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Fulltext Peripancreatic tuberculous lymphadenitis in an immunocompetent patient

Palaniappan S, Aizan H

Med J Malaysia, 2014 Aug;69(4):184-6.
PMID: 25500847 MyJurnal

Tuberculosis, an ancient disease continues to be a health care burden in Malaysia in the 21st century. Extrapulmonary tuberculosis is a less common presentation of tuberculosis and in particular peripancreatic tuberculous lymphadenitis is rarely seen. We report a case of a young immunocompetent boy presenting with a two month history of non productive chronic cough associated with loss of appetite and loss of weight. Investigations including CT Scan and Endoscopic ultrasound revealed multiple mediastinal lymphadenopathy and peripancreatic lymphadenopathy with central caseation necrosis. Histology of cervical lymph node was suggestive of tuberculosis and mycobacterium PCR was positive. The patient was subsequently treated with antituberculous therapy and had marked clinical improvement of his symptoms. This case outlines a rare presentation of a common disease and the application of newer investigative tools in making the diagnosis.
Fulltext A rare case of autoimmune hepatitis overlapping with autoimmune haemolytic anaemia and immune thrombocytopenic purpura in a male patient

Palaniappan S, Ramanaidu S

Med J Malaysia, 2012 Jun;67(3):326-8.
PMID: 23082427 MyJurnal
Ectopic tooth in the roof of the maxillary sinus

Elango S, Palaniappan SP

Ear Nose Throat J, 1991 Jun;70(6):365-6.
PMID: 1893885

Eruption of a tooth into a nonoral environs is rare. Ectopic eruption of the tooth into the nasal cavity and chin has been reported before. This is a report of an ectopic third molar tooth in the roof of the maxillary sinus, which has not, to our knowledge, been reported before.
Nasal manifestations of yaws

Elango S, Palaniappan SP

Ear Nose Throat J, 1989 Nov;68(11):870, 873-5.
PMID: 2612395

Yaws is an infectious, non-venereal disease of the tropical countries, which is caused by Treponema pertenue. Gangosa and goundou were seen commonly in cases of yaws in Africa, particularly in the early part of this century. After successful WHO mass treatment campaigns, these conditions are rarely seen now. A case of yaws with gangosa, goundou, and a nasopharyngeal carcinoma is presented here for its rarity.
Computational prediction of Mycoplasma hominis proteins targeting in nucleus of host cell and their implication in prostate cancer etiology

Khan S, Zakariah M, Palaniappan S

Tumour Biol., 2016 Aug;37(8):10805-13.
PMID: 26874727 DOI: 10.1007/s13277-016-4970-9

Cancer has long been assumed to be a genetic disease. However, recent evidence supports the enigmatic connection of bacterial infection with the growth and development of various types of cancers. The cause and mechanism of the growth and development of prostate cancer due to Mycoplasma hominis remain unclear. Prostate cancer cells are infected and colonized by enteroinvasive M. hominis, which controls several factors that can affect prostate cancer growth in susceptible persons. We investigated M. hominis proteins targeting the nucleus of host cells and their implications in prostate cancer etiology. Many vital processes are controlled in the nucleus, where the proteins targeting M. hominis may have various potential implications. A total of 29/563 M. hominis proteins were predicted to target the nucleus of host cells. These include numerous proteins with the capability to alter normal growth activities. In conclusion, our results emphasize that various proteins of M. hominis targeted the nucleus of host cells and were involved in prostate cancer etiology through different mechanisms and strategies.
Fulltext Inflammatory Bowel Disease-related Colorectal Cancer in the Asia-Pacific Region: Past, Present, and Future

Zhiqin W, Palaniappan S, Raja Ali RA

Intest Res, 2014 Jul;12(3):194-204.
PMID: 25349593 DOI: 10.5217/ir.2014.12.3.194

Patients with inflammatory bowel disease (IBD) are at an increased risk of developing colorectal cancer (CRC), and key contributing factors include chronic colonic inflammation and the extent and duration of disease. This increase in risk is more likely to result from chronic inflammation of the colonic mucosa than from any clearly defined genetic predisposition. However, globally, the true magnitude of this risk is debatable, since results from different studies are heterogeneous in terms of geographical and methodological variables. The prevalence of IBD-related CRC in the Asia-Pacific region ranges from 0.3% to 1.8% and a recent study found that the cumulative incidence of IBD-related CRC is comparable to that in Western countries. However, the CRC mortality rate in the Asia-Pacific region is on the rise compared with that in Western countries, and a few Asian countries show particularly rapid upward trends in CRC incidence. Although our understanding of the molecular and clinical basis for IBD-related CRC has improved substantially, our means of prevention, endoscopic surveillance, chemoprevention, and prophylactic surgery remain modest at best. Furthermore, published data on IBD-related CRC in the Asia-Pacific region is lacking, and this review addresses many aspects including epidemiology, natural history, etiopathogenesis, morphology, and biological behaviors of IBD-related CRC and sporadic CRC in the Asia-Pacific region. In this review, we will also discuss the risk factors for CRC in IBD patients, endoscopic technology screening, and surveillance programs and management strategies for IBD-related CRC.
The way we teach otolaryngology in an integrated problem-based curriculum

