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Fulltext Intractable normal anion gap metabolic acidosis in a patient with diabetic ketoacidosis

Huan, Nai Chien, Wan Awatif Wan Mohd Zohdi

Borneo Journal of Medical Sciences, 2020;14(2):37-40.
MyJurnal

High anion gap metabolic acidosis (HAGMA) is a hallmark of Diabetic Ketoacidosis (DKA). Occasionally, a Normal Anion Gap Metabolic Acidosis (NAGMA) can be seen, especially during the treatment phase. In this case report, a 55-year-old lady with diabetes mellitus who presented with a 2-day history of fever, lethargy and multiple episodes of vomiting and diarrhoea. Initial laboratory investigations revealed: capillary blood glucose as 27 mmol/L, urine ketone as 3+, blood ketone as 3.5 mmol/L, serum bicarbonate as 14 mmol/L, and serum chloride as 95 mmol/L. She was treated with intravenous normal saline fluid resuscitation and constant rate insulin infusion which was fortunately accompanied by stabilization of blood glucose and normalization of blood ketone to 0.2 mmol/L. However, despite normalization of her anion gap (25 to 14), she remained unwell with acidotic breathing due to refractory hyperchloraemic NAGMA with bicarbonate at 11 mol/L and chloride of 112 mmol/L. It was then decided to administer 100 mL of 8.4% Sodium Bicarbonate solution. The next day, she was no longer tachypneic as her bicarbonate and carbon dioxide improved to 21 mmol/L and 32 mmHg respectively. The presence of NAGMA in DKA should prompt clinicians to conduct a thorough search for possible underlying causes, such as gastrointestinal fluid loss, sepsis and chloride load from aggressive fluid resuscitation with normal saline. Sodium bicarbonate should only be considered in intractable cases to correct a NAGMA and not routinely used in the treatment of DKA.
Fulltext Dandy-walker syndrome in a child at rural Kelantan, Malaysia

Low, Qin Jia, Huan, Nai Chien, Tan, Wei Lun

Borneo Journal of Medical Sciences, 2018;12(2):41-45.
MyJurnal

Dandy-Walker syndrome is a rare congenital malformation of the brain that involves the cerebellum and the fourth ventricle. It is characterised by a classical triad of hydrocephalus, cystic dilatation of the fourth ventricle and complete or partial agenesis of the vermis. Majority of cases are diagnosed during neonatal or early infantile period. In this case report, a seven-year-old boy complained of recurrent headaches for the past one year. Physical examination was unremarkable. Examination of the fundus on the same day revealed bilateral papilloedema. His subsequent computed tomography scan of the brain done at a major district hospital demonstrated features in keeping with Dandy-Walker malformation. Our case highlighted the importance of embarking on a detailed and thorough approach when dealing with a child with chronic headache, especially in rural settings where advanced medical equipment is not readily available.
Inverse Gottron's Sign in A Patient With Anti-MDA5 Associated Dermatomyositis With Rapidly Progressive Interstitial Lung Disease

Lee HJ, Feng A, Huan NC

Am J Med Sci, 2021 10;362(4):e35.
PMID: 33582154 DOI: 10.1016/j.amjms.2021.02.008
Pneumothorax: Classification and Etiology

Huan NC, Sidhu C, Thomas R

Clin Chest Med, 2021 12;42(4):711-727.
PMID: 34774177 DOI: 10.1016/j.ccm.2021.08.007

Pneumothorax is a common problem worldwide. Pneumothorax develops secondary to diverse aetiologies; in many cases, there may be no recognizable lung abnormality. The pathogenetic mechanism(s) causing spontaneous pneumothorax may be related to an interplay between lung-related abnormalities and environmental factors such as smoking. Tobacco smoking is a major risk factor for primary spontaneous pneumothorax; chronic obstructive pulmonary disease is most frequently associated with secondary spontaneous pneumothorax. This review article provides an overview of the historical perspective, epidemiology, classification, and aetiology of pneumothorax. It also aims to highlight current knowledge and understanding of underlying risks and pathophysiological mechanisms in pneumothorax development.
Fulltext Diagnostic Accuracy of Lactate Dehydrogenase/Adenosine Deaminase Ratio in Differentiating Tuberculous and Parapneumonic Effusions: A Systematic Review

Nyanti LE, Rahim MAA, Huan NC

Tuberc Respir Dis (Seoul), 2024 Jan;87(1):91-99.
PMID: 37726943 DOI: 10.4046/trd.2023.0107

