Alwi Muhd Besari

Molecular detection of leptospirosis and melioidosis co-infection: A case report

Leptospirosis and melioidosis are important tropical infections caused by Leptospira and Burkholdheria pseudomallei, respectively. As both infections share similar clinical manifestations yet require different managements, complementary laboratory tests are crucial for the diagnosis. We describe a case of Leptospira and B. pseudomallei co-infection in a diabetic 40-year-old woman with history of visit to a freshwater camping site in northern Malaysia. To our knowledge, this is the first case of such double-infection, simultaneously demonstrated by molecular approach. This case highlights the possibility of leptospirosis and melioidosis co-infections and their underlying challenges in the rapid and accurate detection of the etiologic microorganism.

Concurrent hyphema and orbital apex syndrome following herpes zoster ophthalmicus in a middle aged lady

Highlights • Herpes zoster ophthalmicus is an uncommon clinical presentation.• Concurrent hyphema and orbital apex syndrome are rare clinical sequelae.• Hyphema is postulated due to auto immune vasculitis affecting iris vessel.• Orbital apex syndrome results from occlusive vasculitis affecting vasculature of optic nerve and extraocular muscles.• This incidence probably suggests that occlusive vasculitis occurs at more than one site in the affected dermatome.

Post-partum streptococcal toxic shock syndrome associated with necrotizing fasciitis

We report a fatal case of post-partum streptococcal toxic shock syndrome in a patient who was previously healthy and had presented to the emergency department with an extensive blistering ecchymotic lesions over her right buttock and thigh associated with severe pain. The pregnancy had been uncomplicated, and the mode of delivery had been spontaneous vaginal delivery with an episiotomy. She was found to have septicemic shock requiring high inotropic support. Subsequently, she was treated for necrotizing fasciitis, complicated by septicemic shock and multiple organ failures. A consensus was reached for extensive wound debridement to remove the source of infection; however, this approach was abandoned due to the patient’s hemodynamic instability and the extremely high risks of surgery. Both the high vaginal swab and blister fluid culture revealed Group A beta hemolytic streptococcus infection. Intravenous carbapenem in combination with clindamycin was given. Other strategies attempted for streptococcal toxic removal included continuous veno-venous hemofiltration and administration of intravenous immunoglobulin. Unfortunately, the patient’s condition worsened, and she succumbed to death on day 7 of hospitalization.

Intraventricular Tuberculoma with Profound Visual Loss: A Case Report and Literature Review

Intracranial tuberculoma is a rare manifestation of tuberculosis involving the central nervous system. The involvement of the ventricular system is extremely uncommon. We describe a young woman with bilateral papilledema secondary to intraventricular tuberculoma with hydrocephalus. She was treated with anti-tuberculosis therapy and intravenous dexamethasone. Her visual acuity deteriorated after one month of treatment. We provide a literature review of this uncommon ocular sequelae.

Case report: Unusual cause of difficulty in intubation and ventilation with asthmatic-like presentation of Endobronchial Tuberculosis

Endobronchial Tuberculosis is hazardous in causing circumferential narrowing of tracheobronchial tree despite the eradication of tubercle bacilli in the initial insult from Pulmonary Tuberculosis. They may present as treatment resistant bronchial asthma and pose challenge to airway management in the acute setting. We present a 25 year-old lady who was newly diagnosed bronchial asthma with a past history of Pulmonary Tuberculosis that had completed treatment. She presented with sudden onset of difficulty breathing associated with noisy breathing for 3 days and hoarseness of voice for 6 months. Due to resistant bronchospasm, attempts were made to secure the airway which led to unanticipated difficult intubation and ventilation. Subsequent investigations confirmed the diagnosis of Endobronchial Tuberculosis and patient was managed successfully with anti TB medication, corticosteroids and multiple sessions of tracheal dilatation for tracheal stenosis. This case highlights the unusual cause of difficulty in intubation and ventilation due to Endobronchial Tuberculosis, which required medical and surgical intervention to improve the condition.

Acute bacteremic pneumonia due to melioidosis developing in the intensive care setting

Highlights • Patients who are diagnosed with melioidosis pose significant challenges to the medical team involved because it involves a high rate of morbidity and mortality.• Managing cases of melioidosis is multidisciplinary as it may manifest under various clinical situations.• In endemic area, melioidosis can occur in immunocompetent youths with no recognisable risk factors.

Severe Plasmodium knowlesi with dengue coinfection

We report a case of severe Plasmodium knowlesi and dengue coinfection in a previously healthy 59-year-old Malay man who presented with worsening shortness of breath, high-grade fever with chills and rigors, dry cough, myalgia, arthralgia, chest discomfort and poor appetite of 1 week duration. There was a history mosquito fogging around his neighbourhood in his hometown. Further history revealed that he went to a forest in Jeli (northern part of Kelantan) 3 weeks prior to the event. Initially he was treated as severe dengue with plasma leakage complicated with type 1 respiratory failure as evidenced by positive serum NS1-antigen and thrombocytopenia. Blood for malarial parasite (BFMP) was sent for test as there was suspicion of malaria due to persistent thrombocytopenia despite recovering from dengue infection and the presence of a risk factor. The test revealed high count of malaria parasite. Confirmatory PCR identified the parasite to be Plasmodium knowlesi. Intravenous artesunate was administered to the patient immediately after acquiring the BFMP result. Severe malaria was complicated with acute kidney injury and septicaemic shock. Fortunately the patient made full recovery and was discharged from the ward after 2 weeks of hospitalisation.

Muscular sarcocystosis: an index case in a native Malaysian

A previously healthy 20-year-old man presented with prolonged intermittent low grade fever and cough for 6months. He had bilateral calf pain and lower limb weakness 2days prior to admission. Physical examination revealed multiple enlarged lymph nodes with hepatomegaly. There was bilateral calf tenderness with evidence of proximal myopathy. Full blood picture showed lymphocytosis with reactive lymphocytes and eosinophilia. Creatine kinase and lactate dehydrogenase were markedly elevated. Over 2 weeks of admission, patient was treated symptomatically until the muscle biopsy of right calf revealed eosinophilic myositis with muscular sarcocystosis. He was treated with albendazole and high-dose corticosteroids. Symptoms subsided on reviewed at 2weeks and the dose of corticosteroid was tapered down slowly over a month. Due to poor compliance, he was readmitted 1month later because of relapsed. High-dose corticosteroid was restarted and duration for albendazole was prolonged for 1month. His symptom finally resolved over 2weeks.