2005

D Foo, KS Ng
Correspondence: Dr David Foo, david_foo@ttsh.com.sg

ABSTRACT
A 43-year-old Chinese woman complained of a one week history of irregular rapid palpitations associated with chest discomfort and dyspnoea. Her heart rate was more than 160 beats per minute and blood pressure was 154/95 mmHg. 12-lead electrocardiogram (ECG) showed a wide complex tachycardia with a slightly irregular rhythm. Delta waves were also present. She was treated appropriately with intravenous procainamide but developed torsades de pointes secondary to prolonged QT interval. Electrophysiology study revealed atrial tachycardia with a left-sided accessory pathway which was successfully ablated.

Keywords: accessory pathway, long QT, procainamide, wide complex tachcardia, Wolff-Parkinson-White syndrome
Singapore Med J 2005; 46(5): 245-249

P Visrutaratna, K Oranratanachai, S Likasitwattanakul
Correspondence: Pannee Visrutaratna, pvisruta@mail.med.cmu.ac.th

ABSTRACT
A 13-year-old boy had a history of severe headache for two weeks. He also had seizures and vomited many times. Neurological examination was normal except for bilateral papilloedema. Sagittal T1-weighted magnetic resonance (MR) images showed loss of the normal flow void in the superior sagittal sinus. There was hyperintensity, which came from subacute thrombosis in the posterior half of the superior sagittal sinus. MR venography confirmed loss of flow signal in the superior sagittal sinus. There was also thrombosis of the right transverse, right sigmoid, and left transverse sinuses, and haemorrhagic infarctions in the right frontal and left parietal regions. A diagnosis of dural sinus thrombosis with cerebral venous infarction was made. CT, MR imaging, MR venography, and CT venography findings are discussed in patients with cerebral venous thrombosis.

Keywords: cerebral infarction, computed tomography, cranial sinus thrombosis, magnetic resonance imaging
Singapore Med J 2005; 46(5): 238-244

A Srinivasan, S Venkataraman, SG Hansdak, OC Abraham, D Mathai
Correspondence: Dr S Venkataraman, venkatcmc@rediffmail.com

ABSTRACT
Pancreatitis occurring concurrently with fulminant hepatic failure (FHF) is primarily detected on autopsy and is seldom clinically apparent. We report a fatal case of FHF in a 25-year-old woman which was related to acute hepatitis B infection. In this patient, hyperglycaemia needing insulin infusions led to the detection of acute pancreatitis. FHF complicated by acute pancreatitis has a poor prognosis. A high index of suspicion is necessary for its diagnosis. The role of orthotopic liver transplantation and use of antiviral therapies need further evaluation in this situation.

Keywords: fulminant hepatic failure, hepatitis B, hyperglycaemia, pancreatitis
Singapore Med J 2005; 46(5): 236-237

AWC Kow, KBL Lee, YS Wong
Correspondence: Dr Alfred Kow Wei Chieh, Alfredkow@hotmail.com

ABSTRACT
A patient with musculoskeletal melioidosis masquerading as diabetic amyotrophy is described. A 43-year-old man presented with left thigh pain, fever, malaise and loss of weight. He had diabetes mellitus for six years. He was initially diagnosed with diabetic amyotrophy and was treated conservatively. Recurrence of symptoms prompted further investigations which revealed melioidosis of the left femur. Magnetic resonance imaging showed an enhancing subperiosteal collection. The diagnosis was confirmed by open biopsy and tissue culture. Acute treatment consisted of intravenous ceftazidime for 24 days and oral cotrimoxazole. The patient showed marked improvement clinically and biochemically. He was discharged with oral doxycycline and cotrimoxazole for three months. This disease is eminently treatable, but can be a diagnostic challenge when it presents in an uncommon site.