BACKGROUND: Tuberculous pleural effusion (TPE) and parapneumonic effusion (PPE) are often difficult to differentiate owing to the overlapping clinical features. Observational studies demonstrate that the ratio of lactate dehydrogenase to adenosine deaminase (LDH/ADA) is lower in TPE compared to PPE, but integrated analysis is warranted.
METHODS: We conducted a systematic review to evaluate the diagnostic accuracy of the LDH/ADA ratio in differentiating TPE and PPE. We explored the PubMed and Scopus databases for studies evaluating the LDH/ADA ratio in differentiating TPE and PPE.
RESULTS: From a yield of 110 studies, five were included for systematic review. The cutoff value for the LDH/ADA ratio in TPE ranged from <14.2 to <25. The studies demonstrated high heterogeneity, precluding meta-analysis. Quality Assessment of Diagnostic Accuracy Studies Tool 2 assessment revealed a high risk of bias in terms of patient selection and index test.
CONCLUSION: LDH/ADA ratio is a potentially useful parameter to differentiate between TPE and PPE. Based on the limited data, we recommend an LDH/ADA ratio cutoff value of <15 in differentiating TPE and PPE. However, more rigorous studies are needed to further validate this recommendation.
Fulltext Management of extensive subcutaneous emphysema using negative pressure wound therapy dressings

Huan NC, Mohamed Arifin N, Khoo TS, Lai YC

Respirol Case Rep, 2020 Apr;8(3):e00544.
PMID: 32128215 DOI: 10.1002/rcr2.544

Subcutaneous emphysema (SE) is a common but usually self-limiting complication of cardiothoracic procedures. Rarely, it can be life threatening and is characterized by extensive cutaneous tension and airway compromise requiring immediate intervention. There is a paucity of data on the most efficacious treatment methods for extensive SE. We report an 80-year-old gentleman who developed massive SE necessitating intubation for airway protection following a right chest tube insertion for spontaneous secondary pneumothorax. His SE persisted despite adequate thoracic drainage via a new chest tube. It was then decided to insert two negative pressure wound therapy dressings (NPWTD) or vacuum dressings in the patient's subcutaneous tissue layer via incisions made at anterior chest wall. The dressings were removed after four days in view of significant improvements. NPWTD appears to be an effective, well-tolerated, safe, and inexpensive approach that hastens the resolution of SE without the need for invasive thoracic surgeries.
Fulltext Pleural fluid milkshakes: three cases with different aetiologies

Huan NC, Tan HA, Ramarmuty HY, Ponnuvelu S, Letcheminan S, Sivaraman Kannan KK

Respirol Case Rep, 2023 Apr;11(4):e01116.
PMID: 36910134 DOI: 10.1002/rcr2.1116

In clinical practice, chylothorax is usually suspected in any patient with milky pleural fluid. However, contrary to popular belief, milky appearance of pleural fluid is seen in less than half of patients with chylothorax. A high index of suspicion for chylothorax is therefore needed in any turbid, bloody, or serosanguinous effusions of unclear aetiology. In this case series, we present three patients with biochemically proven chylothorax: each with a different presentation, pleural fluid appearance, underlying cause, management strategy and clinical outcome. The first patient developed 'milky' chylothorax secondary to lymphoma while the second patient's 'yellow' chylothorax is related to pleural tuberculosis. The final patient suffered from 'pink' chylothorax in the setting of systemic amyloidosis. In each of the cases, prompt diagnosis of chylothorax followed by efforts to elucidate the underlying cause are crucial steps to guide subsequent management with the main aim to ensure a better clinical outcome.
Pulmonary extra-nodal mucosa-associated lymphoid tissue (MALT) lymphoma: A rare cause of persistent lung consolidation

