Unexpected case of ankle tuberculosis in a young professionals leading to delay in diagnosis

We report a case of a 38 year-old engineer presented with left ankle pain for 2 years and initially treated as gouty arthritis because of high serum uric acid. A year later his left ankle become swollen and plain radiograph showed soft tissue swelling around the ankle with normal articular surface and bone. An MRI investigation reported as gouty arthritis of ankle with tophi. While on treatment for gouty arthritis, he developed pus discharge from the swelling. The ankle pain also worsen and he was unable to weight bear on the affected leg. An incision and drainage shown pus from the ankle joint which grew pseudomonas aeruginosa. He was treated with intravenous followed by oral ciprofloxacin 250 mg bd. However his condition does not improved and a month after antibiotic treatment a repeated radiograph shows narrowing of joint space with irregular cortical destruction, osteopenic bone . suggestive of worsening of his septic arthritis. During this period he deny of having any fever, cough or night sweats. However he did notice some loss of weight and loss of appetite. He has worked in Africa and Russia before in petroleum industry. After 4 months of antibiotic and no sign of improvement, a biopsy and repeat culture was taken from the ankle which reveal tuberculous arthritis and positive for AFB culture. A plain chest radiograph revealed miliary tuberculosis picture. He was started on a anti TB treatment and the wound healed after a few weeks. After 4 months of treatment he was able to walk without support with reduce ankle range of motion. This case illustrate that the diagnosis was delay because tuberculosis was not suspected in a young professionals with ankle pain and elevated serum uric acid level. Further delay in diagnosis because MRI report also suggestive of gouty tophi and the pus culture and sensitivity grew pseudomonas aeruginosa

Emerging respiratory infections threatening public health in the Asia-Pacific region: a position paper of the Asian Pacific Society of Respirology

In past decades, we have seen several epidemics of respiratory infections from newly emerging viruses, most of which originated in animals. These emerging infections, including severe acute respiratory syndrome coronavirus (SARS-CoV), Middle East respiratory syndrome coronavirus (MERS-CoV) and the pandemic influenza A(H1N1) and avian influenza (AI) viruses, have seriously threatened global health and the economy. In particular, MERS-CoV and AI A(H7N9) are still causing infections in several areas, and some clustering of cases of A(H5N1) and A(H7N9) may imply future possible pandemics. Additionally, given the inappropriate use of antibiotics and international travel, the spread of carbapenem-resistant Gram-negative bacteria is also a significant concern. These infections with epidemic or pandemic potential present a persistent threat to public health and a huge burden on healthcare services in the Asia-Pacific region. Therefore, to enable efficient infection prevention and control, more effective international surveillance and collaboration systems, in the context of the ‘One Health’ approach, are necessary

A case report of airway stenting in tracheal compression secondary to right subclavian artery pseudo-aneurysm

We report a 55-year old lady with the presentation of stridor and type II respiratory failure requiring tracheal intubation. She had right Horner’s syndrome associated with pleural effusion. Her chest radiograph revealed right upper zone lobulated opacities and therefore right Pancoast tumor was the initial diagnosis. However, her CECT thorax revealed a huge right subclavian artery pseudoaneurysm with severe tracheal compression. This rare condition imposed a significant diagnostic as well as therapeutic challenge. Vascular surgery is the definitive treatment but it is associated with high risks. The exact role of rigid bronchoscopy for airway stenting is unknown due to limited evidence available. Indeed, this form of central airway obstruction may benefit from temporary tracheal stenting whilst the surgical repair of the lesion is planned. It may facilitate early weaning and allows less complicated airway control

Multiple cavitating pulmonary nodules secondary to Hodgkin's lymphoma

We report a 26-year old lady who presented with chronic cough and breathlessness associated with subtle TB symptoms for 1 year. Her CT thorax showed multiple cavitating pulmonary nodules with mediastinal and cervical lymphadenopathy. Cervical lymph node biopsy and CT-guided pulmonary biopsy at our centre confirmed the diagnosis of Hodgkin’s lymphoma with pulmonary infiltrations. She was successfully treated with ABVD regime but later developed life-threatening bleomycin-induced pulmonary fibrosis. Sadly, she succumbed to respiratory failure due to severe pneumonia with possibility of bleomycin-induced pulmonary fibrosis. Multiple cavitating pulmonary nodules secondary to lymphoma is rare and in TB endemic area, it may result in delayed diagnosis and treatment

