Melioidosis is caused by the gram-negative bacillus, Burkholderia pseudomallei. It is endemic in tropical Australia and in Southeast Asian countries. The overall mortality from this infection remains extremely high despite recent advancement in its treatment. This review discuss about clinical manifestations, diagnosis and management of melioidosis.
Immune thrombocytopenia is the most common diagnosis of isolated thrombocytopenia. The dilemma encountered by paediatricians is missing diagnosis of acute leukaemia in children with isolated thrombocytopenia. We demonstrated childhood ITP could be diagnosed using a four point clinical criteria without missing a diagnosis of acute leukaemia. Hence, bone marrow examination is not necessary in children with typical features compatible with ITP prior to steroid therapy. This can encourage paediatricians to choose steroid therapy, which is cheaper and non-blood product, as first line platelet elevating therapy in children with significant haemorrhage.
Melioidosis is an infection caused by Gram negative bacterium Burkholderia pseudomallei leading to abscesses in lungs, liver, spleen, musculoskeletal system, prostate and sepsis. We present a rare case of purulent pericardial effusion caused by melioidosis with concomitant pneumonia and splenic abscesses. The patient underwent pericardiocentesis and successfully recovered from cardiogenic and septic shock.
Pulmonary cryptococcosis can be clinically silent in non-HIV infected patients but can also present as nodules and masses on the chest radiograph, which can be mistaken for tuberculosis or lung cancer. Common symptoms include fever and cough, and uncommonly haemoptysis. This report illustrates a non-HIV infected patient whose main complaint was haemoptysis and headache. He was diagnosed with pulmonary cryptococcosis from biopsy of an endobronchial mass found on flexible bronchoscopy. Disseminated cryptoccoccal infection should be considered as a differential diagnosis in non-HIV infected patients presenting with haemoptysis and headache. Early recognition and administration of appropriate therapy will improve clinical outcome in these patients.
Pneumothorax is the presence of air in the pleural cavity. It can be classified into spontaneous, traumatic or iatrogenic. The majority of pneumothorax cases are spontaneous, which can be further classified into primary spontaneous pneumothorax (PSP) or secondary spontaneous pneumothorax (SSP), defined by the absence or presence of obvious underlying lung disease respectively. The treatment of spontaneous pneumothorax includes simple aspiration, intercostal tube drainage or surgical intervention. When intercostal tube drainage is used, it is usually attached to an underwater-seal system. Mobile chest drains, such as the Heimlich valve, replace the underwater-seal and allow outpatient management of spontaneous pneumothoraces. The Heimlich valve however, is costly and not readily available in many local hospitals. Cheaper and easily obtainable alternatives which are also safe are being sought. This is a case report describing the use of the urine bag in the management of a patient with spontaneous pneumothrax.
Study site: Hospital Tengku Ampuan Afzan, Kuantan, Pahang, Malaysia.
Evidence-based heart failure management now includes beta-blockers and spironolactone in addition to diuretics and angiotensin-converting enzyme inhibitors. We aim to determine if these recommendations had been applied in practice for acute and chronic stable heart failure, and what difficulties there might be. Data from 80 consecutive patients hospitalized for decompensated heart failure ('acute') between May and July 2003 were analyzed at admission, upon discharge and at 12 weeks follow-up; along with 74 cardiology clinic out-patients with stable congestive heart failure ('chronic'- no decompensation or admission in previous six months). Less than half of study patients with prior left ventricular dysfunction were on ACE-inhibitors (47%), diuretics (39%), ATII antagonists, spironolactone or digoxin (5% each). All 'acute' patients were commenced on diuretics and ACE-inhibitors in hospital. Six patients died or transferred to another center. Compliance with clinic appointment at 12 weeks was 85% despite telephone reminders. Drug prescription at 12 weeks was significantly lower for diuretics and ACE-inhibitors compared to prescription at discharge (all p < 0.05) but higher compared to patients with chronic HF. Diuretics and ACE inhibitors remain under-utilized for patients with recurrent heart failure. Use of spironolactone and beta-blocker is slow due to limited medical experience and funding. Clinic non-attendance is significant and due to patient factors.
Edwardsiella tarda has recently been described as a member of the family Enterobacteriaceae. The genus Edwardsiella contains three species; E. hoshinae, E. ictaluri and E. tarda. Edwardsiella tarda is the only species which has been recognised as pathogenic to humans, especially in those with an underlying disease. The most common presentation is watery diarrhoea. Extra intestinal infections have been reported infrequently. Humans seem to be infected or colonised with Edwardsiella through ingestion or inoculation of a wound. This report is of a patient with multiple liver abscesses due to E. tarda who later developed bacterial peritonitis and septicaemic shock.
