2005

H Yanardag, S Uygun, V Yumuk, M Caner, B Canbaz
Correspondence: Prof Halil Yanardag, halilyanardag@yahoo.com

ABSTRACT
Cerebral tuberculoma is a rare entity and is one of the causes of intracerebral mass lesions. A rapid diagnosis based on pathological findings improves its prognosis. We describe two cases where the tuberculoma was located in the cavernous sinus and prepontine cistern, respectively. The first case was a 36-year-old man who was admitted with progressive headache, left ptosis and diplopia. Computed tomography showed a solid enhancing mass in the left cavernous sinus. Diagnosis of meningioma was proposed and a left pterional craniotomy was performed. Histopathological examination revealed granulomatous inflammation with areas of caseation necrosis. The second case was a 20-year-old man who presented with headache, new-onset strabismus, diplopia, malaise, weight loss and low-grade fever. The lesion mimicked an aggressive meningioma on imaging. The patient was operated for primary diagnosis of cerebral tumour. The histopathological examination of the excised lesion revealed a tuberculoma. Although the incidence of tuberculosis is decreasing, a high index of suspicion must be maintained for the diagnosis of intracranial masses in the presence of risk factors for tuberculosis.

Keywords: cerebral tuberculoma, intracerebral mass, tuberculoma, tuberculosis
Singapore Med J 2005; 46(12): 731-733

IB Yeh, LCS Tan, YY Sitoh
Correspondence: Dr Yeh Ing Berne, berneyeh@gmail.com

ABSTRACT
Clinically mild encephalitis with a reversible lesion in the central splenium of the corpus callosum (SCC) is a recently-described clinicoradiological entity. We report a 20-year-old man presenting with fever and a single episode of generalised seizures. Initial magnetic resonance (MR) images showed an ovoid lesion with T1 and T2 signal prolongation, restricted diffusion and decreased apparent diffusion coefficient values in the centre of the SCC, which resolved completely on a repeat MR imaging done three months later. Clinically, the patient had a mild clinical course and made a full recovery. This clinicoradiological entity with an excellent prognosis is elaborated with possible differential diagnoses given. Emphasis is placed on avoiding unnecessary invasive investigation or therapeutic intervention.

Keywords: acute disseminated encephalomyelitis, corpus callosum, encephalitis, magnetic resonance imaging, seizure
Singapore Med J 2005; 46(12): 726-730

NC Tan, S Ibrahim, KH Tay
Correspondence: Dr Tan Ngian Chye, ngian79@singnet.com.sg

ABSTRACT
Endoscopic treatment of bleeding duodenal varices is less invasive than the usual surgical options. However, there is limited experience with endoscopic treatment of bleeding duodenal varices, especially with that of endoscopic ligation. We report a 55-year-old man with a bleeding duodenal varix that was successfully ligated endoscopically. He has been followed up for nine months with no recurrence of bleeding. Endoscopic ligation may offer a new and effective treatment modality for bleeding duodenal varix.

Keywords: duodenal varix, endoscopic banding, endoscopy, gastrointestinal bleeding
Singapore Med J 2005; 46(12): 723-725

KT Lee, S Singh, CH Lai
Correspondence: Dr Lai Choon Hin, choon_hin_lai@ttsh.com.sg

ABSTRACT
Introduction We retrospectively reviewed the results of total elbow arthroplasty in patients with rheumatoid arthritis of the elbow followed for a minimum of two years.
Methods Between September 1999 and March 2001, seven patients with rheumatoid arthritis of the elbow were treated with total elbow arthroplasty using the semi-constrained Coonrad-Morrey elbow replacement prostheses. One patient died 19 months after her surgery and was excluded from the study. Two patients had bilateral total elbow replacements. Eight elbows were thus available for review. The mean age of our patients at the time of surgery was 55.5 years. The indication for surgery was severe pain and stiffness in six elbows, and distal humerus fractures in two elbows.
Results The mean duration of postoperative hospitalisation stay was 6.6 days. The average length of follow-up was 39.4 months. Six elbows had no pain, while two elbows had mild pain. The mean arc of flexion was 101.3 degrees. The mean Mayo elbow performance score was 93.1 points. Excellent results were achieved in six elbows, while two elbows had good outcome. There was one case of intraoperative lateral condylar fracture treated with internal fixation. One patient developed blisters postoperatively but resolved with dressings and antibiotics.
Conclusion Our small study revealed good to excellent short-term outcome with the use of semi-constrained total elbow arthroplasty for the treatment of rheumatoid arthritis of the elbow in Asian patients.

Keywords: arthroplasty, elbow, replacement arthroplasty, rheumatoid arthritis
Singapore Med J 2005; 46(12): 718-722

YL Lim, T Thirumoorthy
Correspondence: Dr Lim Yen Loo, yllim@nsc.gov.sg

ABSTRACT
Introduction Serious cutaneous adverse reactions to traditional medicines are not well described or reported in the literature, despite growing use of these medicines.
Methods This is a case series of four patients who were found to have various serious cutaneous adverse reactions to the traditional Chinese medicines that they had taken.
Results In this series, there was a patient with toxic epidermal necrolysis from traditional Chinese medicine, another with acute generalised exanthematous pustulosis from piroxicam and salicylate-contaminated traditional Chinese medicine, and two patients with drug hypersensitivity syndrome--one from traditional Chinese medicine and the other from phenylbutazone-adulterated traditional Chinese medicine.
Conclusion The series illustrates that serious cutaneous adverse reactions do occur with traditional medicines and emphasises the importance of being aware of such reactions.