Metabolic changes during ramadan fasting in normal people and diabetic patients

Fasting is obligatory on all Muslims every year during the 9th Islamic lunar month of Ramadan with exemption to sick, travelers and pregnant women. In spite of the fact that Islam provides exemption from fasting to people suffering from illnesses like diabetes, many patients still want to fast for personal convictions. Physicians often face a dilemma as to how to advise them. Several studies have been published on the effects of fasting; some of the results are controversial. The present study was undertaken to establish the effects of Ramadan fasting on various physiological parameters in normal people and in diabetic patients. This could be used as basis for advice to such patients. The study group consisted of 53 diabetic patients (31 male and 22 female) and 56 (21 male 35 female) healthy volunteers as controls. Inclusion criteria of diabetic patients were: to be non-insulin dependent, and be stable and under reasonable control on oral hypoglycemic drugs and or diet control alone. The subjects were evaluated 1-2 weeks before commencement of fasting (visit 1), at the 4th week of Ramadan fasting (visit2) and one month after the end of the Ramadan fast (visit3). Blood samples were collected on each occasion at least 8 hours after the last meal. Our results showed statistically significant weight reduction (P<.001) at the end of Ramadan fast in both groups, however it was not maintained in both groups when values were compared before Ramadan and one month after Ramadan. Fasting blood sugar and HBA1C showed significant reduction (P<.001) among diabetics but not in control group. The other parameters e.g. cholesterol, blood urea and creatinine did not show any significant changes before and during Ramadan. There was statistically significant increase in serum cholesterol and triglyceride and uric acid (P<.001) among healthy volunteers (control group) one month after Ramadan compared to before Ramadan; however no such changes were seen among diabetic group. There was no reported case of serious complication due to fasting in both groups. Conclusion: Ramadan fasting lead to significant body weight reduction and improvement of glycaemic control in diabetic patients with out other significant metabolic changes

Hospitalised patients' awareness of their rights: a cross-sectional survey from a tertiary care hospital on the east coast of Peninsular Malaysia

INTRODUCTION: Optimal patient care varies considerably from place to place and is influenced by scientific as well as social developments. The purpose of this study was to investigate awareness and pertinent issues regarding informed consent among hospitalised patients and to determine lapses, in order to improve the standard of care. METHODS: A questionnaire-based cross-sectional survey was conducted among inpatients at a tertiary care level hospital. RESULTS: 90 percent of patients were aware of their rights, and 85 percent had enough information regarding their illness and modality of treatment. However, treatment options were discussed with 45 percent of cases only, and 65 percent of patients were informed of their duration of treatment. Most of the patients from the surgical group, haemodialysis unit and those with minor ailments were very satisfied with the doctors (92 percent, 86 percent and 96 percent, respectively), as opposed to only 36 percent of cancer patients and 70 percent of acquired immunodeficiency syndrome (AIDS) patients (p-value is less than 0.0001). Almost all patients (99 percent) said that their religious beliefs were respected by the staff and they had no problems in accessing them in times of need. Informed consent was obtained by the doctor in 98 percent of cases and by the nurse in two percent. 98 percent of the patients mentioned that their treatments/examinations were conducted in an atmosphere of privacy and that their personal information was kept confidential by their doctors. CONCLUSION: Patients were reasonably informed about their illness. Their privacy and religious beliefs were duly respected. Treatment options and the duration of treatment were not discussed with all patients. Cancer and AIDS patients were less satisfied with the attending staff. The results suggest that there is a need for periodic surveys of patient satisfaction with the quality of care

Transbronchial needle aspiration of mediastinal lymph node

In Malaysia, transbronchial needle aspiration (TBNA) is a relatively new procedure performed only in a handful of respiratory centres. We reviewed TBNA of mediastinal lymph node performed in Hospital Tengku Ampuan Afzan (HTAA) to determine the yield and its complications. Data was retrieved from endoscopy databases and patients' records, CT thorax images and all cytological and histological slides were reviewed. Twenty-five patients had TBNA performed. TBNA was positive in 15 patients (60%). Overall, 80% had confirmed malignancy after bronchoscopy. Only four patients had documented bleeding after TBNA and in two of them, bleeding stopped spontaneously and another two patients required diluted adrenaline to stop the bleed. No mortality was reported from this procedure. Hence, TBNA is a safe procedure

Risk factors associated with development of dengue haemorrhagic fever or dengue shock syndrome in adults in Hospital Tengku Ampuan Afzan Kuantan

A retrospective study was conducted to investigate 183 serologically-confirmed cases of dengue fever (DF) admitted from October 2004 to March 2005 in a large hospital in Pahang. Clinical and laboratory features, progress and outcome of these patients were analysed in order to identify risk factors associated with development of dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS). Individually, we found that older patients, secondary dengue infection, high baseline haematocrit levels, low platelet levels and prolonged activated partial thromboplastin time (APTT) ratio were significant associations with bleeding tendencies. Of these risk factors, haematocrit and APTT ratio were two independent significant risk factors on multivariate analysis. Older patients with primary infection and younger patients with secondary infection had significant bleeding tendencies. We also verified the validity of the haematocrit levels suggested as cut-off levels for plasma leakage for the Malaysian population by Malaysian Clinical Practice Guidelines for Dengue Infection in Adults (2003)

Epidermal growth factor receptor mutations in non- small cell lung cancers in a multiethnic Malaysian patient population

In Malaysian patients with NSCLC, the EGFR mutation rate was similar to that in other Asian populations. EGFR mutations were significantly more common in female patients and in never smokers. Never smoking status was the only independent predictor for the presence of EGFR mutations