospital for COVID-19 pneumonia. She was treated with hydroxychloroquine and lopinavir/ritonavir as per hospital protocol. She continued taking hydroxyurea and aspirin for her treatment of polycythemia vera. Subsequently, she developed rectal bleeding when her platelet count was 1247 × 103/μl, even though she was not on an anticoagulant. Her aspirin was withheld. One week later, she was readmitted to the hospital for cerebral venous thrombosis and her D-dimer was 2.02 μg/ml. She was commenced on a therapeutic dose of low molecular weight heparin. Following that, her D-dimer level showed a decreasing trend and normalized upon her discharge. Patients with polycythemia vera are prone to develop thrombotic and bleeding complications. Management of this group of patients has become more complex with COVID-19 infection. It is crucial for us to decide when to start an anticoagulant especially when there is a history of recent bleeding. We need to balance the risks of further bleeding versus potentially fatal thrombotic events. Studies have shown that D-dimer can be used as a clinical marker to predict thrombotic events in COVID-19 infection. Patients with COVID-19 infection and polycythemia vera will benefit from both pharmacological thromboprophylaxis and close monitoring for bleeding.

Fulltext Evaluation of the Receptor Activator of Nuclear Factor Kappa B Ligand (RANKL) Expression in Osteosarcoma and Its Association with the Clinicopathological Data

Chua HH, Tuan Sharif SE, Wan Ismail WFN, Zawawi MSF, Abdullah S

Asian Pac J Cancer Prev, 2021 Mar 01;22(3):741-747.

PMID: 33773537 DOI: 10.31557/APJCP.2021.22.3.741

BACKGROUND: The receptor activator of nuclear factor kappa B ligand (RANKL) is one of the key regulators of bone remodelling in bone oncology, including osteosarcoma. We assessed RANKL immunohistochemical expression in osteosarcoma, its association, and disease-free survival with the patients' clinicopathological characteristics.

METHODS: One hundred osteosarcoma cases from 2003 to 2018 in Hospital Universiti Sains Malaysia were retrieved. The tissue samples were stained for RANKL, and the association with the clinicopathological characteristics was evaluated. Staining was interpreted in a semiquantitative scoring system and classified into negative and positive expressions. Results: Eighty-two cases had a positive expression of RANKL in which 56 and 26 patients were classified as low expression and high expression, respectively. The positive expression of RANKL did not show a significant association with clinicopathological characteristics. However, Kaplan Meier survival analysis showed a significant improvement in the disease-free survival patients who underwent limb salvage surgery (LSS) than amputated patients (p-value 0.002), whereas poorer survival was observed among conventional osteosarcomas compared to non-conventional osteosarcoma (p-value 0.01).

CONCLUSION: Limb salvage surgery had proven to improve osteosarcoma patients' survival compared to amputation, which could improve overall quality of life in osteosarcoma patients. However, our data did not show a significant association between positive RANKL immunohistochemistry with any of the clinicopathological characteristics and patients' final survival. Further studies may be acquired to understand the suitability of using RANKL immunohistochemistry as prognostication in the management of osteosarcoma patients.

Factors associated with in-hospital mortality among infective endocarditis patients

Ho YH, Lim CT, Chua CZF, Chow HB, Chua HH, Fong AYY

Med J Malaysia, 2023 Nov;78(6):743-750.

PMID: 38031215

INTRODUCTION: Despite recent advancements in the diagnosis and management of infective endocarditis (IE), it is associated with substantial morbidity and mortality. Our study objective is to determine the factors associated with in-hospital mortality in IE patients among the local population.

MATERIALS AND METHODS: All IE patients who were diagnosed with definite or possible IE and were treated at Sarawak Heart Centre from 1st January 2020 to 31st December 2022 were recruited. We examined the demographic features of the subjects and the factors that contributed to in-hospital mortality. Multivariate logistic regression was used to analyse the associated factors and in-hospital mortality.

RESULTS: Our study population comprised a total of 37 patients with a mean age of 46.4 years and male predominance. The in-hospital mortality rate of IE in this study was 44.4%. Haemodynamic instability and anaemia were found to be strong predictors of IE survival outcome, with an odds ratio of 51.5 and 35.7 respectively. Patients with vascular phenomenon and heart failure were at 10.5- and 6.0-times higher odds of dying, however, these two associations were found to be not statistically significant.

CONCLUSION: The in-hospital mortality due to IE in our study was among the highest in developing countries. Factors of hypotension and optimal response to individual hemodynamic parameters may confer lower mortality. While anaemia is demonstrable as a risk factor for inpatient mortality, a target has yet to be reasonably established.