Keywords: adverse reaction, cutaneous reaction, drug reaction, traditional Chinese medicine
Singapore Med J 2005; 46(12): 714-717

FS Al-Joudi
Correspondence: Dr Fawwaz Shakir Al-Joudi, fajoudi@hotmail.com

ABSTRACT
Introduction Decreased serum albumin (SA) levels have been used extensively as prognostic indicators in many chronic debilitating diseases. The decrease may be partly compensated by globular proteins. The failure of globulins to compensate may reflect advanced disease. We examined the prognostic value of the level of serum globulins in colorectal and breast cancers.
Methods Data of 80 patients with advanced colon and breast cancers were analysed. Of these, 46 patients died within six months of measurement of their serum proteins, and the rest were followed-up for more than six months after measurements of their serum proteins were taken. A mathematical formula, representing the globulin compensation index (GCI), was recently developed from the measured SA levels and globulins. Patients were then classified into three categories: negative GCI and negative compensation; GCI of 0 to less than 1.0 with partial compensation; and GCI equal or greater than 1.0 with full compensation.
Results Among the deceased patients, 45.7 percent had negative GCI, compared to 26.5 percent of patients in the survivors group. For partial compensation, 30.4 percent of patients were from the deceased group, and 32.4 percent were from the survivors group. For full compensation (elevated GCI), 23.9 percent of patients were from the deceased group, compared to 41.1 percent from the survivors group (p-value equals 0.031).
Conclusion Patients with low GCI are more likely to have bad prognoses, whereas those with higher GCI have more favourable prognoses. Globulin compensation may be a reliable prognostic factor in advanced colorectal and breast cancers, and possibly in other chronic illnesses. The GCI may serve as a useful tool in the measurement of this compensation.

Keywords: breast cancer, colon cancer, globulin compensation index, serum albumin, serum globulin
Singapore Med J 2005; 46(12): 710-713

B Chaiwun, N Sukhamwang, S Lekawanvijit, K Sukapan, S Rangdaeng, M Muttarak, PS Thorner
Correspondence: Dr Benjaporn Chaiwun, bchaiwun@mail.med.cmu.ac.th

ABSTRACT
Introduction This study aims to correlate fine-needle aspiration specimens diagnosed as C3 (atypical, probably benign) and C4 (suspicious, probably malignant) with histology and mammography, and to evaluate these two cytology categories in terms of diagnostic usefulness and patient management.
Methods All fine-needle aspiration (FNA) specimens in categories C3 or C4 at the Maharaj Nakorn Chiang Mai Hospital, Thailand between 2000-2004 were reviewed. Results were correlated with available histological and mammographical studies.
Results 148 FNA specimens were identified, comprising 43 category C3 and 105 category C4. Histology was available in 90 cases. 14 (64 percent) C3 cases showed benign histology on biopsy and eight (36 percent) were malignant. 13 (19 percent) C4 cases were benign on biopsy, whereas 55 (81 percent) were malignant. Mammographical studies were available in 56 of the histologically-proven cases. All seven cases with benign mammograms had benign histology, and all 26 cases called "highly suggestive of malignancy" were malignant on histology (five C3 and 21 C4). Of the 23 cases called "suspicious abnormality" on mammography, 14 turned out to be malignant on biopsy (one C3 and 13 C4).
Conclusion Our study supports maintaining cytology categories C3 and C4. About two-thirds of C3 cases were benign on biopsy whereas 81 percent of C4 cases were malignant (p-value is less than 0.001). There was complete correlation between histological and mammographical studies except those with equivocal mammograms. Our study supports the combined use of clinical, mammographical and cytological findings for optimal patient management. This is especially important for patients with C3 aspiration results, in order to avoid unnecessary surgery for benign lesions.

Keywords: breast biopsy, breast cancer, cytology, fine-needle aspiration, mammography
Singapore Med J 2005; 46(12): 706-709

B Norsa’adah, BN Rusli, AK Imran, I Naing, T Winn
Correspondence: Dr Norsa’adah Binti Bachok, norsaadah@kb.usm.my

ABSTRACT
Introduction Breast cancer is the commonest cancer for females in Malaysia, with a prevalence of 86.2 per 100,000 women in 1996. Breast cancer mortality rate shows an increasing trend in Malaysia from 0.61 in 1983 to 1.8 per 100,000 women in 1992. The aim of this study was to identify the risk factors for breast cancer in women in Malaysia.
Methods A matched case-control study was carried out at referral hospitals in Kelantan from July 2000 to June 2001. A standardised questionnaire that comprised socio-demographical factors, obstetrical and gynaecological histories, anthropometric measurements, and other potential risk factors for breast cancer, was used to interview 147 histologically-confirmed breast cancer patients and 147 controls. Controls were non-breast cancer patients who were matched for age and ethnicity, and excluded those with malignancies, or having gynaecological, hormonal or endocrine problems. Simple and multiple conditional logistic regressions were used for analyses.
Results Factors contributing toward increased risk of breast cancer were nulliparity (odds ratio [OR] of 15.3; 95 percent confidence interval [CI] of 3.2, 72.4), overweight (OR of 2.1; 95 percent CI of 1.1, 3.9), family history of breast cancer (OR of 4.3; 95 percent CI of 1.3, 14.1) and previous use of oral contraceptives (OR of 2.5; 95 percent CI of 1.3, 4.8).
Conclusion This study reconfirmed that similar risk factors identified in Western populations were responsible for the occurrence of breast cancer in Kelantan. It also supported the theory that breast cancer occurrence was related to oestrogen exposure and familial factors. It suggested the importance of having children, maintaining ideal body weight and caution for oral contraceptive users and women with a family history of breast cancer.

Keywords: breast cancer, cancer risk factors, oestrogen exposure, oral contraceptive
Singapore Med J 2005; 46(12): 698-705