MyMedR

Thrombotic Thrombocytopenic Purpura in Dengue Fever

Tee TY, Cader RA

Acta Med Indones, 2021 Apr;53(2):208-212.

Thrombotic thrombocytopenic purpura is a rare but life threatening medical condition. Early recognition and treatment of thrombotic thrombocytopenic purpura is important especially in patients who do not present with the classic pentad to reduce the high mortality. Herein, we describe a case of a patient who does not fulfil the classic pentad features thrombotic thrombocytopenic purpura that was induced by dengue fever. The patients' initial full blood picture did not have all the typical features of microangiopathic haemolytic anaemia but there were fragmented red blood cells. However, even a small number of fragmented red blood cells in the peripheral blood should alert physicians of the possible diagnosis of thrombotic thrombocytopenic purpura together with other symptoms. Furthermore, signs and symptoms of thrombotic thrombocytopenic purpura and dengue fever can overlap such as fever, thrombocytopenia, neurological deficit mimicking dengue encephalopathy and dengue induced acute kidney injury.

Fulltext Prominent Oromandibular Dystonia as Levodopa-induced Dyskinesia in Idiopathic Parkinson's Disease

Tee TY, Khoo CS, Norlinah MI

Mov Disord Clin Pract, 2019 Apr;6(4):330-331.

PMID: 31061844 DOI: 10.1002/mdc3.12759

Teaching NeuroImages: Neuroimaging in hemiplegic migraine

Tee TY, Khoo CS, Raymond AA, Syazarina SO

Neurology, 2019 08 06;93(6):e626-e627.

PMID: 31383811 DOI: 10.1212/WNL.0000000000007905

Fulltext A Treatable Encephalopathy in a Peritoneal Dialysis Patient - Cefepime-Induced Encephalopathy

Khoo CS, Tee TY, Tan HJ, Ali RA

J Neurosci Rural Pract, 2019 4 20;10(2):324-326.

PMID: 31001027 DOI: 10.4103/jnrp.jnrp_315_18

We report a patient with end-stage renal disease on peritoneal dialysis, who developed encephalopathy after receiving a few doses of cefepime. He recovered clinically and electroencephalographically after having discontinued the culprit agent and undergone hemodialysis. This case highlights the importance of promptly recognizing this reversible encephalopathy, which can lead to the avoidance of unnecessary workup, reduce the length of hospital stay, and thereby improve the patients' outcome.

Fulltext A rare extrapyramidal manifestation in a patient with primary central nervous system lymphoma

Tee TY, Khoo CS, Ibrahim NM, Osman SS

Neurol India, 2019 3 13;67(1):297-299.

PMID: 30860142 DOI: 10.4103/0028-3886.253620

Proteomic analysis of Moroccan cobra Naja haje legionis venom using tandem mass spectrometry

Malih I, Ahmad rusmili MR, Tee TY, Saile R, Ghalim N, Othman I

J Proteomics, 2014 Jan 16;96:240-52.

PMID: 24269350 DOI: 10.1016/j.jprot.2013.11.012

The proteome of the venom of Naja haje legionis, the only medically important elapid species in Morocco, has been elucidated by using a combination of proteomic techniques that includes size exclusion chromatography, reverse-phase HPLC, Tricine/SDS-Page, tryptic digestion, Q-TOF tandem mass spectrometry and database search. The sequence analysis of venom fractions revealed a highly complex venom proteome which counts a total of 76 proteins identified from database that can be assigned into 9 proteins families. We report the identification of: cobra venom factor (CVF), l-amino-acid oxidases (LAAO), acetylcholinesterase (AChE), snake venom metalloproteinases (SVMP), cysteine rich secretory proteins (CRISP), venom nerve growth factor (vNGF), phospholipases A2 (PLA2), vespryns, kunitz-type inhibitor, short neurotoxins, long neurotoxins, weak neurotoxins, neurotoxin like proteins, muscarinic toxins, cardiotoxins and cytotoxins. Comparison of these proteins showed high sequence homology with proteins from other African and Asian cobras. Further works are needed to assess the contribution of individual toxins in venom toxicity.

Isolation and characterization of α-elapitoxin-Bf1b, a postsynaptic neurotoxin from Malaysian Bungarus fasciatus venom

Rusmili MR, Tee TY, Mustafa MR, Othman I, Hodgson WC

Biochem Pharmacol, 2014 Mar 15;88(2):229-36.

PMID: 24440452 DOI: 10.1016/j.bcp.2014.01.004

Bungarus fasciatus is one of three species of krait found in Malaysia. Envenoming by B. fasciatus results in neurotoxicity due to the presence of presynaptic and postsynaptic neurotoxins. Antivenom, either monovalent or polyvalent, is the treatment of choice in systemically envenomed patients. In this study, we have isolated a postsynaptic neurotoxin which we named α-elapitoxin-Bf1b. This toxin has an approximate molecular weight of 6.9 kDa, with LCMS/MS data showing that it is highly homologous with Neurotoxin 3FTx-RI, a toxin identified in the Bungarus fasciatus venom gland transcriptome. α-Elapitoxin-Bf1b also shared similarity with short-chain neurotoxins from Laticauda colubrina and Pseudechis australis. α-Elapitoxin-Bf1b produced concentration- and time-dependent neurotoxicity in the indirectly-stimulated chick biventer cervicis muscle preparation, an effect partially reversible by repetitive washing of the preparation. The pA2 value for α-elapitoxin-Bf1b of 9.17 ± 0.64, determined by examining the effects of the toxin on cumulative carbacol concentration-response curves, indicated that the toxin is more potent than tubocurarine and α-bungarotoxin. Pre-incubation of Bungarus fasciatus monovalent and neuro polyvalent antivenom failed to prevent the neurotoxic effects of α-elapitoxin-Bf1b in the chick biventer cervicis muscle preparation. In conclusion, the isolation of a postsynaptic neurotoxin that cannot be neutralized by either monovalent and polyvalent antivenoms may indicate the presence of isoforms of postsynaptic neurotoxins in Malaysian B. fasciatus venom.

