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.
Brachial plexopathy is usually related to trauma like direct injury to the nerve and stretching injuries. Neurological complications following bee sting are uncommon. Here, we describe a rare case of acute brachial plexopathy as a neurological complication following bee sting. A23-year-old maleinitially presented with angioedema and anaphylactic shock one hour after a bee stung at his neck. Twenty four hours after the incidence, he presented with sudden onset of left upper limb weakness. Nerve conduction study and electromyography had shown evidence of left brachial plexopathy.
Acute disseminated encephalomyelitis (ADEM) is an inflammatory demyelinating disease of the central nervous system (CNS) that is known to occur spontaneously in association with specific and non-specific viral illnesses and after vaccination against various pathogens. Although it is often a self-limited monophasic illness, the fatality rate is estimated to be as high as 20%, and many patients suffer residual neurologic impairment 1. The diagnosis is mainly based on clinical and radiological findings. The clinical presentation varies from merely, an asymptomatic condition to loss of consciousness, seizures, ataxia, optic neuropathy, cranial nerve palsies, and motor dysfunction. MRI of the brain is the single most important diagnostic radiological investigation and can facilitate early diagnosis and prompt treatment. This case report describes a patient with ADEM presenting with only seizures after vaccination with anti-tetanus toxin.
In Malaysia, there is limited information on the mortality and morbidity after an acute stroke in hospitalised patients. The objective of the study was to identify the type, time of onset, and frequency of medical and neurological complications following an acute ischaemic stroke. Consecutive patients with acute ischaemic stroke who were admitted to Hospital Universiti Kebangsaan Malaysia from June 2000 to January 2001 were observed. The complication rate was 20.9%. The most common individual complication was pneumonia (12.3%), followed by septicaemia (11.0%), urinary tract infection (4.3%), and upper gastrointestinal haemorrhage (3.7%). The overall mean length of stay was 7.48 days. The independent risk factors for complications were diabetes mellitus (OR 2.87; 95%CI 1.06 to 7.78), middle cerebral artery (MCA) infarcts (OR 10.0; 95%CI 4.1 to 24.3), and Glasgow coma score (GCS) less than 9(OR 3.8; 95%CI 1.03 to 14.3). Infection was the commonest complication observed. Patients with diabetes mellitus, poor GCS and large MCA infarcts had a higher risk of developing complications.
Background and purpose: Diabetes mellitus is a strong risk factor for stroke. However, the prognosis in terms of mortality after a stroke is still unclear, especially in diabetic patients. The main purpose of this study was to compare and evaluate the features of stroke in patients having diabetes mellitus with those without diabetes mellitus and to identify factors that influence survival following a stroke.
Subjects and methods: In a prospective hospital-based study consecutive patients with acute ischaemic stroke were enrolled. A single observer, using predefined diagnostic criteria recorded the demographics, risk factors and the type of stroke and deaths that occurred during the in-patient period.
Results: One hundred and sixty-three patients with acute ischaemic stroke were enrolled in the study. Type 2 diabetes mellitus was present in 90 (55.2%) patients. Diabetes was a significant independent predictor of mortality (OR 4.88; 95%CI 1.25-19.1). Among the diabetic patients middle cerebral artery (MCA) territory infarct (OR 34.8, 95%CI 4.5-269.4) and Glasgow coma score (GCS) less than 9 (OR 12.3, 95%CI 3.7-198.1) were independent predictors of mortality.
Conclusions: MCA infarcts and poor conscious level increase the mortality in diabetic patients with stroke. Mortality is also significantly related to a high level of blood glucose at admission.