Keywords: Diabetes amyotrophy, diabetes mellitus, melioidosis, musculoskeletal infection
Singapore Med J 2005; 46(5): 233-235

V Poulose, P Chiam, WT Poh
Correspondence: Dr Vijo Poulose, vijopoulose@pol.net

ABSTRACT
Introduction Kikuchi's disease is a benign form of cervical lymphadenopathy that commonly affects young adults. We report a case series from our hospital.
Methods The clinical features of 23 cases of Kikuchi's disease diagnosed at Changi General Hospital over a seven year period are presented. The cases were identified from pathology records using the search term histiocytic necrotising lymphadenitis.
Results Most of our patients (78 percent) were young women who presented with cervical lymphadenopathy. The median age was 31 years. In the 18 cases who completed follow-up at the hospital, there was spontaneous resolution of symptoms within a six-month period. One patient demonstrated seropositivity for systemic lupus erythematosus (SLE) and was initially started on steroids. However, the treatment was discontinued shortly afterwards since she did not meet the diagnostic criteria for SLE. Excision biopsy of the affected lymph node was the diagnostic method of choice.
Conclusion Kikuchi's disease is not uncommon in the Singaporean population. Establishing an early diagnosis is crucial since the clinical presentation can mimic tuberculous lymphadenitis or malignant lymphoma. The diagnostic method of choice is excision biopsy.

Keywords: histiocytic necrotising lymphadenitis, Kikuchi’s disease, lymph node, lymphadenopathy
Singapore Med J 2005; 46(5): 229-232

SK Tiwari, AA Khan, KS Ahmed, I Ahmed, F Kauser, MA Hussain, SM Ali, A Alvi, A Habeeb, Z Abid, N Ahmed, CM Habibullah
Correspondence: Prof C M Habibullah, cmhabib@rediffmail.com

ABSTRACT
Introduction Current guidelines that recommend Helicobacter pylori eradication treatment without endoscopy in selected patients underscore the importance of non-invasive testing. The accuracy of saliva as a non-invasive specimen was compared with that of invasive tests in pretreatment diagnosis of H. pylori infection.
Methods One hundred patients undergoing gastroscopy were grouped into 80 symptomatic and 20 asymptomatic subjects and were investigated for the presence of H. pylori in saliva and stomach. Samples tested comprised saliva and gastric biopsies collected from each patient. Exclusion criteria were history of peptic ulcer, bleeding ulcer, cancer or recent use of antibiotics, proton pump inhibitors and non-steroidal anti-inflammatory drugs. Two sets of primers homologous to 534 bp fragment of H. pylori DNA, which have been shown previously to be highly specific and sensitive, were used for the polymerase chain reaction (PCR) amplification.
Results 72 (90 percent) of the symptomatic group and 10 asymptomatic subjects were infected with H. pylori in the stomach as determined by histology and direct PCR amplification of biopsy DNA obtained from each subject. H. pylori DNA was identified in the saliva of 70 (87.5 percent) symptomatic subjects and 12 (60 percent) asymptomatic control subjects.
Conclusion High rates of detection using saliva as a specimen indicate that saliva of the infected person could serve as a reliable non-invasive alternative to detect the presence of H. pylori infection in comparison to the currently available standard diagnostic tests.

Keywords: duodenal ulcer, gastritis, Helicobacter pylori, polymerase chain reaction saliva, 16S ribosomal RNA genes
Singapore Med J 2005; 46(5): 224-228

HC Chan, WAW Aasim, NM Abdullah, NN Naing, JM Abdullah, MHM Saffari, A Osman
Correspondence: Prof Jafri Malin Abdullah, deptneurosciencesppspusm@yahoo.com