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%.
Establishing a microbial diagnosis for patients with community-acquired pneumonia (CAP) is still challenging and is often achieved in only 30-50% of cases. Polymerase chain reaction (PCR) has been shown to be more sensitive than conventional microbiological methods and it could help to increase the microbial yield for CAP patients. This study was designed to develop, optimize and evaluate multiplex real-time PCR as a method for rapid differential detection of five bacterial causes of CAP namely Streptococcus pneumoniae, Burkholderia pseudomallei and atypical bacterial pathogens, Mycoplasma pneumoniae, Chlamydophila pneumoniae and Legionella pneumophila. Duplex and triplex real-time PCR assays were developed using five sets of primers and probes that were designed based on an appropriate specific gene for each of the above CAP pathogens. The performance of primers for each organism was tested using SYBR Green melt curve analysis following monoplex realtime PCR amplification. Monoplex real-time PCR assays were also used to optimize each primers-probe set before combining them in multiplex assays. Two multiplex real-time PCR assays were then optimized; duplex assay for the differential detection of S. pneumoniae and B. pseudomallei, and triplex assay for the atypical bacterial pathogens. Both duplex and triplex real-time PCR assays were tested for specificity by using DNA extracted from 26 related microorganisms and sensitivity by running serial dilutions of positive control DNAs. The developed multiplex real-time PCR assays shall be used later for directly identifying CAP causative agents in clinical samples.
Introduction: Various initiatives and medications have been introduced to achieve better control of bronchial asthma. However total control according to Global Initiative for Asthma (GINA) remains elusive even at tertiary referral hospitals. Our study is to determine the level of asthma control (according to GINA 2009), Asthma Control Test (ACT) scores and the types of medications used among patients with bronchial asthma in a large tertiary hospital.
Methods: A cross-sectional study of all patients with bronchial asthma who attended the Chest Clinic at Hospital Tengku Ampuan Afzan (HTAA) from 2009 to 2011. Patient demographics, self-administered ACT scores, GINA-defined level of asthma control and medications were documented.
Results: 208 patients were recruited. There were 23.2%, 46.3% and 30.5% of patients with controlled, partly controlled and uncontrolled asthma respectively. The median ACT scores was 19 [inter quartile range (IQR) 6]. The most frequently used preventer therapy was inhaled long-acting β-agonist/corticosteroids (LABA/ICS) fixed-dose combination (61.7%), and 9.6% were not on preventer therapy. 75% of patients with controlled asthma were on LABA/ICS compared to 58.5% of the partly controlled and uncontrolled groups (p=0.039).
Conclusion: The majority of the asthmatic patients attending the Chest Clinic at HTAA did not have GINA-defined controlled asthma. Patients with higher ACT scores had better control of asthma. There were more patients with controlled asthma who were on LABA/ICS combination.
KEYWORDS: Bronchial asthma, level of control, Asthma Control Test
Study site: Chest Clinic, Hospital Tengku Ampuan Afzan (HTAA), Kuantan, Pahang, Malaysia
Device, Questionnaire & Scale: Asthma Control Test (ACT)
Optimal patient care varies considerably from place to place and is influenced by scientific as well as social developments. The purpose of this study was to investigate awareness and pertinent issues regarding informed consent among hospitalised patients and to determine lapses, in order to improve the standard of care.
Melioidosis is known to cause abscesses in various organs, including the cranium, though less commonly. We present a patient with scalp abscess and subdural empyema that was visible on computed tomography of the brain. The neurosurgical drainage grew Burkholderia pseudomallei. Despite our best effort to treat the patient using parenteral antibiotics and surgical drainage, the patient did not survive.
Previous studies have reported high rates of undetermined causes of pleural effusions. We aimed to find out the proportion of pleural effusions in which the aetiology is uncertain despite commonly available investigations.
This study was carried out to determine the prevalence, patient's characteristic and reasons for defaulting follow-up and treatment among patients with lung cancer.
Monitoring treatment response to anti-tuberculous therapy remains unsatisfactory in resource-limited countries where sophisticated and expensive tests are not readily available. Sputum culture for mycobacterium is desirable, but not obtainable in many developing countries. Sputum acid-fast bacilli (AFB) smear alone can be misinterpreted in the presence of unviable bacilli or non-tuberculous mycobacteria. Hence the search for a cheaper but reliable monitoring tool, or a combination of several tools, continues. Interesting reports from studies in third world nations have considered weight gain/loss as one such monitoring tool. Since pulmonary tuberculosis is endemic in this country, we take the opportunity to evaluate weight gain and chest radiograph, compared to sputum AFB smear in monitoring patient's response.
