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Unilateral hemihyperhidrosis in a stroke patient and literature review on its clinicoanatomical correlation

May, Honey Ohn, Khin, Maung Ohn, Khin, Nyein Yin, Teh, Yong Guang, Ng, Pey Luen, Chin, Li Bing

Borneo Journal of Medical Sciences, 2020;14(2):41-47.
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Contralateral hyperhidrosis from the cardiovascular accident has been infrequently described in the stroke literature. The clinical significance and pathogenesis are yet well understood. This is a case of a 60-year-old man who developed excessive sweating of the paralyzed side with a pure division along the midline of the body secondary to a subcortical stroke, which region is supplied by branches of middle cerebral artery territory known as deep perforating lenticulostriate. To the best of our knowledge, a precise clinicoanatomic correlation between hyperhidrosis and subcortical stroke has not been widely reported. In this review, we summarize the existing literature of post-stroke hyperhidrosis to evaluate the correlation between clinical manifestation and its neuroanatomical location. According to the location of the infarction and clinical features, it can be concluded that both tracks en route through the ipsilateral internal capsule, after originating in the opercular cortex before crossing the brain stem and terminal connections with the contralateral thoracic spinal cord. Therefore, the phenomenon of hyperhidrosis in anterior circulation stroke might be postulated as due to the disruption of the sympathoinhibitory pathway that controls sweat glands, similarly like posterior circulation stroke.
Fulltext Heterotopic ossification in stroke is not that rare: lesson from rehabilitation standpoint

Fatimah Ahmedy, Nurul Diyanah Zenian, Wan Juhaini Paizi, Teh Yong Guang, Khin Nyein Yin, D. Maryama Ag Daud, et al.

Malaysian Journal of Medicine and Health Sciences, 2019;15(106):71-71.
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Introduction:Stroke is a major public health concern and treating its complications is important for functional recov-ery. Heterotopic ossification (HO), a condition where bone is developed in non-skeletal tissue, is not an uncommon stroke-related complication with reported occurrence up to 12%. It typically presents with joint range of motion (ROM) limitation, pain and swelling. Detecting HO is important to prevent forceful joint manipulation during reha-bilitation that can cause pain and fracture. Two cases of diagnosing HO during the course of stroke rehabilitation are presented. Case description: First case was a subacute stroke in 25 year-old male with right-sided hemiparesis and right hip joint ROM limitation. He did not consent to have passive ROM exercise and refused to be seated due to severe right hip pain. Second case was a 41 year-old male with chronic right-sided hemiparetic stroke exhibiting ipsilateral lower limb neurological recovery but inability to perform bed mobility and walking despite regaining motor function. The right hip joint ROM was limited in the absence of pain. Radiographs demonstrated presence of HO in the affected hip of both patients. Gentle hip ROM exercise was prescribed and noted improvement in ROM with subsequent ability for sitting (first case) and short-distance ambulation (second case). Conclusion: HO should be considered as a differential diagnosis in stroke patients having limited ROM, hence the importance of thorough physical examination. Presence of HO would guide rehabilitation process by encouraging gentle ROM exercise in the attempt to reduce public health burden from halted functional recovery in stroke.
Fulltext Case report: Ballotable abdominal mass in a child - Definitely renal in origin?

Lim GT, Teh YG, Ng CY, Mohd Khalid H, Hayati F

Ann Med Surg (Lond), 2021 Feb;62:84-87.
PMID: 33505677 DOI: 10.1016/j.amsu.2021.01.003

Introduction and importance: The differential diagnosis of a paediatric abdominal mass can be extensive, as it potentially involves multiple organs including gastrointestinal, genitourinary, endocrine, and gynaecological systems. Hence, a systematic approach to history taking and physical examination is needed to clinch the diagnosis. Specifically, the approach for assessing, investigating, and managing a ballotable left hypochondrial mass in a child can be challenging.
Case presentation: We report a 10-year-old Dusun girl presenting with left hypochondrial pain and noted a left hypochondrial mass on examination. This report highlights the role of clinical imaging during the pre-operative and post-operative phases.
Clinical discussion: Ultrasound and CT imaging was useful in determining that the tumor originated from the tail of the pancreas. The presence of a definite capsule with internal solid-cystic components helped narrowed the differential diagnosis to solid pseudopapillary neoplasm (SPN) of the pancreas. MR liver was useful to rule out liver metastasis in this child.
Intervention and outcome: The patient was scheduled for laparotomy and tumour excision at a regional paediatric centre. Successful excision of the tumor en-mass was performed and the child's subsequent recovery was uneventful.
Conclusion: Clinical imaging plays a critical role in the diagnosis and management of paediatric solid organ tumours. Other than renal origin, suspicion of pancreatic tail origin should be considered by clinicians when encountering a ballotable left abdominal mass.
Fulltext Wilms tumor presenting as small bowel obstruction in a neonate: A diagnostic challenge