Kou L, Huan NC, Nyanti LE, Chin JS, Mohamad NB, Ramarmuty HY

Respirol Case Rep, 2023 Aug;11(8):e01197.
PMID: 37501686 DOI: 10.1002/rcr2.1197

Pulmonary extra-nodal marginal zone B-cell lymphoma, also known as extra-nodal mucosa-associated lymphoid tissue (MALT) lymphoma, is rare among all non-Hodgkin lymphomas and generally among all pulmonary malignancies. We present a 46-year-old lady with persistent right lower lung consolidation despite earlier treatment efforts with intravenous antibiotics for community acquired pneumonia. Apart from initial presentation with a short 3-day history of fever, cough and shortness of breath, she had remained largely asymptomatic throughout the follow-up period. Flexible bronchoscopy done ruled out infectious aetiologies but transbronchial lung biopsies showed atypical lymphocytes. A computed tomography guided core biopsy of her right lung consolidation was subsequently performed, confirming a diagnosis of pulmonary MALT lymphoma. She was promptly referred to the haematology team for further management and commencement of chemotherapy. Pulmonary MALT lymphoma, albeit uncommon and often follows a relatively indolent cause, should be considered as a differential diagnosis among patients with persistent lung consolidation.
Fulltext Utilizing medical thoracoscopy for the diagnosis of myelomatous pleural effusion: 2 case reports

Ng KL, Tan SN, Huan NC, Nasaruddin MZ, Othman N, Rahaman JAA

Respirol Case Rep, 2024 Mar;12(3):e01333.
PMID: 38528948 DOI: 10.1002/rcr2.1333

Multiple myeloma (MM) is characterized by neoplastic proliferation of monoclonal antibody producing plasma cells. In clinical practice, pleural effusion is seen in up to 6% of MM patients, with many causative factors. Nevertheless, true myelomatous pleural effusion, defined as infiltration of the pleura by myeloma cells, is very rare. In this case report, we present two patients with biopsy proven myelomatous pleural effusion. The first patient developed myelomatous pleural effusion as initial presentation while the second patient's pleural effusion occurred during disease relapse. In both cases, prompt diagnosis via medical thoracoscopy (MT) followed by early commencement of myeloma specific chemotherapy led to clinical, biochemical, and radiological resolution and therefore were crucial steps in the management of myelomatous pleural effusion.
Fulltext Pulmonary mucormycosis masquerading as endobronchial tumour in an immunocompetent pregnant young lady

Ng KL, Huan NC, Nasaruddin MZ, Muhammad NA, Daut UN, Abdul Rahaman JA

Respirol Case Rep, 2021 Feb;9(2):e00704.
PMID: 33364028 DOI: 10.1002/rcr2.704

Pulmonary mucormycosis is a rare but rapidly progressing and life-threatening fungal infection, usually affecting immunocompromised patients. We report a case of a previously healthy young lady who presented with prolonged cough, weight loss, and haemoptysis. Imaging showed left hilar mass with infiltration into the left main bronchus and concurrent mediastinal lymphadenopathy. Flexible bronchoscopy revealed an endobronchial mass occluding the left main bronchus. Tumour debulking was performed using rigid bronchoscopy with cryoprobe and snares. Histopathological examination revealed inflamed tissue with fungal organism. Fungal polymerase chain reaction (PCR) confirmed Rhizopus microsporus. She was treated with two weeks of intravenous amphotericin-B with complete clinical and radiological resolution.
Fulltext Conservative management of airway tear as a complication of silicone endobronchial stenting in bronchomalacia secondary to endobronchial tuberculosis

Huan NC, Ng KL, Nasaruddin MZ, Muhammad NA, Daut UN, Abdul Rahaman JA

Respirol Case Rep, 2020 Dec;8(9):e00684.
PMID: 33194207 DOI: 10.1002/rcr2.684

Tracheobronchial stenosis due to tuberculosis (TSTB) is a potentially debilitating complication of endobronchial tuberculosis (EBTB). Endobronchial interventions including silicone stent insertion is an acceptable approach to improve quality of life among patients with TSTB. However, little is known about the optimal management strategy for patients with bronchomalacia secondary to EBTB (B-EBTB) and whether stent-related complication rates are higher among this group of patients. Herein, we report two patients with B-EBTB who unfortunately developed bronchial tear related to silicone endobronchial stenting. Both patients were successfully managed conservatively without the need for emergency open surgery. We hypothesize that endobronchial intervention might be more beneficial for patients with pure TSTB and might be riskier in cases of bronchomalacia with reduced airway thickness and loss of airway cartilaginous support. More future studies are needed to bridge the current gap in knowledge regarding the optimal management and role of endobronchial interventions among patients with B-EBTB.
Fulltext Topical mitomycin-C as an adjuvant to multimodal endoscopic treatment for tracheobronchial stenosis secondary to endobronchial tuberculosis