Hand hygiene promotion delivered by change agents-Two attitudes, similar outcome

Lee YF, McLaws ML, Ong LM, Amir Husin S, Chua HH, Wong SY, et al.

Infect Control Hosp Epidemiol, 2020 03;41(3):273-279.

PMID: 31928551 DOI: 10.1017/ice.2019.339

OBJECTIVE: To assess the effect of peer-identified change agents (PICAs) compared to management-selected change agents (MSCAs) on hand hygiene behavior in acute care.

DESIGN: Randomized-controlled study.

SETTING: Two internal medicine wards of a public, university-affiliated, tertiary-care hospital in Malaysia.

METHODS: We randomly allocated 2 wards to hand hygiene promotion delivered either by PICAs (study arm 1) or by MSCAs (study arm 2). The primary outcome was hand hygiene compliance using direct observation by validated auditors. Secondary outcomes were hand hygiene knowledge and observations from ward tours.

RESULTS: Mean hand hygiene compliance in study arm 1 and study arm 2 improved from 48% (95% confidence interval [CI], 44%-53%) and 50% (95% CI, 44%-55%) in the preintervention period to 66% (63%-69%) and 65% (60%-69%) in the intervention period, respectively. We detected no statistically significant difference in hand hygiene improvement between the 2 study arms. Knowledge scores on hand hygiene in study arm 1 and study arm 2 improved from 60% and 63% to 98% and 93%, respectively. Staff in study arm 1 improved hand hygiene because they did not want to disappoint the efforts taken by the PICAs. Staff in study arm 2 felt pressured by the MSCAs to comply with hand hygiene to obtain good overall performance appraisals.

CONCLUSION: Although the attitude of PICAs and MSCAs in terms of leadership, mode of action and perception of their task by staff were very different, or even opposed, both PICAs and MSCAs effectively changed behavior of staff toward improved hand hygiene to comparable levels.

Fulltext Immunodeficiency and Thymoma: A Case Report on Good Syndrome, a Diagnosis Frequently Missed and Forgotten

Tang ASO, Loh WH, Wong QY, Yeo ST, Ng WL, Teoh PI, et al.

Am J Case Rep, 2021 Mar 13;22:e928659.

PMID: 33712551 DOI: 10.12659/AJCR.928659

BACKGROUND Good syndrome (thymoma with immunodeficiency) is a frequently missed and forgotten entity. It is a rare cause of combined B and T cell immunodeficiency in adults. To date, fewer than 200 patients with Good syndrome have been reported in the literature. CASE REPORT We report a case of type AB Masaoka-Koga stage I thymoma which predated the evidence of immune dysregulation by 5 years, manifesting as bilateral cytomegalovirus retinitis, multiple bouts of pneumonia, and bronchiectasis in a HIV-seronegative 55-year-old man. Intravitreal ganciclovir was administered in addition to intravenous systemic ganciclovir, which resulted in severe neutropenic sepsis. A thorough immunodeficiency workup confirmed the presence of hypogammaglobulinemia with complete absence of B cells and reduced CD4/CD8 ratio. The patient responded well to monthly intravenous immunoglobulin replacement therapy, with no further episodes of infection since then. The immunoglobulin level doubled after 1 year of treatment. However, as the patient refused further intravitreal and CMV-targeted treatment, his vision did not recover. CONCLUSIONS Clinicians should be aware that thymoma can precede the onset of immunodeficiency. Clinical suspicion should be heightened in at-risk patients who present with multiple bouts of infection, particularly in thymoma cases with adult-onset immune dysfunction. It is of paramount importance to follow up those patients with annual clinical reviews and immunodeficiency screening.

Fulltext Central nervous system melioidosis in systemic lupus erythematosus: A clinical vignette

Cheok LH, Tang ASO, Desmond S, Wong YL, Cheong YK, Ng SC, et al.

IDCases, 2021;26:e01255.

PMID: 34458097 DOI: 10.1016/j.idcr.2021.e01255

Central nervous system melioidosis is an uncommon presentation of melioidosis infection. We report a case of a disseminated melioidosis infection with central nervous system, pulmonary, spleen, bone and cutaneous involvement in a patient with underlying systemic lupus erythematous. The diagnosis was confirmed based on positive blood and cerebrospinal fluid cultures coupled with radiological findings. Agriculture contact and underlying immunocompromised state were the predisposing risk factors for melioidosis infection in this case. Our patient was successfully treated with 10 weeks of intensive antibiotics therapy and 1 year of eradication antibiotics therapy with significant clinical and radiological improvement.

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