Ahmed S, Nadarajan C, Ng CY, Teh YG, Abdul Muien MZ, Liew CSL

Radiol Case Rep, 2021 Oct;16(10):2908-2912.
PMID: 34401023 DOI: 10.1016/j.radcr.2021.06.058

Wilms tumor is the most common primary malignant renal tumor of childhood which usually presents between 2 and 6 years of age. Its presentation in the neonatal period is extremely rare and presenting with intestinal obstruction is perhaps unknown. We report a 2-day-old baby girl who manifested features of acute upper gastrointestinal obstruction with frequent post-feeding vomiting and abdominal distension. The initial abdominal radiograph showed abnormally displayed small bowel loops to the right hemiabdomen. Subsequent ultrasound and computed tomography scan of the abdomen detected a massive left renal mass. Left-sided nephrectomy was performed, and histopathology demonstrated left-sided Wilms tumor with favorable histology. Post-treatment yearly follow-up for 5 years recorded a disease-free, normally thriving child.
Fulltext CT findings of congenital neonatal pyriform aperture stenosis

Sidek HAB, Teh YG, Tangaperumal A, Zaki FM, Kew TY

Oxf Med Case Reports, 2021 May;2021(5):omab018.
PMID: 34055355 DOI: 10.1093/omcr/omab018

Congenital neonatal pyriform aperture stenosis (CNPAS) is a rare but potentially lethal condition that causes respiratory distress. The characteristic narrowing of the pyriform aperture along with other associated craniofacial dysmorphism is diagnosed using cross-sectional imaging such as computed tomography (CT) and magnetic resonance imaging. CT scan is the imaging of choice for confirming and characterizing CNPAS. Infants are obligate nasal breathers in the first 5 months of life. Hence, a high degree of clinical suspicion, prompt imaging diagnosis and adequate respiratory support is critical to help reduce the morbidity of this condition.
Fulltext Rare late-presentation congenital diaphragmatic hernia mimicking a tension pneumothorax

Muien MZA, Jeyaprahasam K, Krisnan T, Ng CY, Teh YG

Radiol Case Rep, 2021 Sep;16(9):2542-2545.
PMID: 34276850 DOI: 10.1016/j.radcr.2021.06.024

Congenital Diaphragmatic Hernia (CDH) is due to a defect in the diaphragm and is usually detected soon after birth. However, in rare cases, asymptomatic CDHs can be missed and present later in life. Late-presentation CDH can be misdiagnosed as tension pneumothorax leading to iatrogenic complications. We report a case of a 10-year-old boy who presented with non-specific symptoms of vomiting and occasional breathlessness, but was subsequently diagnosed as late-presentation CDH. This case highlights the role of imaging in the diagnosis and management of late-presenting CDH. The role of CT imaging as an invaluable tool to further evaluate equivocal radiographic findings in CDH is discussed.
Fulltext MR imaging of hypothalamic hamartoma in a patient with gelastic seizures

Wan Chek WAF, Teh YG, Eddy Suryono DN, Ng CY, Ahmed S

Radiol Case Rep, 2021 Sep;16(9):2706-2709.
PMID: 34345334 DOI: 10.1016/j.radcr.2021.06.061

Hypothalamic hamartomas (HHs) are non-neoplastic malformations that occur in the region of the hypothalamus. HH is the leading cause of gelastic seizures in children and adolescents, where laughing is characteristically manifested. However, these patients can also experience different forms of complex or generalized tonic-clonic seizures that can obscure the diagnosis of HHs. We present a case of a 10 year-old boy that experienced several seizure types, but was subsequently diagnosed with HH after MR imaging was performed. This case highlights the complementary role of MR imaging in ascertaining seizure etiololgy when the clinical history and EEG findings are non-specific. The importance of early diagnosis with MR imaging is further underscored by the fact that patients diagnosed with HH usually develop drug resistance towards antiepileptic drugs, mandating neurosurgical assessment and intervention.
Fulltext Case Report: Unusual High-Grade Diffuse Leptomeningeal Glioneuronal Tumor Mimicking Tuberculous Meningitis in a Child From an Endemic Region