Subclinical cerebral infarcts (SCI) have been increasingly shown to cause a significant clinical impact. However, there are limited data available on Asian patients. The objectives of this study were to determine the prevalence of SCI in ischaemic stroke patients seen in the Hospital Universiti Kebangsaan Malaysia (HUKM) and to identify its associated risk factors. We evaluated the brain computed tomography (CT) evidence of subclinical infarcts in ischaemic stroke patients. The patients were selected from those who were on regular follow up in the neurology clinic following an ischaemic stroke. The risk factors associated with subclinical infarct were documented. The brain CTs were done during acute admission and reviewed for SCI. Sixty-one patients were enrolled in this study. Twenty-two (36.1%) out of the 61 patients had SCI. The risk factors for SCI in our study were hypertension (OR 14.16 CI 2.04-97.89), diabetes mellitus (OR 12.48; CI 1.95-79.77) and leukoaraiosis (OR 28.39; CI 2.33-284.16). Subclinical cerebral infarcts were present in about one third of our ischaemic stroke patients. This finding is higher than in previous studies done on Caucasians. Hypertension, diabetes mellitus and leukoaraiosis independently predict SCI.
Study site: Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM)
Dysphagia occurs frequently after a stroke. It is a major problem as patients are at risk of malnutrition and aspiration pneumonia. We aimed to identify the risk factors for and outcome of dysphagia over the first one month after an acute ischaemic stroke. Patients with acute first-ever ischaemic stroke admitted to the medical ward of Hospital Universiti Kebangsaan Malaysia (HUKM) between July 2004 and December 2004 were prospectively examined. Observation was done using pre-defined criteria. Demographic data, risk factors, and type of stroke were recorded on admission. The assessment of dysphagia was made using standardized clinical methods. All patients were followed up for three months. One hundred and thirty four patients were recruited in the study. Fifty-five patients (41%) had dysphagia at presentation. This number was reduced to 29 (21.6%) patients at one month. Logistic regression analysis revealed that age of more than 75 years [OR 5.20 (95% CI 1.89 - 14.30)], diabetes mellitus [OR 2.91 (95% CI 1.07 - 7.91)] and MCA infarct [OR 2.48 (95% CI 1.01-6.14)] independently predicts the occurrence of dysphagia after an acute stroke. Dysphagia at presentation was found to be an independent predictor of mortality at one-month [OR 5.28 (95% CI 1.51-18.45)] post ischaemic infarct. Dysphagia occurred commonly in ischaemic stroke. Advance age, diabetes mellitus and large infarcts were independently associated with the presence of dysphagia. Early stroke mortality can be independently predicted by the presence of dysphagia.
Increasing evidence suggests that inflammation plays an important role in the development of both cardiovascular and cerebrovascular events. Recently C-reactive protein (CRP) levels have been reported to be a prognostic factor for cerebrovascular and cardiovascular events. The main objective of the study was to evaluate the prognostic value of CRP levels in a first ever ischaemic stroke at one month. All ischaemic stroke patients who were admitted to Hospital Universiti Kebangsaan Malaysia (HUKM) between May 2002 and July 2002 were eligible for the study. CRP levels were taken within 72 hours after an acute ischaemic stroke. The functional ability was assessed using the Barthel Index (BI) after one month of stroke. During the study period 84 patients were admitted to HUKM with the diagnosis of ischaemic stroke; 49 patients were enrolled and 35 were excluded. Twenty-nine patients (59.2%) had elevated CRP levels (median 1.64+/-3.07 mg/dL, range 0.06 to 16.21 mg/dL). Elevated CRP levels were found to be a predictor of severe functional disability (BI<5) and were also associated with larger infarcts. In conclusion, elevated CRP levels are associated with poorer functional outcome and predict a larger infarct size.
Cerebral angioinvasive aspergillosis is a rare manifestation of disseminated aspergillosis which may result in stroke in immunocompromised individuals. Reports of such disease in patients with diabetes mellitus are rare. We describe a 45-year-old man with diabetes mellitus who presented with a three-day history of right-sided limb weakness and aphasia. Cerebral computed tomography showed features of an acute infarct involving the left anterior and middle cerebral arteries. He was initially treated for an acute ischaemic stroke. Further history revealed that he was investigated for a growth in the sphenoid sinus two months earlier. Culture of the biopsied material from the sphenoid sinus grew Aspergillus fumigatus. Magnetic resonance imaging showed an extension of the growth to the brain, causing the acute ischaemic stroke. He was subsequently diagnosed with angioinvasive cerebral aspergillosis and was commenced on intravenous amphotericin B. Unfortunately, he succumbed to his illness despite treatment.
