We report a case of a 19-year-old immunocompetent Malay woman who presented with a worsening psychotic disorder of 1-year duration. She initially presented with social isolation with subsequent mutism and stupor. Physical examination revealed a stuporous, emaciated, dehydrated woman with Glasgow Coma Scale of 11/15 (E4V2M5). She had a blank stare, mutism and akinesia. Motor examination revealed upper motor neuron findings. Neck stiffness was present, however, Kernig's and Brudzinski's signs were negative. There were no other findings on other systems. Brain imaging and EEG were normal. Cerebrospinal fluid investigations revealed positive cerebrospinal fluid Mycobacterium tuberculosis PCR (MTB PCR). The patient was treated with empirical antituberculosis drugs and steroids. On follow-up visit 1 month later, her psychotic symptoms had fully resolved. She was able to ambulate and care for herself; she was unable to recall the symptoms she had experienced before and during admission.
We describe a case of extensive ocular injury secondary to an electronic cigarette (e-cigarette)-related explosion. The explosion was the result of modifications made to a heating element of the e-cigarette device by a non-professional. Extensive ocular injuries that result from an explosion of an e-cigarette device can potentially cause significant and permanent visual impairment.
A 25-year-old gravida 2 para 1 with 12-week amenorrhoea presented a second time for recurrent vomiting in pregnancy. She was diagnosed to have a missed miscarriage following absent fetal heart seen in an early scan. She opted for conservative management. However, on the third presentation, her vomiting continued. Repeated transvaginal ultrasound scan showed a fetus with a crown rump length of 19 mm, which is equivalent to 8 weeks and 4 days, with absence of fetal heart pulsation. Thyroid function tests and β human chorionic gonadotropin were then requested. Results showed that the patient's serum β human chorionic gonadotropin level was markedly raised to 147,000. A molar pregnancy was suspected. Her thyroid function tests came back normal. Suction curettage was performed and histopathology confirmed a partial molar pregnancy. On follow-up, the β human chorionic gonadotropin level was normal by 7 weeks after the curettage.
Spondyloarthropathy (SpA) is a group of inflammatory conditions that include spondylitis, sacroiliitis, asymmetrical peripheral arthritis and enthesitis. This condition is known as juvenile SpA when the diagnosis is made in patients up to 16 years of age. Enthesitis is a highly specific feature that occurs more often in juvenile SpA than in the adult form. In contrast to adult onset SpA, the initial manifestation of juvenile SpA rarely presents as inflammatory back pain. Peripheral arthritis is the more common presenting feature. We report a case of a 12-year-old boy who presented with a 1-year history of progressive low back pain, gluteal pain and thigh pain. There were no clinical symptoms of arthropathy of the distal extremities. MRI of the whole spine was performed twice, which, unfortunately, was unyielding. Finally, MRI of the sacroiliac joints revealed asymmetric sacroiliitis as well as enthesitis of the hips and pelvis. Further laboratory data showed negative rheumatoid factor and positive human leucocyte antigen (HLA) B27. A diagnosis of juvenile SpA with sacroiliitis and enthesitis was made. The imaging characteristics of juvenile SpA are highlighted.
Congenital spinal fusion of an odontoid process to an atlantal hemiarch is very rare. The unfamiliarity of the medical fraternity with this congenital malformation can easily be mistaken for an acute fracture, chronic infection or inflammatory disease. We present our experience of managing an adult who presented with neck pain after a motor vehicle accident. Radiological investigation revealed congenital fusion of the odontoid process to the atlantal hemiarch. The prevalence, embryology and clinical significance of this anomaly are discussed. As the natural progression of this anomaly is not well documented, we suggest periodic follow-up to monitor the progression of degenerative changes and instability of the occipitoatlantal junction.
Fibrous dysplasia is a non-neoplastic hamartomatous developmental fibro-osseous lesion of bone. Monostotic fibrous dysplasia is more common than the polyostotic form and usually involves jaw bones, ribs and femur. Maxillary lesions may extend to involve the maxillary sinus, zygoma, sphenoid bone and floor of the orbit and require surgical intervention resulting in an acquired defect of the involved site. A multidisciplinary team approach involving an oral pathologist, oral surgeon, oral medicine expert and maxillofacial prosthodontist is required for successful treatment and rehabilitation of such patients. This article describes a case of a patient with fibrous dysplasia of the left maxilla, which was successfully managed by integrating surgical intervention and postoperative rehabilitation, with a surgical obturator and an interim partial denture prosthesis that successfully limited the detrimental effects of surgery, and helped the patient in resocialisation, thereby improving her quality of life.
Hypercementosis is excessive deposition of non-neoplastic cementum over normal root cementum, which alters root morphology. This cementum may be either hypocellular or cellular in nature. The aetiopathogenesis of hypercementosis is ambiguous. Although most of the cases are idiopathic, several local and systemic factors are also linked to this condition, such as Paget's disease, acromegaly, vitamin A deficiency, etc. We report two rare cases of hypercementosis associated with systemic lupus erythematosus, not previously described in the literature, and also discuss the possible aetiopathogenesis.
We present the case of a 24-year-old man who presented with vertigo and right-sided weakness. Subsequent imaging demonstrated a lateral ventricle haemangioblastoma. This is the first case ever to be treated with surgical excision augmented by preoperative endovascular embolisation, as illustrated with perfusion CT scanning performed pre-embolisation and postembolisation. We present the case followed by a summary of the previously published cases and a discussion of the advantages of perfusion scanning and endovascular embolisation in these highly vascular (and therefore potentially dangerous) lesions.
