A prospective study on the practicality of an out-patient management protocol for dengue infection in adults was carried out during a 2-month period. Doctors were requested to follow the protocol and assessment was done on the patients' outcome, the admission rate, and the compliance to the protocol by doctors and patients. One hundred and sixty-two patients (mean age 27.3 years) were clinically diagnosed to have dengue illness. Among them, 82.7% had dengue fever (DF); 13.0% had dengue haemorrhagic fever (DHF) and 4.3% had dengue shock syndrome (DSS). Dengue aetiology was confirmed in 69.4% of the DF group and 85.7% of the DHF and DSS groups. There were no deaths among the 162 patients. The admission rate was 43.8%. A high compliance rate of 86.4% by the doctors and a low patient default rate of 16.4% showed that the protocol was practical.
T-agglutination patterns of 190 strains of group A streptococci isolated between January 1989 and December 1993 from body fluids (10), throat culture (56), pus (51) and skin lesions (73) were determined. Mucoid colonial morphology was exhibited by 6.3% (12/190) of the strains on initial isolation. Type T-5,11,27,44 comprised 23.7%, followed by T-1,3,13,B3264 (11.1%), T-4,6 (8.4%) and T-8,25, Imp 19 (7.9%). About 42% (80/190) strains could not be characterized by T agglutination pattern. T-typing of 71 selected strains at WHO Collaborating Center, Minneapolis yielded similar results. Nineteen selected strains were further characterized by M-typing; only three strains were M-typeable. These strains were isolated from throat (M1), sputum (M5) and pus (M12). About 68% (48/71) isolates produced serum opacity factor. These data support the existence of as yet uncharacterized group A streptococcal serotypes in this region.
Entomological investigations on malaria and bancroftian filariasis transmission were carried out in the endemic area of Baram District, Sarawak. The Anopheles composition, survival and infection rates of malaria and filariasis were compared in the village and 0.5 km from the village ecotype, in forested areas. Anopheles leucosphyrus, An. barbirostris and An. donaldi are the vectors for malaria and bancroftian filariasis in both ecotypes. Biting and infection rates vary, but An. leucosphyrus differed with a peak around midnight in the forested area and soon after dusk in the village setting. The parous rate of An. leucosphyrus was significantly higher in the forest ecotype (P < 0.0001); however, the proportion of 3-parous and older was not overall higher in the forest ecotype (P = 0.68). The entomological inoculation of malaria parasites by An. leucosphyrus was comparatively higher in the forested areas (P > 0.5). The implications of malaria and filariasis transmission in the forested areas in Baram District are discussed.
A renal transplant patient presented with ileal perforation due to histoplasmosis 3 years after transplantation. Mesenteric lymph nodes and lungs were also affected by the disease. She was successfully treated with amphotericin B followed by ketoconazole.
HBV-DNA were analysed in 330 HBsAg-positive carriers in Malaysia by dot-blot hybridization and polymerase chain reaction. Seventy-three (22.12%) were positive for the virus. Of these, 65 (89%) were males and 8 (11%) were females. Statistically, there was no significant difference (P = 0.13). No significant decline in HBV-DNA with age in the Malay and Chinese males was observed (P = 0.2). Prevalence of HBV-DNA was higher in the Chinese carriers than in the Malay carriers for most age groups in both sexes. Sixty-one HBV-DNA-positive carriers were also positive for HBeAg. However, three individuals were positive only for anti-HBe, one was positive for both HBeAg and anti-HBe, and eight were negative for both HBeAg and anti-HBe. Fifty-seven were positive for HBeAg but negative for HBV-DNA. No relation was observed between raised alanine aminotransaminase and aspartate aminotransaminase levels and the presence of HBV-DNA (P = 0.4).
