2005

CT Wai, G Lau, DS Sutedja
Correspondence: Dr Chun-Tao Wai, waict@nuh.com.sg

ABSTRACT
A 56-year-old man underwent triphasic computed tomography (CT) of the abdomen as part of his work-up for liver transplantation. A mottled, rounded lesion with a dense rim was noted in the gastric lumen, which remained unchanged in appearance in the arterial, portal venous, and delayed phases of the CT. Gastroscopy performed three days later confirmed the presence of trichobezoar. The foreign body was broken down into smaller pieces by an endoscopic snare and was passed out spontaneously. The clinical presentation, radiological findings, and management of trichobezoars are discussed.

Keywords: computed tomography, gastroscopy, hairball, stomach lesion, trichobezoar
Singapore Med J 2005; 46(7): 359-362

M Muttarak, B Lojanapiwat
Correspondence: Prof Malai Muttarak, mmuttara@mail.med.cmu.ac.th

ABSTRACT
Many disease processes, including inflammation, testicular torsion, testicular trauma, and testicular cancer, may have a similar clinical presentation as a painful scrotum. Differentiation of these disease processes is important for proper management. High-resolution ultrasonography (US) combined with colour Doppler ultrasonography (CDUS) is the imaging modality of choice in evaluating these patients. Gray-scale US helps to better characterise scrotal lesions. CDUS demonstrates testicular perfusion which aids in reaching a specific diagnosis. This pictorial essay is intended to review the causes, US appearances of disease processes causing the painful scrotum, and examination pitfalls of scrotal US.

Keywords: epididymitis, orchitis, scrotal abnormalities, testicular torsion, testicular trauma, testicular neoplasms, ultrasonography
Singapore Med J 2005; 46(7): 352-358

YC Kwah, YH Leow
Correspondence: Dr Yung Chien Kwah, raykyc@yahoo.com

ABSTRACT
Acute generalised exanthematous pustulosis (AGEP) is an adverse drug reaction that can occur in any age group. It is commonly mistaken as pustular psoriasis or cutaneous infection, resulting in unnecessary commencement of medications such as methotrexate and antibiotics that can cause harm to the patient or interact and adversely affect the efficacy of other medications. Early diagnosis of AGEP avoids unnecessary investigations and treatment, which not only can harm the patient but also escalate health care, as the condition is self-limiting. This case report illustrates AGEP secondary to Cefaclor occurring in a 72-year-old Chinese woman. Although the literature has documented the occurrence of AGEP with Cefaclor, the unique feature of this case is the occurrence of AGEP following repeated uneventful courses of Cefaclor. This case highlights that AGEP must never be forgotten in the work-up for pustular eruptions in an elderly patient.

Keywords: acute generalised exanthematous pustulosis, cefaclor, drug allergy, pustular eruptions
Singapore Med J 2005; 46(7): 349-351

W Zhang, KS Ho, HJ Han, CS Kong, KW Eu
Correspondence: Dr Eu Kong Weng, gcsekw@sgh.com.sg

ABSTRACT
We report a 67-year-old woman who underwent laparoscopic-assisted abdomino-perineal resection for rectal carcinoma. She sustained hypotension of 40/20 mmHg associated with bradycardia (heart rate 30 to 45 beats per minute) and an end-tidal carbon dioxide level of zero when she was raised to a head-up position at the end of surgery to facilitate pelvic irrigation. Pulmonary air embolism was confirmed by aspiration of 15 millilitres of foamy blood from her central venous line. Resuscitation was successful and she recovered completely with no neurological deficits.

Keywords: air embolism, colectomy, laparoscopic surgery, rectal cancer, surgery complications
Singapore Med J 2005; 46(7): 347-348

I Naqiyah, M Rohaizak, FA Meah, MJ Nazri, M Sundram, AR Amram
Correspondence: Dr Naqiyah Ibrahim, naqiyah@mail.hukm.ukm.my

ABSTRACT
The occurrence of urinary bladder paragangliomas is rare. A 12-year-old Chinese girl who presented with history of blurring of vision was found to have grade IV hypertensive retinopathy. Investigations revealed a phaeochromocytoma on the posterior wall of the urinary bladder. A partial cystectomy with right ureter reimplantation was undertaken and her hypertension was promptly controlled. The diagnosis and management of this rare tumour is discussed.