We analyzed the epidemiological data of all people who were involved in the search and rescue operation in Lubuk Yu, a natural recreational forest with waterfall and stream. The hospital admission records of the cases who fulfilled the case definition and the environmental samples result taken at Lubuk Yu recreational area were studied. 153 people were exposed to this outbreak, 85 (55.5%) were professional rescuers from various government agencies and 68 (44.5%) were villagers. 21 fulfilled the case definition. Ten cases were confirmed melioidosis, six melioidosis alone and four coinfected with leptospirosis. There were eight deaths in this outbreak, seven were villagers and one professional rescuer. Overall case fatality was 70%. All confirmed melioidosis cases and seven who died had diabetes mellitus. The morbidity rate were higher among the villagers, 23.5% compared to professional rescuers, 5.9%. The case fatality rate were also higher in this group which was 100% compared to 33.3% in professional rescuers. The soil and water samples in Lubuk Yu recreational area were positive for leptospira and Burkholderia pseudomallei. The presence of co-infection and co-morbidities especially diabetes mellitus among the exposed led to the high mortality in this outbreak hence a high index of suspicion is important among the healthcare professionals in the management of melioidosis cases. To avoid similar incident in future, search and rescue operation should be only conducted by professional rescuers with appropriate personal protective equipment. A register of rescuers should be maintained for surveillance and follow up if necessary.
Spontaneous pneumothorax (SP) is a common medical condition but continues to be a frequent management problem among doctors. Despite the availability of guidelines on management of SP, studies have shown that the compliance with the guidelines is low. The various treatment options available in treating this condition further confuse doctors on the right approach in managing SP. The objective of this study is to investigate the awareness of the availability of these existing guidelines and to investigate how the doctors involved in the initial management of SP would manage this condition. A self completed questionnaire which included three case scenarios were distributed among doctors in two teaching university hospitals and two large Ministry of Health hospitals. This study showed that there is a lack of awareness of the existing guidelines even among the senior doctors and there is a variation in the initial management of SP. Therefore a locally produced guideline may be beneficial to standardise and improve the management of SP.
A retrospective study was conducted to investigate 183 serologically-confirmed cases of dengue fever (DF) admitted from October 2004 to March 2005 in a large hospital in Pahang. Clinical and laboratory features, progress and outcome of these patients were analysed in order to identify risk factors associated with development of dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS). Individually, we found that older patients, secondary dengue infection, high baseline haematocrit levels, low platelet levels and prolonged activated partial thromboplastin time (APTT) ratio were significant associations with bleeding tendencies. Of these risk factors, haematocrit and APTT ratio were two independent significant risk factors on multivariate analysis. Older patients with primary infection and younger patients with secondary infection had significant bleeding tendencies. We also verified the validity of the haematocrit levels suggested as cut-off levels for plasma leakage for the Malaysian population by Malaysian Clinical Practice Guidelines for Dengue Infection in Adults (2003).
Klebsiella ozaenae is a Gram negative bacillus. It has been described as a colonizer of oral and nasopharyngeal mucosa and is a cause of atrophic rhinitis. Klebsiella ozaenae has seldom been isolated from serious infections. However, several reports have stated that Klebsiella ozaenae may cause invasive infections and even mortality. We report a 55-year-old man with Klebsiella ozaenae infection causing abscesses involving the right eye and left kidney and possibly also in the brain, lungs and prostate. The isolates were sensitive to ceftazidime, ciprofloxacin, chloramphenicol, gentamicin and sulfamethoxazole-trimethoprim but resistant to ampicillin. He responded well to 4 weeks of i.v. ceftazidime and i.v. amoxycillin-clavulanic acid. To our knowledge, such a multiorgan infection has not been reported previously for this organism.
Medical thoracoscopy has gain its popularity in Malaysia recently. This paper presents our early experience in thoracoscopy using semi-rigid fiberoptic thoracoscope. All thoracoscopy records since October 2006 were retrieved. The patients' records, thoracocentesis investigations results, thoracoscopic findings and all pleural biopsy results were reviewed. Twenty-four thoracoscopic procedures on 22 patients in whom two patients had repeated thoracoscopy. Ten patients were confirmed carcinoma. Eight patients had inconclusive thoracoscopic pleural biopsy results. Three patients underwent pleurodesis for malignant effusion. One patient had adhesiolysis for empyema. There was no procedure-related deaths or intraoperative accidents. Thoracoscopy is a relatively safe procedure.