IIUM Medical Journal Malaysia (IMJM)
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Neuropsychiatric Systemic Lupus Erythematosus (NPSLE) – Masquerade Diagnosis: A Case Report
Get PDFIntroduction: Diagnostic challenge is seen in Systemic Lupus Erythematosus (SLE) due to insidious onset, unpredictable course, broad spectrum of clinical presentation that mimic other diseases manifestation and possibility not fulfilling the classification criteria at the earlier course of the disease. Case report: We highlighted a case of a man, lived with diagnosis of Schizophrenia for almost 15 years subsequently revealed him suffered from neuropsychiatric lupus as he fulfilled the SLE classification criteria. His initial presentation was altered sensorium treated as acute psychosis-the tip of an iceberg to the underlying disease. His multiple admissions to psychiatric ward were believed contributed by episode of lupus flare. Necessary investigation is important to exclude another medical condition before make a diagnosis of Schizophrenia using DSM-V criteria. The misdiagnosis has significantly impaired his social life and untreated disease had leads to morbidity and severe organ damage. This case emphasizes on the crucial aspect of assessing patient as a whole, follow-up the progression and re-evaluates patient’s condition for a new hint. Even though there is no cure yet for SLE, correct and early diagnosis is able to guide for individualized treatment and thus helping in good disease control that warrant better outcome
Molecular Characterization of gyrA, parC and qepA Genes in Quinolone Resistant ESBL Producing E. Coli Isolated from Patients in HTAA, Kuantan
Get PDFIntroduction: Quinolone resistance and extended spectrum beta lactamase production has increased in E.coli and considered a serious problem worldwide. It is worth to monitor resistance mechanism in E.coli to provide guidance for optimizing antimicrobial treatments,control and spread of resistance. The objective of this study was to molecularly characterize gyrA, parC genes and plasmid mediated qepA efflux pump gene, in QR-ESBL E. coli isolates obtained from patients in HTAA, Kuantan. The antibiotic susceptibility profile was also studied. Materials and Method: 32 QR-ESBL and six quinolone-susceptible E. coli isolates from September 30 November,2018) included in the study. The isolates were reconfirmed with known phenotypic tests and antibiotic susceptibility test was performed. PCR and DNA sequencing were performed for the identification of mutations in quinolone resistance determining region. Result: Resistance to ampicillin, tetracycline, nalidixic acid was (100%) followed by cefotaxime (96.9%), ciprofloxacin (78.1%) trimethoprim sulfamethoxazole (75%), ceftazidime (56.3%), cefepime (43.8%) and gentamycin (25%). None of the isolates was resistant to piperacillin-tazobactam, amikacin, imipenem, meropenem, ertapenem, and colistin. PCR successfully amplified the gyrA and parC genes, however, qepA gene was not detected by PCR in the isolates. Majority of the isolates had point mutation in (QRDR) of GyrA at codons 83 and 87 and in ParC at codons 80 and 84. Two isolates had mutations outside of QRDR at codons 144 and 167 in ParC. Strong positive correlation was found between MIC levels of ciprofloxacin and the number of resistance mutations. Sequencing of 6 (QS-ESBL) E. coli revealed absence of resistance mutations. Conclusion: Quinolone resistance in the isolates was mainly due to mutations in gyrA, ParC genes. Acquisition of multidrug resistance genes through innate gene mutations and mobile genetic elements contribute to the emergence of (MDR). This study reinforces the importance of being vigilant in utilizing molecular techniques to monitor for emergence of resistance genes in different locations
Sacral Marjolin's Ulcer: A Case of Delayed Diagnosis in a Paraplegic Patient
Get PDFMarjolin's ulcer is a rare and aggressive malignancy ulcerating squamous cell carcinoma of the skin presenting in a previously injured or chronically inflamed area. However, the diagnosis may be delayed particularly in chronic sacral sores due the insidious onset and low index of suspicion, resulting in suboptimal management and poor outcome.A 42-year-old Malay gentleman sustained complete spinal cord injury in 1998 and consequently paraplegic. Five years prior to presentation in 2019, he noted a small ulceration at the sacral area. Despite regular dressing and multiple hospitalization for wound debridement, the wound condition worsened and involved gluteus and right thigh,associated with loss of weight and appetite. The patient also had rectocutaneous fistula and subsequently underwent diversion colostomy. Upon presentation at our hospital, he was in septic shock requiring prolonged inotropic support. Local examination revealed a 20x40cm sacral and gluteal sores with copious purulent discharge and presence of slough intermixed with granulation tissue and irregular