Elango S, Arumainayagam GC, Palaniappan SP

Med Teach, 1991;13(1):63-6.
PMID: 1865800

The University Science Malaysia, Penang, the third medical school in Malaysia, is following an integrated curriculum. In this curriculum, the students are taught the subject of otolaryngology from the second year of their course unlike the traditional schools where they are taught in the fourth or fifth year. This paper describes how otolaryngology is introduced in this integrated, problem-based curriculum.
Fulltext Oesophageal food bolus impaction

Elango S, Palaniappan SP, Lingam VS, George L

Singapore Med J, 1990 Dec;31(6):624-6.
PMID: 2281364

Impaction of food usually occurs in patients having obstructive lesions of the oesophagus. The food bolus impaction normally occurs in patients older than 60 years of age. Though food bolus impaction in the oesophagus is not uncommon, food bolus in the oesophagus causing complete obstruction resulting in total dysphagia is rare. This is a case report of a woman who had complete obstruction of the oesophagus following impaction by a piece of meat. The various treatment modalities available for such a condition are discussed.
Fulltext Prediction of mycoplasma hominis proteins targeting in mitochondria and cytoplasm of host cells and their implication in prostate cancer etiology

Khan S, Zakariah M, Rolfo C, Robrecht L, Palaniappan S

Oncotarget, 2017 May 09;8(19):30830-30843.
PMID: 27027344 DOI: 10.18632/oncotarget.8306

Although the idea of bacteria causing different types of cancer has exploded about century ago, the potential mechanisms of carcinogenesis is still not well established. Many reports showed the involvement of M. hominis in the development of prostate cancer, however, mechanistic approach for growth and development of prostate cancer has been poorly understood. In the current study, we predicted M. hominis proteins targeting in the mitochondria and cytoplasm of host cells and their implication in prostate cancer. A total of 77 and 320 proteins from M. hominis proteome were predicted to target in the mitochondria and cytoplasm of host cells respectively. In particular, various targeted proteins may interfere with normal growth behaviour of host cells, thereby altering the decision of programmed cell death. Furthermore, we investigated possible mechanisms of the mitochondrial and cytoplasmic targeted proteins of M. hominis in etiology of prostate cancer by screening the whole proteome.
Identification of NOD2/CARD15 mutations in Malaysian patients with Crohn's disease

Chua KH, Hilmi I, Ng CC, Eng TL, Palaniappan S, Lee WS, et al.

J Dig Dis, 2009 May;10(2):124-30.
PMID: 19426395 DOI: 10.1111/j.1751-2980.2009.00374.x

The NOD2/CARD15 gene has been identified as an important susceptibility gene for Crohn's disease (CD) but the three common disease predisposing mutations (DPM) found in developed countries have not been identified in Asian populations. The aim of our study was to look for the DPM in our multiracial population and to discover whether there were any differences in the three major ethnic groups; Malay, Chinese and Indian.
Vaccine-induced immune thrombocytopaenia purpura in autologous haematopoietic stem cell transplantation

Wan Jamaludin WF, Kok WH, Loong L, Palaniappan SK, Zakaria MZ, Ong TC, et al.

Med J Malaysia, 2018 12;73(6):430-432.
PMID: 30647224

Immune Thrombocytopenia Purpura (ITP) secondary to vaccinations is rare, especially after autologous hematopoietic stem cell transplantation (HSCT). A 31-yearold female received autologous HSCT for relapsed Hodgkin Disease, with platelet engraftment at Day+14. One week after receiving second scheduled vaccinations, she developed severe thrombocytopenia (3x109/L) associated with pharyngeal hematoma. Bone marrow (BM) examinations were consistent with ITP, possibly secondary to Influenza vaccine. Platelet increment was poor despite high dose corticosteroids, intravenous immunoglobulin (IVIG), Danazol and Eltrombopag. A repeated BM biopsy was in agreement with ITP. Re-treatment with tapering doses of prednisolone resulted in stable platelet counts at 120x109/L a year later.
Optic Nerve Infiltration in Systemic Metastatic Retinal Lymphoma (SMRL): Multimodal Imaging and Challenges in Diagnosis