BACKGROUND/AIMS: In view of the differing sensitivity and specificity of the Mini-Mental State Examination (MMSE) in the non-English-speaking populations, we conducted the first validation study of the Malay version (M-MMSE) in Malaysia among 300 subjects (from the community and outpatient clinics).
METHODS: Three versions were used: M-MMSE-7 (serial 7), M-MMSE-3 (serial 3) and M-MMSE-S (spell 'dunia' backwards). Dementia was assessed using the criteria of the Diagnostic and Statistical Manual of Mental Disorders IV. The optimal cutoff scores were obtained from the receiver operating characteristics curves.
RESULTS: Seventy-three patients (24.3%) had dementia and 227 (75.7%) were controls. Three hundred patients completed the M-MMSE-7, 160 the M-MMSE-3 and 145 the M-MMSE-S. All 3 versions were valid and reliable in the diagnosis of dementia. The optimal cutoff scores varied with each version and gender. In the control group, significant gender differences were observed in the patients with the lowest educational status. Increasing educational levels significantly improved the M-MMSE performance in both genders.
CONCLUSION: All 3 versions of the M-MMSE are valid and reliable as a screening tool for dementia in the Malaysian population, but at different cutoff scores. In those with the lowest educational background, gender-adjusted cutoff scores should be applied.
Study site: Community, neurology and dementia outpatient clinics, Perubatan Universiti Kebangsaan Malaysia (PPUKM), University Malaya Medical Centre (UMMC)
Stroke remains a major health burden worldwide. The incidence and prevalence rates of stroke are decreasing in developed countries, an opposite trend is taking place in the Asia Pacific, where an increasing number of patients are being diagnosed with acute stroke. The results of the present study on acute stroke in multi-ethnic Malaysia will significantly contribute to the global stroke epidemiological data. We aimed to present epidemiological data of stroke including incidence and prevalence rates as well as associated risk factors from a prospective nationwide hospital-based registry from 2010 to 2014.
Gender as an independent predictor in stroke has been well documented. However, data on gender differences among first-ever ischemic stroke in developing country are limited. We aim to describe gender effects on clinical characteristics, thrombolysis treatment received, and outcomes of patients with first-ever ischemic stroke.
Dribbling (sialorrhoea) affects about 10 per cent of patients with chronic neurological disease. The variety of treatments currently available is unsatisfactory. This study was a clinical trial of the efficacy of ultrasound-guided, intraglandular injection of botulinum toxin A for dribbling, performed within the otorhinolaryngology department of the National University of Malaysia. Both pairs of parotid and submandibular glands received 25 U each of botulinum toxin A. Twenty patients were enrolled in the study. The median age was 15 years. All 20 patients (or their carers) reported a distinct improvement in symptoms after injection. Using the Wilcoxon signed rank test, there were significant reductions in dribbling rating score, dribbling frequency score, dribbling severity score, dribbling visual analogue score and towel changes score, comparing pre- and post-injection states (p<0.001). There were no complications or adverse effects during or after the injection procedure. Intraglandular, major salivary gland injection of botulinum toxin A is an effective treatment to reduce dribbling. Ultrasound guidance enhances the accuracy of this procedure and minimises the risk of complication.