looking mass. Diagnosis of septic shock secondary to infected Marjolin's ulcer was made. Four quadrant biopsies were taken, and the histopathological examination revealed well-differentiated squamous cell carcinoma. CT thorax, abdomen and pelvis revealed multiple calcified lung nodule, local spread of squamous cell carcinoma and invasion into whole rectum, posterior part of bladder , prostate gland ,and posterior part of penis . In view of the extensive local disease and lung metastases, patient opted for palliative treatment.The sepsis was unresolved and the wound remained infected, the patient succumbed and died due to the sepsis.A high index of suspicion and prompt oncologic management is required in managing chronic non- healing ulcer. An early referral to oncologic centre will improve the prognosis of patients with Marjolin's ulcer. Late diagnosis and superimposed infection will ultimately result in very poor outcome
Identification of Celiac Trunk Variations using Multi-Detector Computed Tomographic Angiography
Get PDFIntroduction: Variation in celiac trunk is common and has importance in preoperative planning to reduce the risk of accidental vascular injuries during surgical and radiological intervention. Our aim was to measure the prevalence of coeliac trunk types and describe its different variations using MDCT angiography among patients in Hospital Tengku Ampuan Afzan (HTAA), Kuantan. Materials and method: A retrospective cross sectional study was conducted. Computed Tomographic Angiography (CTA) images were retrieved from July till December 2017. Images were reconstructed in 3D Volume Rendering (VR) format using workstation and reviewed for the normal and anatomical variations of the celiac trunk. The variations were classified using Uflacker’s classification. The results were calculated using IBM SPSS statistic version 22. Results: A total of 140 cases were found, from which 23 were excluded. Mean age was 57.3 years and male/female percentage was 65.8/34.2. Anatomical variation of the CT was found in 54 (46.2%) cases. The most common variation was the origin of inferior phrenic artery (IPA) from the CT in 21 (17.9%) cases followed by celiac-colic trunk in 15 (12.8%) cases. However, 31 (26.5%) cases displayed variations not described in Uflacker’s classification. They include celiaco-phrenic trunk, coexistence of IPA with other Uflacker’s variations, Buhler arc, accessory hepatic artery from the CT and coexistence of celiac-colic trunk with gastro-splenic and hepato-splenic trunk in one case each. Conclusion: Accurate knowledge and identification of anatomical variations in CT is crucial before undergoing any surgical or invasive imaging procedure. This can help surgeons and interventional radiologists to prevent accidental vascular injuries and perform a safe procedure
General Paresis in a Child with Unusual Presentation
Get PDFIntroduction: Acute onset quadriparesis can be a manifestation of a variety of neurological, metabolic or autoimmune conditions. Rarely, it could be one of many clinical presentations of juvenile dermatomyositis which belongs to the group of idiopathic inflammatory myopathies of childhood. We report the case of a 9-year old girl who presented with global myopathy over a two-month period. Case report: A 9-year-old girl referred with a 2 months history of generalised muscular pain and weakness. There were no significant history of preceded illness, trauma or excessive strenuous exercises. She had no other systemic complaints such as fever or skin rash. Past medical history was unremarkable except for recurrent tonsillitis. Physical examination revealed a child with normal alertness and behaviour. She has notable generalised swelling of all four limbs. Her neurological examination revealed normal tone however her power was definitely reduced in all four limbs (Graded 3/5). She demonstrated signs of proximal myopathy. Subsequent investigations revealed high Creatinine Kinase (CK) levels of 6470U/L, ESR 84mm/hr with deranged transaminases and positive serum mycoplasma and CMV IgM. Her MRI brain and spine along with lumbar puncture results were normal. She was referred to tertiary centre for further evaluation as her weakness progressed. An MRI muscle demonstrated marked inflammation in all four limbs including paravertebral muscles. Her muscle biopsy showed inflammatory myopathy leading to a diagnosis of juvenile dermatomyositis (JDM). She is now showing sustained clinical improvements following a course of immunoglobulin and corticosteroids therapy. Discussion: The diagnosis of JDM is generally considered in patients with rash-associated muscle weakness. Essentially, it involves assessment of muscle, skin, lung and cardiac involvement on top of baseline list of investigations that has been outline by Single Hub and Access point for pediatric Rheumatology in Europe (SHARE). This case reflects that JDM is possible despite non-existent of skin involvement.  