Fulltext Myasthenia gravis and premature ovarian failure - a causal link

Mohamed Arifin N, Khoo CS, Leong D, Tee TY, Tan HJ

Neurol Neurochir Pol, 2021;55(2):233-235.

PMID: 33555605 DOI: 10.5603/PJNNS.a2021.0015

A case series of super-refractory status epilepticus successfully treated with electroconvulsive therapy

Tan HJ, Tee TY, Husin M, Khoo CS, Woon LS

Epileptic Disord, 2020 Dec 01;22(6):828-833.

PMID: 33337333 DOI: 10.1684/epd.2020.1233

Super-refractory status epilepticus (SRSE) is a neurocritical emergency, associated with significant morbidity and mortality. The precise pathophysiology is still not completely understood. The likelihood of spontaneous seizure termination reduces with time, and it is of paramount importance to abort status in order to prevent permanent long-term neurological sequelae and death. A few neuroprotective strategies, such as general anaesthesia, steroids, ketogenic diet and hypothermia, have been used to treat SRSE, however, the clinical outcome remains inconclusive. We herein present two cases of SRSE, which were successfully treated with electroconvulsive therapy (ECT) after failing all pharmacological measures.

Fulltext Acute Encephalitis Associated with SARS-CoV-2 Confirmed in Cerebrospinal Fluid: First Case in Malaysia

Tee TY, Thabit AAM, Khoo CS, Shahrom HM, Chan EZ, Marzukie MM, et al.

J Clin Neurol, 2021 Jul;17(3):490-492.

PMID: 34184463 DOI: 10.3988/jcn.2021.17.3.490

Fulltext A Non-severe Coronavirus Disease 2019 Patient With Persistently High Interleukin-6 Level

Hambali NL, Mohd Noh M, Paramasivam S, Chua TH, Hayati F, Payus AO, et al.

Front Public Health, 2020;8:584552.

PMID: 33304877 DOI: 10.3389/fpubh.2020.584552

Interleukin 6 (IL-6) is one of the markers of immune system activation indicating existent infection and inflammation. We present here a case of a 55-year-old male COVID-19 patient with an unusual high level of interleukin 6 (IL-6). Further investigation revealed he had hepatocellular carcinoma (HCC) with underlying hepatitis B. He did not present with respiratory symptoms although a baseline chest x-ray showed changes, and the patient was categorized as Class 3A of COVID-19. Routine investigations proceeded with high-resolution computed tomography and IL-6 to monitor for progression to severe COVID-19. Notably, there was a high IL-6 level but other parameters did not show he was in severe COVID-19. In this report, we conclude that elevated IL-6 level in a COVID-19 patient is not necessarily associated with severe COVID-19.

Efficacy of Early Treatment with Favipiravir on Disease Progression among High Risk COVID-19 Patients: A Randomized, Open-Label Clinical Trial

Chuah CH, Chow TS, Hor CP, Cheng JT, Ker HB, Lee HG, et al.

Clin Infect Dis, 2021 Nov 19.

PMID: 34849615 DOI: 10.1093/cid/ciab962

BACKGROUND: Role of favipiravir in preventing disease progression in COVID-19 remains uncertain. We aimed to determine its effect in preventing disease progression from non-hypoxia to hypoxia among high risk COVID-19 patients.

STUDY DESIGN: This was an open-label, randomized clinical trial conducted at 14 public hospitals across Malaysia from February to June 2021 among 500 symptomatic, RT-PCR confirmed COVID-19 patients, aged ≥50 years with ≥1 co-morbidity, and hospitalized within first 7 days of illness. Patients were randomized on 1:1 ratio to favipiravir plus standard care or standard care alone. Favipiravir was administered at 1800mg twice-daily on day 1 followed by 800mg twice-daily until day 5. The primary endpoint was rate of clinical progression from non-hypoxia to hypoxia. Secondary outcomes included rates of mechanical ventilation, intensive care unit (ICU) admission, and in-hospital mortality.

RESULTS: Among 500 patients were randomized (mean age, 62.5 [SD 8.0] years; 258 women [51.6%]; and 251 [50.2%] had COVID-19 pneumonia), 487 (97.4%) patients completed the trial. Clinical progression to hypoxia occurred in 46 (18.4%) patients on favipiravir plus standard care and 37 (14.8%) on standard care alone (OR 1.30; 95%CI, 0.81-2.09; P=.28). All three pre-specified secondary end points were similar between both groups. Mechanical ventilation occurred in 6 (2.4%) vs 5 (2.0%) (OR 1.20; 95%CI, 0.36-4.23; P=.76), ICU admission in 13 (5.2%) vs 12 (4.8%) (OR 1.09; 95%CI, 0.48-2.47; P=.84), and in-hospital mortality in 5 (2.0%) vs 0 (OR 12.54; 95%CI, 0.76- 207.84; P=.08).

CONCLUSIONS: Among COVID-19 patients at high risk of disease progression, early treatment with oral favipiravir did not prevent their disease progression from non-hypoxia to hypoxia.

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