A healthy Danish man presented with infected prepatellar bursitis 8 months after being involved in a car accident in Malaysia resulting in exposure of a laceration of his knee to stagnant water. Tissue samples grew Burkholderia pseudomallei and diagnostic work up revealed no secondary foci. The patient was successfully treated with surgical debridement and 3 months of oral trimethoprim-sulfamethoxazole. At 6 months follow-up the patient was without relapse.
We report a case of renal cell carcinoma diagnosed after a patient was treated successfully with intravenous cyclophosphamide for her active proliferative lupus nephritis (classes III and V). After the intravenous cyclophosphamide regimen, the patient was asymptomatic with persistent microscopic haematuria, and no proteinuria. The renal cell carcinoma was located on the left kidney; incidentally, this was where the initial renal biopsy was done to diagnose lupus nephritis.
Care of an acutely ill parturient is particularly difficult when we have to balance the needs of both mother and the fetus to survive. The literature suggests there should be emphasis on stabilising the mother's condition. In dealing with metabolic acidosis, however, we believe delivering the baby early might not only relieve the threat of the acidosis on the mother, it may be the only way to deliver a live baby. We report two parturient women with severe metabolic acidosis which was considerably reduced very soon after the delivery and how our timely delivery resulted in the birth of two neurologically intact babies.
Pseudotumours are rare, occurring in 1-2% of severe haemophiliacs. Osseous locations are far less frequent than soft tissue location. We report a case of a 43-year-old man with haemophilia A, who presented with a gradually enlarging left thigh mass for 8 months. There were no constitutional symptoms. Plain radiograph showed an expansile lytic lesion with 'soap-bubble' appearance arising from the left femur diaphysis. On MRI, it appeared as a non-enhancing, multilobulated lesion expanding the medullary and subperiosteal spaces. The mass exhibited concentric ring sign with heterogeneous intermediate signal intensity in the core lesion, reflective of chronic haematoma with blood degradation products of different stages. A diagnosis of haemophilic pseudotumour was made. Hypercalcaemia, however, raised a diagnostic dilemma as bone malignancy needed to be considered. An open excisional biopsy and subsequent amputation confirmed the diagnosis of osseous haemophilic pseudotumour. Nuclear medicine study later revealed a concurrent parathyroid adenoma.
Infratemporal fossa abscess is a rare and challenging condition to diagnose and manage. A few reported cases have been mostly due to odontogenic infections and were managed by external or intraoral drainage. This is the first reported case of an infratemporal fossa abscess that was successfully managed by endoscopic drainage via a transmaxillary approach.
A 62-year-old man presented with a right-sided hemichorea-hemiballismus secondary to underlying non-ketotic hyperglycaemia. This condition is recognised to have a unique finding of unilateral basal ganglia lesion, which is hyperdense on CT and hyperintense on T1-weighted MRI. The clinical course of this condition is benign and has a good prognosis with early correction of the hyperglycaemia.
A 58-year-old man presented with diplopia and partial ptosis for 10 years. It was non-progressive in nature, despite inadequate medical attention the patient received from non-specialists/general practitioners. He did not have fatigability or diurnal variation in weakness and was clinically stable without exacerbations of disease for a decade. He did not have features of Graves's disease, oculopharyngeal dystrophy, cranial nerve paralysis, polymyositis and stroke. The possibility of an atypical presentation of myasthenia gravis (MG) was considered and the patient was evaluated. Ice pack test was negative, Cogan's lid twitch (CLT) test was positive and high titres of acetylcholine receptor antibodies (AChR Ab) suggestive of MG were found. He was treated accordingly with a very good response.
Midgut malrotation commonly presents in the neonatal period, and rarely manifests its symptoms in adulthood with an estimated incidence of 0.2-0.5%. Nevertheless, the symptoms are non-specific with no strong pointers towards the clinical diagnosis. Consequently, the diagnosis is usually disclosed with imaging or surgery. We report a case of small bowel obstruction secondary to a congenital peritoneal band with underlying midgut malrotation in a 48-year-old man.
Bilateral vocal cord paralysis is a known possible complication following thyroid surgery. It owes to the close relationship between the recurrent laryngeal nerve and the thyroid gland. The most feared complication of bilateral vocal cord paralysis is airway compromise. We report the case of a 39-year-old woman who underwent total thyroidectomy for multinodular goitre. The surgery was uneventful. However she developed stridor in the recovery bay needing intubation. We postulate that the cause was attributed to bilateral vocal cord paresis due to the use of the intraoperative nerve monitoring (IONM) whose high setting throughout the surgery was overlooked. She made a complete recovery without the need of a tracheostomy. We share our lessons learnt from this case.
The patella is an uncommon site for all primary and metastatic bone tumours and primary intra-osseous tumours of the patella are very rare. A majority of the patella tumours are benign. We report a patient with a sudden onset swelling and pain of the right knee following a staircase fall. The plain radiograph showed an expansile multiseptated patella lesion and it was further assessed with an MRI. The radiological findings and the initial histopathological features from a limited sample were suggestive of a primary aneurysmal bone cyst. However, the final histopathological diagnosis from a more adequate specimen was a giant cell tumour with a secondary aneurysmal bone cyst.