Is there any Need for Health Intervention on Pediculosis Capitis in Public Primary Schools in Kuantan, Pahang?
Get PDFIntroduction: Pediculosis capitis among primary school children is a global problem which poses significant consequences among school children and caregivers alike. Previous studies showed an association between pediculosis capitis and sociodemographic factors such as school location, age, gender, ethnicity, parental education, monthly household income, number of siblings and number of family members. Primary schools in Malaysia consist of National School and National-type school (Chinese) and (Tamil), all of which have different sociodemographic backgrounds. Thus, this study aims to investigate and compare the prevalence of pediculosis capitis among children of different types of primary school in Kuantan to properly plan for future intervention. Materials and method: An analytical crosssectional study using stratified random sampling was carried out. The schools were stratified according to their types. Number of respondents from each school was determined by proportionate-to-size. Respondents from standard one to six were given self-administered validated questionnaire. Then, their hair and scalp were examined for the evidence of pediculosis capitis. Data was analysed using descriptive statistics. Results: There were 1,365 respondents involved in this study; consisting of students from National Schools (n=791), Chinese Schools (n=424) and Tamil Schools (n=150). The overall median age was 8.0 years. Majority of them were males (53.41%), of Malays ethnicity (60.29%), with household income between RM1000-RM2999 (31.87%) and from urban school location (98.68%). The overall prevalence of pediculosis capitis was 9.6% (n=131). The prevalence of pediculosis capitis among the selected schools was found to be the highest in National-type school (Tamil) at 33.33% (n=50), followed by National School at 7.33% (n=58) and National-type school (Chinese) at 5.42% (n=23). Conclusion: Pediculosis capitis showed an endemicity in all types of primary schools. Hence, preventive measures are necessary to reduce the transmission of head lice among school children
Effects of Water-Based Contrast Media on Experimentally Induced Established Atherosclerotic Plaques in Rabbits
Get PDFINTRODUCTION: Imaging techniques involving optical coherence tomography, computed tomography (CT) and high-resolution magnetic resonance imaging (MRI) are used as tools to identify atherosclerotic plaques. However, the effects of water-based contrast media used in Post Mortem Computed Tomography Angiography (PMCTA) on the histopathology of atherosclerotic plaques have not been widely explored. The objective of this study is to determine the effects of water-based contrast media used in PMCTA on the histopathology of atherosclerotic plaques and biomarkers of atherosclerosis in experimentally induced established atherosclerotic rabbits. MATERIALS AND METHODS: Twenty male New Zealand white rabbits were divided into 2 groups. One group was given a high cholesterol diet (HCD) for 12 weeks to establish atherosclerosis and the control group normal diet (ND). Five rabbits from each group were then given intravenous water-based contrast media before being sacrificed. The entire length of aorta was dissected and submitted for histopathological examination and determination of tissue biomarkers α-SMA and MMP-9. RESULTS: Histopathological examination of the aorta including percentage of area covered by plaque and foam cell formation showed no significant difference in atheromatous plaque formation in both groups of HCD rabbits with or without intravenous contrast media injection (plaque: 55±41 vs. 63±15, p=0.731; foam cells: 124±83 vs. 171±55, p=0.325). Similarly, α-SMA and MMP-9 protein expression also showed no significant difference in both groups (α-SMA: 70±20 vs. 67±26, p=0.807; MMP-9: 60±12 vs. 57±17, p=0.785). CONCLUSION: Water-based contrast media used in PMCTA does not affect the morphology or the immunohistochemistry staining of SMA and MMP-9 in atherosclerotic plaques
Blood Pressure Control and Cardiovascular Risk Profiles among Post-stroke Survivors: A Cross-sectional Study
Get PDFINTRODUCTION: Control of modifiable risk factors is important in recurrent stroke prevention strategies. This study aimed to determine the control of blood pressure and other cardiovascular risk profiles among poststroke patients. Factors associated with uncontrolled blood pressure were also determined. MATERIAL AND METHODS: A cross-sectional study was conducted in the outpatient clinics of three hospitals located in the East Coast region of Peninsular Malaysia from May to August 2019. Information on socio-demographic characteristics, clinical profiles, and lifestyle practices were acquired. Univariate and multivariate logistic regression analyses were carried out. Crude odds ratio and adjusted odds ratio (aOR) were reported. RESULTS: From a total of 398 stroke patients, majority of the respondents were elderly with first-ever stroke, ischaemic type, and duration of stroke less than 24 months. Uncontrolled blood pressure (52%), overweight and obesity (65%), abdominal obesity (54%), and low physical activity level (65%) were common among the patients. Patients with hypertension (aOR= 3.11, 95% CI: 1.38, 6.99), diabetes mellitus (aOR 1.57, 95% CI: 1.03, 2.38), not taking prescribed medication every day (aOR 2.28, 95% CI: 1.29, 4.01), overweight (aOR 1.75, 95% CI:1.02, 2.99), obesity (aOR 1.99, 95% CI: 1.12, 3.53), and low physical activity level (aOR 2.10, 95% CI: 1.35, 3.27) were at a higher risk of having uncontrolled blood pressure. CONCLUSION: Uncontrolled blood pressure and other major cardiovascular risk factors were highly prevalent among poststroke patients. Increased efforts must be made to optimise the risk profiles management of these high-risk patients to prevent recurrent vascular events in the future. 
