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Sarawak Health Journal
Towards Better Clinical Outcomes
Volume 3 2016
Datu Dr Zulkifli Jantan (Sarawak State Health Director)
Medical care has always been an important component to
improve the quality of health care services in our country and has been
improved beyond recognition over the past decades. An important
contribution for this improvement is clinical research.
Clinical research includes many different types and complexity of
research ranging from basic research, patient-oriented research,
translational research and outcome research. Implementation of clinical
research findings help to move health care towards more widespread use
of evidence-based medicine, with the ultimate goal for achieving better
patient diagnosis, treatment and rehabilitation. For example, the
development of effective drugs has revolutionised the treatment of heart attacks and hypertension and
enabled many people with chronic illnesses such as schizophrenia and type I diabetes mellitus to stay
at home with medication without the need to be admitted to hospital.
Malignancies such as acute leukaemia have now become treatable, and people can now live
with many types of cancers instead of dying from them. Advanced imaging technologies such as CT
(Computed Tomography) scan and MRI (Magnetic Resonance Imaging) have provided more accurate
diagnosis resulting in correct and focussed treatments. For example, a patient who is now diagnosed
with ischaemic stroke through CT scan after ruling out haemorrhagic stroke is able to receive
treatment with streptolysis within the golden hour period, whereby the neurological deficit might be
reversible resulting in better prognosis.
Sarawak has been active in research and has contributed to new scientific knowledge that has
global implications. A number of our medical research and case studies have been published in
international journals. The initial discovery of Plasmodium knowlesi in Kapit, Sarawak has enormous
implications on malaria control and treatment especially for tropical countries of South East Asia
leading to reduced mortality. The study of the effects of Japanese encephalitis vaccination and
controlling of climate variability in Sarawak by Dr Daniel Impoinvil, Dr Ooi Mong How
(Paediatrician of Sarawak General Hospital) et al has shown the true extent of reduction in the
incidence of Japanese Encephalitis transmission by taking into account climate inter-annual
variability. The discovery of enterovirus 71 as an important cause of Hand, Foot and Mouth Disease
(HFMD) outbreak and mortality in Sarawak has enormous implications in the management of HFMD
outbreaks and clinical cases.
With rapidly increasing healthcare demands, driven by population growth rate and increasing
lifetime expectancy, more and more clinical research are needed to achieve the ultimate goal of better
patient diagnosis, treatment and rehabilitation. There are 30 Ministry of Health (MOH) hospitals with
clinical research centres in Malaysia which include three hospitals in Sarawak, namely Sibu Hospital,
Sarawak General Hospital and Miri Hospital. For the State Research Day 2015, we had more than
100 participations from the whole Sarawak. They consisted of different categories of staff ranging
from clinical and public health specialists, medical officers, nurses and allied health staff.
As the Sarawak State Health Director and advisor for Sarawak State Health Research Day
2015, I would like to express a warm thank you to all who have been involved in the State Research
Day preparation, and to congratulate all the participants for their impressive research and
presentations. I hope that some of the research findings can be applied in medical practice in future
and contribute to bring better health and quality of life of patients in Sarawak as well as the rest of
the world.
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Sarawak Health Journal
Volume 3 2016
The New Clinical Research Centre at Sarawak General Hospital – A Review and
Update
Dr Alan Fong Yean Yip
The new Clinical Research Centre at Sarawak General Hospital (CRC SGH) is slated to open
this year.
The concept of a purpose-built CRC, located within a public-access tertiary referral centre,
originated in 2005, when there was an increase in clinical trials, both industry-sponsored (ISR) and
investigator-initiated (IIR), at SGH. With an increasing number of clinicians developing interest in
clinical research, and steady success since early 2000, the Ministry of Health added SGH to its
Network of Clinical Research Centres (NCRC) in 2003.
Prof Dr Sim Kui Hian, as the first Head of CRC SGH, oversaw the birth and early growth of
CRC SGH. He also initiated plans to construct a purpose-built CRC at SGH - a facility that was able
to undertake early and late phase clinical trials. Such a facility would not only address the limitations
associated with the heavy clinical responsibilities of a tertiary care centre, but also augment research
output directly at the site, and also for its collaborative partner institutions. In addition to critical
knowledge generation, it was envisioned that this centre would also accelerate the growth of the entire
clinical research ecosystem – locally and nationally.
The new CRC SGH was constructed at the site adjacent to the critical care block, operating
theatres and the clinical Block D of SGH. The foundation stone was laid by the then Director General
of Health, Tan Sri Dato’ Seri Dr Hj Mohamed Ismail bin Merican, on 27 September 2007. Foundation
works commenced on 15th January 2011. Following a steady construction schedule, this new CRC
SGH block aims to be completed this year. The new CRC SGH is located over three levels in the new
block – Level 4 – clinical areas, Level 5 – administrative areas, Level 6 – archiving areas. The clinical
areas have a 10-bedded intensive monitored ward and five clinic consultation rooms. In addition, it
will house a fully equipped bioanalytical laboratory and a human physiology laboratory - the former
containing advanced instruments for drug level measurements, and the latter instruments to assess
heart, lung and brain functions. There are monitored bioarchiving facilities and an internal electronic
data capture system. These instruments are to optimise safety and efficiency of clinical trial execution,
especially for early phase studies. In-house staff training was done in earnest since conception of
CRC SGH and the centre now has 45 staff.
In conjunction with efforts in partnership with the NCRC and Clinical Research Malaysia, the
new CRC SGH aims to be a leading clinical research facility of the Ministry of Health Malaysia, in
this region.