A prospective study was carried out to determine the aetiology of cerebral abscess in relation to the primary source of infections. Seventy-five patients with cerebral abscess were included in the study in the period January 1985 to December 1988. More than half of the patients studied had single lesions and the overall most common sites were in the frontal and parietal regions. Chronic suppurative otitis media, cyanotic congenital heart diseases and meningitis were among the important predisposing conditions in these patients. Approximately 25% of the patients with cerebral abscesses had no documented antecedent infections. Pure cultures were found to be predominant (66.7%) and sterile cultures were obtained from 10 (13.3%) patients. Streptococci were isolated from 23 (30.7%) patients, the commonest species being Streptococcus milleri. Proteus sp, Pseudomonas aeruginosa, Pseudomonas putrifaciens and Bacteroides sp were almost exclusively found in cerebral abscesses secondary to chronic suppurative otitis media; these organisms were found in mixed cultures. Streptococcus milleri, Bacteroides sp and Eikenella corrodens were found in pure cultures in patients with cyanotic congenital heart disease. In patients with ventriculoperitoneal shunts in-situ, Staphylococcus aureus, Staphylococcus epidermidis and diphtheroids were common. Anaerobes were found in 15 (20.0%) patients, the majority in mixed cultures. Culture, as well as gas-liquid chromatographic analysis of volatile fatty acids of cerebral pus, was carried out to enhance the detection of the anaerobes. Based on these findings, an antibiotic regimen consisting of penicillin, chloramphenicol and metronidazole is recommended as an initial therapy while awaiting culture and sensitivity results.
A 17-year-old girl was admitted to hospital with dengue fever. On the ninth day of fever she developed haemoptysis and chest X-ray changes consistent with haemorrhage in her lungs. Thrombocytopaenia and mild coagulopathy were the most likely cause of this unusual haemoptysis in this patient. Investigations excluded other causes for the haemoptysis.
In this study we examined the incidence of hypercalcaemia among patients with tuberculosis in Malaysia. Serum calcium concentration and other calcium metabolism parameters were studied in 43 newly diagnosed tuberculous patients from the Kuala Lumpur General Hospital and the National Tuberculosis Centre. Forty-four patients admitted to the medical wards of the General Hospital, Kuala Lumpur were recruited as controls. The incidence of hypercalcaemia was found to be only 1/43 (2.3%). There was no significant difference between the mean serum calcium and other calcium metabolism parameters between the patients and the controls. Despite earlier reported incidences of 30-50%, this study showed that hypercalcaemia in tuberculosis is uncommon in Malaysia.
A total of 350 strains of group B streptococci (308 from adults and 42 from neonates) were serotyped. The majority of the isolates from adult patients were from the genito-urinary tract and most of the neonatal isolates were from babies less than 10 days old. Serotype III was the predominant type among all groups of patients and accounted for 50.9% of all serotypes. The second and third most frequently occurring serotypes were II and Ic respectively. Together with type III they made up 87% of the isolates.
The status of P. falciparum resistance to chloroquine in Sabah, Malaysia were not know until 1971-1972. Several in-vivo and on in-vivo studies were conducted from 971-1975, and the result showed 51% out of total 57 cases studied were resistant to chloroquine. The latest in-vitro study (collaborative with WHO) started in July 1978, to continue till 1980, to cover the whole State. The preliminary result shows 65 cases (85%) out of a total 76 successful tests are resistant to chloroquine. On the basis of this preliminary result, the radical treatment for P. falciparum infection was changed from chloroquine to Fansidar from June 1979 throughout the State.
The infant immunization coverage for triple antigen (DPT) from 1968 and trivalent oral polio vaccine (TOPV) from 1972 to 1985 for Peninsular Malaysia are presented. It shows that immunization coverage improved when the recommended age for first dose of DPT was changed from the fourth to the second month of life in 1972 and declined when the recommended age for the first dose of DPT and TOPV was revised again from the second to the third month of life in 1980. The advantages of immunizing children early in life are discussed.