ABSTRACT
Introduction Paediatric minor head injuries (MHI) are just as common in both bigger and smaller towns in Malaysia. Urban-based MHI are due more to motor vehicular injuries compared to rural-based MHI which are mainly due to non-motor vehicular injuries. The main objectives of this study were to compare incidence of admitted patients to accident and emergency departments of hospitals in two different settings in Malaysia, namely: Ipoh (urban-based) and Kota Bharu (rural-based); and to correlate to demographical characteristics, types of accident, clinical signs and symptoms, radiological and computed tomography (CT) findings, management; and finally, to determine clinical predictors of intracranial injury in MHI.
Methods A cross-sectional study of 153 paediatric patients aged 2-18 years who were admitted to the Ipoh Hospital, Perak and 112 patients of the same age group admitted to Hospital Universiti Sains Malaysia, Kelantan were included in this study. The study period was between 1 January 1998 and 31 December 2001. Data collection was done prospectively. Chi-square and independent t-tests were applied to compare characteristics of patients admitted to these two hospitals. Backward stepwise multiple logistic regression was applied to determine clinical predictors of intracranial injury.
Results There were significant differences of age, race, types of accidents, clinical signs and symptoms, Glasgow coma scale (GCS), skull fracture and CT findings between two hospitals. Significant clinical predictors were headache (OR 20.8, 95 percent CI 3.9-25.2, p-value is less than 0.001), unequal pupils (OR 8.4, 95 percent CI 4.3-17.9, p-value is equal to 0.0413) and GCS score of 13 (OR =3.8, 95 percent CI 1.9-6.8, p-value is equal to 0.005). Skull fractures and intracranial injuries were more common in Kota Bharu due to children riding motorcycles without helmets than in Ipoh (p-value is less than 0.001).
Conclusion In the rural Malaysian community, both the police and physicians must be alerted to the fact that unhelmeted children riding motorcycles are more likely to sustain morbidity than those in urban areas. More aggressive traffic policing of the village roads should be done by the relevant authorities.

Keywords: childhood injury, craniocerebral trauma, emergency medicine, head injury, minor head injury
Singapore Med J 2005; 46(5): 219-223

HH Tan, R Chan
Correspondence: Dr Tan Hiok Hee, hhtan@nsc.gov.sg

ABSTRACT
Introduction Infections caused by Chlamydia trachomatis (C. trachomatis) is one of the commonest sexually transmitted infections (STI). As there is currently no laboratory in Singapore that offers the chlamydia culture tests, alternative laboratory methods were developed and antigen detection methods such as enzyme immunoassays (EIA) proved to be even less sensitive than cell culture. This study was done to assess the accuracy and sensitivity of pooling five endocervical swabs collected for C. trachomatis testing by polymerase chain reaction (PCR) technology, as compared to the currently used EIA on individual swabs, in female sex workers who were seen at a STI clinic in Singapore.
Methods A total of 1,182 endocervical swab specimens were analysed by EIA as well as in pools of five specimens using PCR. Any pool with a positive PCR result for C. trachomatis infections was subjected to repeat PCR testing of the five individual specimens in the pool.
Results There were a total of 48 confirmed cases of C. trachomatis infection. EIA detected 19 positive samples for C. trachomatis, yielding a prevalence of 1.6 percent among the sex workers tested. Pooled PCR testing showed a higher prevalence rate of 4.1 percent, with 48 PCR positive samples. All cases that were EIA positive were also PCR positive. Individual runs on 200 random samples as well as on 220 individual samples from positive pooled results showed PCR inhibition rates ranging from 1.5 percent to 2.3 percent. However, the PCR inhibition rate was 0 percent with the use of pooling. Sensitivity of EIA was 39.6 percent, with 100 percent specificity. EIA tests had a false negative rate of 60.4 percent. PCR was found to be 100 percent sensitive and specific.
Conclusion C. trachomatis infections among female sex workers attending the clinic were found to be higher using PCR technology. Less sensitive methods such as EIA result in undertreatment of otherwise undetected cases. The pooling strategy using pool sizes of five specimens, with a disease prevalence of 4.1 percent is reliable and cost-effective, and has since been introduced in the current medical surveillance scheme for sex workers in the clinic.

Keywords: Chlamydia trachomatis, enzyme immunoassays, polymerase chain reaction
Singapore Med J 2005; 46(5): 215-218