Knowledge, Attitude and Practices Towards Lifestyle Related Non-Communicable Diseases (NCDs): A Cross Sectional Study among Indigenous Orang Asli Adults in Negeri Sembilan, Malaysia
Get PDFINTRODUCTION: An increase in the prevalence of non-communicable diseases (NCDs) among Orang Asli in Malaysia was reported to be associated with their lifestyle changes. This study aimed to determine the level of knowledge, attitude, and practice (KAP) on NCDs among the Orang Asli community and its association with demographic factors of gender, age, and education level. MATERIAL AND METHODS: A cross-sectional study among consented adult Orang Asli in Jelebu, Negeri Sembilan, was conducted by a face-to-face interview using a validated questionnaire. Their knowledge, attitude, and practice on selected NCD risk factors, complications, and treatment was recorded. Bivariate analysis was performed to test the association between their demographic profile and KAP score. RESULTS: A total of 325 respondents with a mean age of 39.9 (±13.2) ranged from 18 to 83 years old participated in this study. Majority of the participants (72.3%) had inadequate knowledge. Despite the inadequacy, they have a good attitude (72.3%) and a moderate practice level (63.4%). Respondents with higher education backgrounds had significantly better knowledge scores compared to lower education background (p<0.001). Female respondents had better practice scores than male respondents (p=0.001). CONCLUSIONS: The study shows that the level of knowledge on NCDs among Orang Asli is low with a moderately healthy lifestyle. Improving the Orang Asli understanding of NCDs prevention by incorporating health programs regularly in their community is a strategic method to increase their awareness. Hence, escalating their good practice on NCDs and eventually their health
The Psychological Impact of COVID-19 on Antenatal Women: A Scoping Review
Get PDFThe widespread transmission of the new coronavirus disease COVID-19 has caused great psychological distress across diverse populations in many countries. Antenatal women are at greater risk of emotional instability and vulnerability due to hormonal changes, and multiple maternal roles. This paper aims to determine the common types of psychological distress and potential interventions amongst antenatal women during COVID19 outbreak. This review was conducted as a rapid review in response to the COVID-19 outbreak. The PubMed, Scopus, and Google Scholar databases were searched using keywords namely “novel coronavirus”, “COVID-19”, “nCoV”, “maternal mental health”, “pregnant”, “psychology”, “anxiety”, “depression” and “stress” in various permutations and combinations. A total of five papers were included in the final analysis. Thematic analysis was used to analyse the selected papers. Findings from the papers reviewed showed that COVID-19 has independently increased the prevalence of psychological distress among antenatal mothers. The most common types of distress were anxiety (57%- 83.3%), followed by worry (50.7%) and depression (34.2-37%). The distress experienced by the antenatal women with COVID-19 was found to be associated with suicidal thought. Social support, psychological hotlines, and online counselling have been suggested to alleviate the symptoms of mental distress among antenatal women. The COVID-19 pandemic has independently caused psychological distress among antenatal women to rise. Maternal mental health should be prioritised during the pandemic, and mental support should be made available and accessible during and after the COVID-19 outbreak in ensuring the ongoing provision of mental health services