A stable population at risk of Malaysian schistosomiasis was studied. Census results indicated that approximately one-fourth of the inhabitants used a stream where Schistosoma malayensis-infected snails were present as their principal source of water for bathing, drinking, and household tasks. The general population also contacted this stream when fording it or while fishing. Serological surveys using enzyme-linked immunosorbent assay (ELISA) and the circumoval precipitin (COP) test revealed six (9%) and three (4%) positives, respectively, among 67 persons examined. No schistosome ova were found in a general survey of 56 persons which included five ELISA positive and two COP test positive patients. ELISA and COP test prevalences among those dependent on the foci of transmission for water, 13 and 7% respectively, were only slightly higher than prevalences among the remainder of the population, 8 and 4% respectively. These results indicate that even among a stable population at risk of Malaysian schistosomiasis the prevalence is low. Our findings support the hypothesis that S. malayensis is a zoonotic infection in man and that it is unlikely to become a significant public health problem.
A total of 819 Indian inhabitants (from 6 months to over 60 years of age) in an oil-palm plantation in West Malaysia was examined for soil-transmitted helminthiases using the brine flotation and Kato thick smear techniques. Half (51.0%) of the inhabitants were found to be infected (33.9% had Ascaris lumbricoides; 36.4% had Trichuris trichiura and 15.6% had Necator americanus). Soil-transmitted helminthiases (both single and mixed infections) were significantly more common among children and young adults from 6 months to 20 years of age where 67.1% (range: 64.7-70.3%) of this age group were infected. The infection rate declined to about 25% or less among elderly people over 50 years of age. Trichuris trichiura was the commonest helminth observed--both as single and mixed infections--and Trichuris mixed with Ascaris was the commonest type of double infection reported. However, there were no significant differences in the distribution of the types of single and double infections among inhabitants of different age groups, nor were there any significant differences in the distribution of soil-transmitted helminthiases among male and female inhabitants. The socioeconomic, environmental and cultural factors contributing to persistently high rates of infection with soil-transmitted helminths among plantation inhabitants are discussed.
Between 1981 and 1986, 10 consecutive cases of melioidosis were seen at the University Hospital, Kuala Lumpur, Malaysia. They illustrate the amazing guises of melioidosis presenting as: abscesses of the supraspinatus muscle, psoas muscle, brain and liver; three different pulmonary forms; an acute suppurative dermal lesion; an acute septicaemia; and chronic lymphadenitis. The majority had underlying diseases: diabetes mellitus, the commonest, was present in six, out of whom three had previous pulmonary tuberculosis; other predisposing conditions were renal failure, corticosteroid therapy and malnutrition. Three patients who died had pre-existing renal impairment and developed renal failure later, suggesting that the former is a bad prognostic sign. Clinical diagnosis was difficult: all cases were diagnosed bacteriologically. A high level of clinical awareness is necessary, especially when presentation simulates pulmonary or extrapulmonary tuberculosis in patients with diabetes or other compromised states.
Tuberculous liver abscess is uncommonly seen in our experience. We report a case of a 17-year-old boy who presented with typical clinical features of liver abscess, where a diagnosis of tuberculous liver abscess was made on laparotomy and biopsy of the abscess wall.
Tuberculosis of the genital tract was diagnosed in only 12 patients during the 17 year period from March 1968 to February 1985 at the University Hospital, Kuala Lumpur, which serves as a major referral centre in Malaysia. The incidence was 0.31 per 1000 gynaecological admissions and the peak age incidence was in the age group 26 to 35 years. The surgical management was mainly conservative as infertility was the most frequent mode of presentation (50%). Evidence of previous pulmonary tuberculosis was present in only five cases. Adnexal adhesions were the commonest pelvic finding; the fallopian tubes and endometrium were affected with equal frequency. Positive cultures for Mycobacterium tuberculosis were obtained in only five of the 12 patients. All patients received combination anti-tuberculosis drugs with satisfactory response.
Five patients illustrate various aspects of obstetrical defibrination in West Malaysia, resulting from exaggeration of changes in fibrinolytic-coagulation equilibrium that occur at delivery. Hypofibrinogenaemia and fibrinolysis may occur in association or either feature predominate. These patients are from a population in which a variety of genetic and environmental factors may interact, e.g. abnormal haemoglobins, cold agglutinins, viral and other infections, introducing additional complications.