Keywords: bladder neoplasm, extra-adrenal tumour, hypertension, phaeochromocytoma, urinary bladder tumour
Singapore Med J 2005; 46(7): 344-346

MK Thong, TL Soo
Correspondence: Dr Thong Meow Keong, thongmk@um.edu.my

ABSTRACT
Introduction Beta-thalassaemia major is one of the commonest genetic disorders in South East Asia. The strategy for the community control of beta-thalassaemia major requires the characterisation of the spectrum of beta-globin gene mutations in any multi-ethnic population. There is only a single report of mutation analyses of the beta-globin gene in an isolated Kadazandusun community in Kota Belud, Sabah, Malaysia, which showed the presence of a common 45 kb deletion.
Methods To confirm the observation that this large deletion is the commonest beta-globin gene mutation among the Kadazandusun and other indigenous populations in Sabah, Malaysia, we performed polymerase chain reaction (PCR) analysis of the beta-globin gene in ten children with beta-thalassaemia major attending the Thalassaemia Centre, Queen Elizabeth Hospital, the major paediatric referral centre in Kota Kinabalu, Sabah.
Results The 45 kb deletion was confirmed to be the commonest mutation found in the Kadazandusun, Bajau and Murut populations, whereby it was detected in 19 out of the 20 (95 percent) alleles analysed. The other mutation was due to an IVS-1 position 1 G > T mutation.
Conclusion This finding confirmed the deletion in the homozygous state was associated with a severe phenotype. The reason for the predominance of this mutation in Kota Kinabalu is most likely to be due to founder effects and possibly intermarriages between the various ethnic groups. Prenatal diagnosis using PCR for this common mutation is feasible in this community. Medical workers and scientists at molecular diagnostic centres serving large South East Asian populations should incorporate a diagnostic strategy for this deletion in the appropriate population. Future studies on these indigenous ethnic groups in other areas and other groups in Sabah are required.

Keywords: beta-thalassaemia, gene deletion, genetic disorder, mutation, thalassaemia
Singapore Med J 2005; 46(7): 340-343

NC Tan, SL Cheah
Correspondence: Dr Ngiap-Chuan Tan, Tan.Ngiap.Chuan@singhealth.com.sg

ABSTRACT
Introduction Asymptomatic chronic hepatitis B virus (HBV) carriers, followed-up in primary care, present a challenge to primary care physicians as they encounter problems in monitoring this group of patients. The study aims to explore the barriers faced by primary care physicians in the management of patients with chronic hepatitis B infection in primary care.
Methods Qualitative analysis of eight focus group discussions with 43 primary care physicians in Singapore was conducted.
Results Primary care physicians highlighted the HBV carriers' poor compliance to disease monitoring as a major hurdle, attributing to their lack of understanding of the disease, state of denial, fear of stigmatisation in society, failure to perceive benefits, costs and reluctance of investigations due to physical discomfort. The carriers' health-seeking behaviour, such as doctor hopping and the use of traditional medication, were other barriers. The investigators noted that the physicians placed emphasis on passive disease monitoring, focusing on the investigation results when they reviewed the carriers. They were less proactive in explaining the disease's natural history nor discussing the possibility of definitive anti-viral treatment for suitable carriers. These physicians varied in their approaches in disease monitoring of chronic HBV infection. The fees-for-service healthcare system allowed the carrier to seek consultation from different doctors, which could result in disruption of disease surveillance. This was further compounded by the differential cost of investigations in private practices and government-aided polyclinics. The absence of a national HBV registry and recall system and waiting time for referral to specialist clinics in restructured hospitals, were other barriers.
Conclusion The management of HBV carriers in primary care could be enhanced by measures that eliminate the barriers involving the patient, doctor and healthcare system.

Keywords: chronic hepatitis B infection, hepatitis, primary care physicians
Singapore Med J 2005; 46(7): 333-339