Mohd Fauzi Yap MFB, Mohd Zain A, Tumain NR, Palaniappan S, Nasaruddin RA, Md Din N

Ocul Immunol Inflamm, 2020 Sep 24.
PMID: 32967510 DOI: 10.1080/09273948.2020.1800050

A 45-year-old man was diagnosed with diffuse large B-cell lymphoma stage IV which was confirmed by celiac lymph node biopsy. He subsequently completed six cycles of R-CHOP chemotherapy. Six months later, he presented with panuveitis OU with positive relative afferent pupillary defect OD. OCT revealed hyper-reflective lesions and irregularity of the retinal pigment epithelium OU. Fundus fluorescein angiogram shows hyper-auto fluorescence and granular changes on the retina. A month later, he developed swollen optic disc OD and hemorrhagic retinitis OU and treated as presumed CMV retinitis. Anti-TB was started after a positive Mantoux test. He finally consented for a vitreous biopsy which showed atypical lymphoid cells highly suggestive for vitreoretinal lymphoma and subsequently received intravitreal methotrexate OU.
CONCLUSION: Optic nerve infiltration in systemic metastatic retinal lymphoma may have initial occult signs but with profound visual loss. Ocular infections like CMV retinitis and tuberculosis may mask and delay the diagnosis in immunocompromised patients.
Fulltext User experience design in virtual reality medical training application

Sattar MU, Palaniappan S, Lokman A, Shah N, Riaz Z, Khalid U

J Pak Med Assoc, 2021 Jul;71(7):1730-1735.
PMID: 34410236 DOI: 10.5455/JPMA.22992

OBJECTIVE: To investigate the effects of design parameters on the user experience of virtual reality medical training.
Methods: The quantitative study was conducted at Punjab (Pakistan) from July 2018 to October 2018, and comprised final year students from eight medical colleges in Pakistan. Each respondent was given to experience laparoscopy operation in text, video and virtual reality-based learning methodologies. User experience and usefulness was assessed against a pre-validated scale and compared with the three learning methodologies.
RESULTS: Of the 87, students, 50(57.5%) were male and 37(42.5%) were female. The overall mean age was 22.5±4 years. Result of virtual reality was better than others (p<0.05). Data was analysed using SPSS 20.
CONCLUSIONS: Virtual reality-based learning provided better user experience than traditional learning methodologies.
Fulltext Effects of Virtual Reality training on medical students' learning motivation and competency

Sattar MU, Palaniappan S, Lokman A, Hassan A, Shah N, Riaz Z

Pak J Med Sci, 2019;35(3):852-857.
PMID: 31258607 DOI: 10.12669/pjms.35.3.44

Objectives: To determine the need of contemporary immersive approaches (Virtual Reality) in teaching and training at medical sector. The main objective of this study was to explore the effects of text, video and immersive technologies learning methodologies for participants' learning in public and private medical colleges and universities of Pakistan.
Methods: In this quantitative research 87 medical students of 4th year from three public and five private medical colleges and universities participated. A laparoscopy operation was selected in consultation with senior medical consultants for this experiment. The experimental material was arranged in virtual reality, video and text based learning. At completion of each of which, participants completed a questionnaire about learning motivation and learning competency through the different mediums.
Results: Statistical t-test was selected for the analysis of this study. By comparing the mean values of virtual reality, video, and text based learning methodologies in medical academics; result of virtual reality is at top of others. All performed model are statistically significant (P=0.000) and results can be applied at all population.
Conclusion: Through this research, we contribute to medical students learning methodologies. In medical studies, both theoretical and practical expertise has a vital role, while repetition of hands-on practice can improve young doctors' professional competency. Virtual reality was found best for medical students in both learning motivation and learning competency. Medical students and educationist may select virtual reality as new learning methodology for curriculum learning.
Fulltext Stroke thrombolysis at 5.5 hours based on computed tomography perfusion

Sahathevan R, Azmin S, Palaniappan S, Nafisah WY, Tan HJ, Norlinah MI, et al.