Teh YG, Azizan N, Mohd Naim NA, Ng CY, Wong KJ, Mohd Zaki F

Front Pediatr, 2021;9:767614.
PMID: 34956980 DOI: 10.3389/fped.2021.767614

Background: Diffuse leptomeningeal glioneuronal tumor (DL-GNT) is a new entity described in the 2016 World Health Organization (WHO) classification of brain tumors. While DL-GNT is predominantly an indolent tumor that affects young boys, high-grade DL-GNT is unusual and seldom reported in children. Case Presentation: In this report, we describe the challenges and pitfalls associated with diagnosing this high-grade variant in a tuberculosis-endemic region. We highlight the importance of identifying non-typical imaging findings, i.e., non-enhancing cystic lesions with high T2 signal along the leptomeningeal surface, that may expedite the diagnosis of this condition. Histopathologic correlations with MR spectroscopy findings are also discussed. Conclusion: We provide the first clinical imaging report of utilizing MR spectroscopy to distinguish DL-GNT from tuberculosis with histopathologic correlation.
Fulltext Forensic age estimation in living children: how accurate is the Greulich-Pyle method in Sabah, East Malaysia?

Nang KM, Ismail AJ, Tangaperumal A, Wynn AA, Thein TT, Hayati F, et al.

Front Pediatr, 2023;11:1137960.
PMID: 37397141 DOI: 10.3389/fped.2023.1137960

BACKGROUND: The Greulich and Pyle's Radiographic Atlas of Skeletal Development of the Hand and Wrist (GP Atlas) is the most widely used method of determining the bone age (BA) of a child. It is also a widely accepted method for forensic age determination. As there is limited local bone age data for forensic age estimation, the purpose of this study was to assess the accuracy of the GP Atlas for forensic age determination in living Sabahan children.
METHOD: This study recruited 182 children between the ages of 9 years to 18 years. BA estimation of the left-hand anteroposterior radiographs were performed by two experienced radiologists using the Greulich-Pyle method.
RESULTS: The BA estimates from two radiologists had very high interobserver reliability (ICC 0.937) and a strong positive interobserver correlation (r > 0.90). The GP method, significantly and consistently underestimated chronological age (CA) by 0.7, 0.6 and 0.7 years in overall children, boys and girls respectively with minimal errors. Mean absolute error and root of mean squared error for overall children was 1.5 and 2.2 years respectively, while mean absolute percentage error was 11.6%. This underestimation was consistent across all age groups but was statistically significant only at 13-13.9 and 17-18.9 years old age groups.
CONCLUSION: Despite high interobserver reliability of BA estimation using the GP Atlas, this method consistently underestimates the age of the child in all children to a significant degree, for both boys and girls across all age groups, with an acceptably low level of error metrics. Our findings suggest that locally validated GP Atlas or other type of assessments (artificial intelligence or machine learning) are needed for assessment of BA to accurately predict CA, since current GP Atlas standards significantly underestimated chronological age with minimal error for children in Sabah. A larger population-based study would be necessary for establishing a validated atlas of a bone age in Malaysia.
Fulltext Skeletal manifestations of congenital syphilis: Rare but clinically relevant

Pg Mohammad Hussein PMN, Kew ST, Nang KM, Kadir F, Teh YG

Radiol Case Rep, 2021 Dec;16(12):3635-3637.
PMID: 34630789 DOI: 10.1016/j.radcr.2021.09.004

Congenital syphilis occurs as a result of maternal transmission of treponema pallidum in utero. This condition is mainly diagnosed by treponemal and non-treponemal serologic tests. However, both maternal nontreponemal and treponemal IgG antibodies can be transferred through the placenta to the fetus, thus complicating its interpretation soon after birth. We report a case of a neonate with congenital syphilis whose mother became infected after the first trimester of pregnancy. We report how skeletal radiographs expedite the clinical decision-making process and direct further management of neonates. This case also highlights the need for repeated syphilis screening in the latter part of pregnancy.