This study was conducted to compare the treatment efficacy between a prandial glucose regulator, repaglinide and a new sulphonylurea, glimepiride in Muslim Type 2 diabetic patients who practice Ramadan fasting. Forty-one patients, previously treated with a sulphonylurea or metformin, were divided to receive either repaglinide (n=20, preprandially three-times daily) or glimepiride (n=21, preprandially once daily) 3 months before the month of Ramadan. During Ramadan, patients modified their eating pattern to two meals daily, and the triple doses of repaglinide were redistributed to two preprandial doses. Four point blood glucose monitoring were performed weekly during the month of Ramadan and the subsequent month. Measurements of the 4-point blood glucose were significantly lower in the glimepiride group compared to the repaglinide group both during and after Ramadan. The glycaemic excursion was better in the morning for the repaglinide group and better in the afternoon and evening for the glimepiride group during the Ramadan period. There was no statistically significant difference in the incidence of hypoglycaemia between the two groups during and after Ramadan. There was no difference in the glycaemic excursion post-Ramadan. The longer duration of action of glimepiride may offer an advantage over repaglinide during the 13.5 hours of fast in Ramadan for diabetic patients.
Infection is a frequent complication after an acute stroke and may affect stroke outcome. We identified predictors of early infection, type of infection, their relation to initial disability, and the eventual outcome during the inpatient period.
Retraction notice: Following investigations of duplicate publication in Parkinsonism and Related Disorders 2009; 15: 670–674, we have determined that there is indeed a substantial overlap between the two articles. As such, we fully retract this paper from the published record of the Singapore Medical Journal.
Professor Teo Eng Kiong, Editor, Singapore Medical Journal
http://smj.sma.org.sg/5201/5201rec1.pdf
There are limited studies reporting the frequency of sleep-disordered breathing (SDB) in Parkinson's disease (PD), and the figures quoted are variable, ranging from 2.5 to 66 percent. This study aimed to determine the prevalence and types of SBD in PD patients attending the Universiti Kebangsaan Malaysia Medical Centre neurology clinic, and the correlation between the subjective sleep symptoms using the Parkinson's disease sleep scale (PDSS) and the objective measurements using polysomnography (PSG).
METHODS: This was a cross-sectional study involving 46 PD patients over a period of six months. The patients' demographic data, Hoehn and Yahr staging and PDSS scores were collected. The patients were then subjected to overnight PSG using the Somnomedic system.
RESULTS: There were 27 male and 19 female patients with a mean age of 64.0+/-9.7 years. 29 were Chinese, 15 Malay and 2 Indian. The mean duration of illness was 5.8+/-4.3 years. The mean PDSS score was 120.3+/-13.5. SDB was found in 54.6 percent of the patients (apnoeahypopnoea index [AHI] 5 and above), with 27.3 percent having moderate and severe SDB (AHI 15 and above). The median AHI was 6.7 (range 0-40.4). The prevalence of SDB in PD patients based on the AHI cutoffs were 27.3 percent for mild, 18.2 percent for moderate and 9.1 percent for severe. There were statistically significant positive correlations between the AHI and the neck circumference and between the AHI and the waist-hip ratio. There was no significant correlation between the AHI and PDSS, or the AHI and disease severity.
CONCLUSION: There was a high prevalence of SBD in our PD patients, which was comparable to other studies. Obstructive sleep apnoea was the dominant type of SBD. There was no correlation between the subjective sleep symptoms using the PDSS and the objective measurements using PSG.
Study site: Neurology clinic, Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM)
Bell's palsy is a benign lower motor neuron facial nerve disorder. It is almost always unilateral. We report a 20-year-old nulliparous woman with five episodes of recurrent Bell's palsy. A review of recent medical literature revealed a paucity of case reports involving an individual with five episodes of recurrent Bell's palsy, with none found in Asian neurology medical literature. Despite the multiple episodes of Bell's palsy recurrences, the patient did not suffer much neurological sequelae from the disease.
Leukoaraiosis (LA) is a term that defines an abnormal appearance of the subcortical white matter of the brain on neuroimaging. This study was done to evaluate the predictive value of LA in terms of mortality, disability and cognitive decline at three months post-stroke and also to identify the risk factors that are independently associated with LA in a stroke population.