Malays J Med Sci, 2014 Mar;21(2):78-81.
PMID: 24876813 MyJurnal

A young man was admitted with sudden onset of right-sided weakness. He was assessed in the emergency department, and an immediate computed tomography (CT) perfusion study of the brain was arranged, which showed a left middle cerebral artery territory infarct with occlusion of the M1 segment. There was a significant penumbra measuring approximately 50% of the arterial territory. By the time his assessment was completed, it was 5.5 hours from the onset of symptoms. He was nonetheless administered intravenous recombinant tissue plasminogen activator (rtPA) based on the significant penumbra. He was discharged from the hospital after one week with significant residual deficit. At 2 months clinic follow-up, he showed almost complete recovery with a Modified Rankin Score of 1. We hope to demonstrate that a significant penumbra is an important determinant for good neurological recovery and outcome following stroke thrombolysis, even when patients present outside the 4.5 hours onset-to-treatment time window.
Fulltext Autologous mononuclear cells from different sources are seen to improve wound healing in patients with haematological malignancies

Wan Jamaludin WF, Mohamad Yusoff F, Ismail NA, Mohd Idris MR, Palaniappan S, Ng CKK, et al.

Malays J Pathol, 2018 Apr;40(1):61-67.
PMID: 29704386 MyJurnal

INTRODUCTION: Immunosuppressive state due to haematological malignancies and chemotherapy may cause disruption to wound healing despite optimum conventional treatment and standard wound dressing. Non-healing wounds are predisposed to infection whereas chemotherapy dose reductions or interruptions are associated with poor survival.
BACKGROUND: Mononuclear cells contain progenitor cells including haematopoietic and mesenchymal stem cells, endothelial progenitor cells and fibroblasts which facilitate wound healing through cytokines, growth factor secretions, cell-cell interactions and provision of extracellular matrix scaffolding. Clinical applications of autologous mononuclear cells therapy in wound healing in non-malignant patients with critical limb ischaemia have been reported with remarkable outcome.
METHODS: We report three patients with haematological malignancies undergoing chemotherapy, who received autologous mononuclear cells implantation to treat non-healing wound after optimum conventional wound care. The sources of mononuclear cells (MNC) were from bone marrow (BM), peripheral blood (PB) and mobilised PB cells (mPB-MNC) using granulocyte colony stimulating factor (G-CSF). The cells were directly implanted into wound and below epidermis. Wound sizes and adverse effects from implantation were assessed at regular intervals.
RESULTS: All patients achieved wound healing within three months following autologous mononuclear cells implantation. No implantation adverse effects were observed.
CONCLUSIONS: Autologous mononuclear cells therapy is a feasible alternative to conventional wound care to promote complete healing in non-healing wounds compounded by morbid factors such as haematological malignancies, chemotherapy, diabetes mellitus (DM), infections and prolonged immobility.
Fulltext Rare but Potentially Fatal Presentations of Diffuse Large B-cell Lymphoma: Leukemic Phase or Hemophagocytic Syndrome in Bone Marrow

Wan Mohd Zohdi WA, Ismail AZ, Yusof N, Ithnin A, Shuib S, Masir N, et al.

Clin Pathol, 2022 01 09;15:2632010X211070774.
PMID: 35036912 DOI: 10.1177/2632010X211070774

Diffuse large B-cell lymphoma (DLBCL) is a type of non-Hodgkin Lymphoma commonly presenting as a solid tumor either by nodal or extra-nodal manifestations. Here we describe two atypical presentations of lymphoma, finally resulting in the diagnosis of DLBCL. Case 1: A 53-year-old man with a previous history of nasopharyngeal carcinoma presented with a two-week history of B-symptoms and hyperleukocytosis. Peripheral blood film showed 78% abnormal mononuclear cells. Immunohistochemical stain showing Ki-67 of 90%, negative c-myc, BCL2 and BCL6, and negative c-MYC with fluorescence in-situ hybridization studies on the trephine biopsy, concluded the diagnosis of CD5+ DLBCL of ABC subtype. He received intravenous cyclophosphamide and oral prednisolone for cytoreduction, followed by 6 cycles of chemo-immunotherapy. However, he succumbed due to severe sepsis after the completion of therapy. Case 2: A 56-year-old lady who was initially investigated for pyrexia of unknown origin was noted to have hemophagocytosis upon bone marrow aspirate examination. The bone marrow trephine biopsy revealed some atypical clusters of B-cells positive for CD20 which was inconclusive. PET-CT scan noted an enlarged hypermetabolic spleen without lymphadenopathy. Splenic biopsy with immunohistochemical studies revealed DLBCL of ABC subtype. The diagnosis was consistent with primary splenic DLBCL. She became unwell post splenic biopsy and was admitted to the intensive care unit where she passed away 2 weeks later from Candida and Sternotrophomonas septicemia. These cases highlight the atypical presentations of a common subtype of NHL in our center. Arriving at the definitive diagnosis can be difficult especially when patients are acutely ill, hampering the necessary invasive procedures for diagnosis. The outcomes of both cases are briefly discussed hoping to spread awareness among clinicians on the rare and acutely critical presentations of DLBCL.

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