Huan NC, Ng KL, Nasaruddin MZ, Muhammad NA, Daut UN, Abdul Rahaman JA

Respirol Case Rep, 2021 Mar;9(3):e00711.
PMID: 33532074 DOI: 10.1002/rcr2.711

Tracheobronchial stenosis secondary to endobronchial tuberculosis (TSTB) is a rare but debilitating complication of endobronchial tuberculosis (EBTB). Topical mitomycin-C (TMC) has been successfully utilized to restore airway patency and to prevent recurrence of TSTB, although little is known about its exact efficacy. Here, we report the biggest case series to date involving seven patients who received TMC as part of multimodality endoscopic treatment for TSTB with varying levels of success. All patients presented with dyspnoea during or after treatment completion for pulmonary tuberculosis (PTB). Four patients had short-segment concentric membranous TSTB while two patients had concurrent bronchomalacia. Another one patient had a thick fibrotic band adjacent to luminal opening. We hypothesize that TMC is more efficacious in short membranous stenosis without concurrent bronchomalacia and/or thick fibrotic bands. More studies are needed to bridge the current gaps in knowledge regarding the optimal role and benefits of TMC for TSTB patients.
Fulltext The utility of endobronchial ultrasound-guided transbronchial mediastinal cryobiopsy (EBUS-TBMC) for the diagnosis of mediastinal lymphoma

Huan NC, Lee WL, Ramarmuty HY, Nyanti LE, Tsen MSL, Yunus D

Respirol Case Rep, 2024 Apr;12(4):e01342.
PMID: 38576853 DOI: 10.1002/rcr2.1342

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a revolutionary tool for the diagnosis and staging of mediastinal disorders. Nevertheless, its diagnostic capability is reduced in certain disorders such as lymphoproliferative diseases. EBUS-guided transbronchial mediastinal cryobiopsy (EBUS-TBMC) is a novel technique that can provide larger samples with preserved tissue architecture, with an acceptable safety profile. In this case report, we present a middle-aged gentleman with a huge anterior mediastinal mass and bilateral mediastinal and hilar lymphadenopathy. He underwent EBUS-TBNA with rapid on-site evaluation (ROSE) followed by EBUS-TBMC, all under general anaesthesia. Histopathological analysis showed discordance between EBUS-TBNA and EBUS-TBMC in which only TBMC samples provided adequate tissue to attain a diagnosis of primary mediastinal large B-cell lymphoma. This case report reinforced the diagnostic role of EBUS-TBMC in the diagnosis of lymphoproliferative diseases.
Multiple intrathoracic extramedullary haematopoiesis as visualised on medical thoracoscopy

Lee JH, Nyanti LE, Huan NC, Ramarmuty HY, Sivaraman Kannan KK

Thorax, 2024 Jul 05.
PMID: 38969502 DOI: 10.1136/thorax-2024-221593
Fulltext Interventional Pulmonology and COVID-19: Experience from a Malaysian Tertiary Hospital

Huan NC, Ng KL, Tang JT, Kua HN, Daut UN, Muhammad NA, et al.

Ann Acad Med Singap, 2020 12;49(12):1013-1017.
PMID: 33463660 DOI: 10.47102/annals-acadmedsg.2020364

The ongoing pandemic of COVID-19 has presented multiple challenges to global healthcare services, dictating changes in almost every aspect of daily medical practice. Performing aerosol generating procedures (AGPs) in the field of interventional pulmonology can lead to profound formation of aerosols, leading to a high risk of infection among healthcare workers (HCWs). We share our experiences on performing AGPs in the midst of a COVID-19 pandemic by focusing on changes in AGP practices. In a pandemic, HCWs ought to adapt to the ever-changing situation and use available resources to provide the best possible healthcare to patients, ensure safety of staff, and continue medical education of future pulmonologists.
Fulltext Early experience of endobronchial ultrasound-guided transbronchial nodal cryobiopsy: a case series from Sabah, Malaysia

Ramarmuty HY, Huan NC, Nyanti LE, Khoo TS, Renganathan T, Manoh AZ, et al.

Ther Adv Respir Dis, 2024;18:17534666241231122.
PMID: 38357899 DOI: 10.1177/17534666241231122

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an established minimally invasive method for the diagnosis of benign and malignant conditions. Continuous efforts are underway to improve the material adequacy of EBUS-TBNA, including the introduction of a new technique called EBUS-guided transbronchial nodal cryobiopsy (EBUS-TBNC). This method allows for the retrieval of larger and well-preserved histologic samples from the mediastinum. We present a case series of four patients who underwent combined EBUS-TBNA and EBUS-TBNC procedures in our centre. All procedures were performed under general anaesthesia using a convex probe EBUS scope (Pentax EB-1970UK). Two patients were diagnosed with malignancy and two with benign disorders (silicosis and tuberculosis). In the malignant cases, both EBUS-TBNA/cell block and cryobiopsy provided a diagnosis but cryobiopsy yielded more material for ancillary tests in one patient. However, in the benign cases, there was discordance between EBUS-TBNA/cell block and cryobiopsy. Only cryobiopsy detected granuloma in the patient with TB (tuberculosis), and in the patient with silicosis, TBNC provided a better overall histological evaluation, leading to a definitive diagnosis. No complications were observed. This case series supports the potential diagnostic value of combining EBUS-TBNA and EBUS-TBNC, particularly in benign mediastinal lesions (granulomatous diseases), and in cases requiring additional molecular tests in cancer diagnosis.
Fulltext An explorative analysis on the optimal cryo-passes and freezing time of the ultrathin cryoprobe in endobronchial ultrasound-guided transbronchial mediastinal cryobiopsy

Kho SS, Tan SH, Soo CI, Ramarmuty HYD, Chai CS, Huan NC, et al.

Sci Rep, 2024 Aug 12;14(1):18653.
PMID: 39134712 DOI: 10.1038/s41598-024-69702-y

EBUS-guided transbronchial mediastinal cryobiopsy (TBMC) has emerged as a promising biopsy tool for diagnosing hilar and mediastinal pathologies. However, several fundamental technical aspects of TBMC remain unexplored. This study aims to determine the optimal number of cryo-passes and freezing time of the ultrathin cryoprobe in EBUS-TBMC concerning specimen size and procedural diagnostic yield. We conducted a retrospective chart review of patients with mediastinal and hilar lesions who underwent EBUS-TBMC between January 2021 and April 2023 across three hospitals in Malaysia. A total of 129 EBUS-TBMC procedures were successfully completed, achieving an overall diagnostic yield of 88.4%. Conclusive TBMC procedures were associated with larger specimen sizes (7.0 vs. 5.0 mm, p
Fulltext Determinants of Willingness to Undergo Lung Cancer Screening among High-Risk Current and Ex-smokers in Sabah, Malaysia: A Cross-Sectional Pilot Study

Nyanti LE, Chua CZ, Loo HC, Khor CZ, Toh ESY, Gill RS, et al.

Tuberc Respir Dis (Seoul), 2023 Oct;86(4):284-293.
PMID: 37643812 DOI: 10.4046/trd.2023.0051

BACKGROUND: Attitudes towards smoking, lung cancer screening, and perceived risk of lung cancer have not been widely studied in Malaysia. The primary objective of this study was to describe the factors affecting the willingness of high-risk current smokers and ex-smokers to undergo low-dose computed tomography (LDCT) screening for lung cancer.
METHODS: A prospective, cross-sectional questionnaire study was conducted in current smokers or ex-smokers aged between 55 and 80 years at three hospitals in Kota Kinabalu, Sabah, Malaysia. The questionnaire recorded the following parameters: perceived lung cancer risk; Prostate Lung Colon Ovarian Cancer 2012 risk prediction model excluding race and ethnicity predictor (PLCOm2012norace); demographic characteristics; psychosocial characteristics; and attitudes towards lung cancer and lung cancer screening.
RESULTS: A vast majority of the 95 respondents (94.7%) indicated their willingness to undergo screening. Stigma of lung cancer, low levels of knowledge about lung cancer symptoms, concerns about financial constraints, and a preference for traditional medication were still prevalent among the respondents, and they may represent potential barriers to lung cancer screening uptake. A desire to have an early diagnosis (odds ratio [OR], 11.33; 95% confidence interval [CI], 1.53 to 84.05; p=0.02), perceived time constraints (OR, 3.94; 95% CI, 1.32 to 11.73; p=0.01), and proximity of LDCT screening facilities (OR, 14.33; 95% CI, 1.84 to 111.4; p=0.01) had significantly higher odds of willingness to undergo screening.
CONCLUSION: Although high-risk current smokers and ex-smokers are likely to undergo screening for lung cancer, several psychosocial barriers persist. The results of this study may guide the policymakers and clinicians regarding the need to improve lung cancer awareness in our population.

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