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Volume 3 2016
Hospital
Observational
Research
Hospital Observational Research
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Sarawak Health Journal
Volume 3 2016
Procedure Duration Estimation & Accuracy: A New Key Performance Index?
Chan WK1, Kuan PX2, Teo SC1 & Norzalina E1
1
Anaesthesiology and Intensive Care Unit, Sarawak General Hospital, Malaysia; 2Clinical Research
Centre, Sarawak General Hospital, Malaysia
Corresponding Author: Chan Weng Ken ([email protected])
Introduction: Malaysia reported a total health expenditure of 4.5% Gross Domestic Product in 2012,
of which RM 14,331 million (63.8%) goes into services of curative care in public sector (MNHAU,
2014). Typical operating theatre (OT) consumes at least 10% of the hospital budget ( Macaulay et al,
1966). As a measure to improve productivity and harmony of the workflow, National Health Service
in United Kingdom has introduced ‘The Productive Operating Theatre’ in September 2008. Since its
implementation, it had resulted in significant savings, an average of £7 million per hospital (NHS,
2013). In our recent OT audit done in December 2014, there were an average of 1.6 elective patients
cancelled daily, eight to 24 emergency cases brought forward daily, and 35 elective operating theatres
overshot more than 60 minutes. These numbers translated into cancellation of elective cases, longer
waiting time for emergency cases due to overshot elective OT’s which resulted in rising bed
occupancy rate, patients’ dissatisfaction and medical complications from prolonged hospital stay and
delayed operation. These escalated the cost in treating patients. There is a need to utilize OT
efficiently especially in regards to time management to avoid wastage. Hence, we look into clinicians’
ability to estimate the duration of their procedure as better accuracy will results in better planning,
therefore more efficacious resource management.
Main Objectives:
i) To assess the accuracy of anaesthetists and surgeons in estimating time taken to complete a
procedure.
ii) To determine the relationship between American Society of Anaesthesiologists (ASA)
classification, mode of anaesthesia and surgical discipline with duration to complete a
procedure.
Methods: Retrospective analysis on estimated time vs actual duration taken to complete a procedure
for all elective cases done in Sarawak General Hospital Main OT in February 2015. Prior to operation,
both surgeons and anaesthetists were asked to estimate the procedure’s duration, which were
subsequently compared with the actual time taken. All data were entered and analysed in Statistical
Package for Social Science version 20 using paired sample T-test, Analysis of Variance and KruskalWallis.
Results and Discussion: Actual time for induction, skin to skin and reversal showed statistically
significant overestimation reflecting the predicting inaccuracies of the participants in procedural time
(p<0.001). A possible explanation would be that participants tend to overestimate during this audit
period. Anaesthetists were more often accurate in estimating induction and reversal time as compared
with surgeons in estimating preparation and skin-to-skin time. There is no significant relationship
between ASA classes during induction (p=0.770) likely due to efficient utilization of manpower when
inducing patients who were ASA>2. Longer induction time for total intravenous anaesthesia cases
(50 mins) could be explained by the preponderance of Neurosurgery and Spine cases. Plexus block
and subarachnoid block resulted in significantly shorter reversal time, 33.3% and 46.7% respectively
the time needed for general anaesthesia / intermittent positive pressure ventilation (GA/IPPV).
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Sarawak Health Journal
Volume 3 2016
Conclusion: We propose that multi-disciplinary pre-operative discussion among anaesthetists and
surgeons should be held in order to improve the use of resources and patient management. We also
advocate regional anaesthesia to improve turn-around-time.
Key Words: Procedure duration estimation; operating theatre management
References:
1. Malaysia National Health Accounts Unit (MNHAU). Malaysia National Health Accounts:
Health Expenditure Report 1997-2012. MOH 2014. Retrieved from: http://www.moh.gov.my/
english.php/pages/view/56 on 18 April 2015.
2. Macaulay HMC & Davies RL. Hospital planning and administration. WHO 1966. Retrieved from:
http://apps.who.int/iris/handle/10665/41781 on 18 April 2015.
3. National Health Service. Evaluation of the productive operating theatre programme 2013.
Retrieved from: http://www.optimitymatrix.com/wp-content/uploads/2013/09/Evaluation-ofThe-Productive-Operating-Theatre-programme-FINAL.pdf on 18 April 2015.
Table 1: Accuracy of estimation according to surgical discipline
Discipline
Induction
Preparation
Skin to skin
Reversal
General Surgery
Accurate
Accurate
Often misestimate
Accurate
Plastic & combined
Accurate
Accurate
Often misestimate
Accurate
Paediatric Surgery
Accurate
Often misestimate
Accurate
Misestimate
Neurosurgery
Accurate
Often misestimate
Often misestimate
Accurate
Orthopaedic
Accurate
Accurate
Often misestimate
Accurate
Ear, Nose & Throat
Accurate
Accurate
Accurate
Accurate
Misestimate
Accurate
Accurate
Often misestimate
Obstetrics & Gynaecology
Accurate
Accurate
Misestimate
Accurate
Dental
Accurate
Accurate
Accurate
Accurate
Misestimate
Accurate
Often misestimate
Accurate
Accurate
Often misestimate
Often misestimate
Accurate
Eye
Urosurgery
Spine
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Sarawak Health Journal
Volume 3 2016
Effectiveness of the Introduction of Modified RE-LY Warfarin Dosing Algorithm in
International Normalized Ratio Clinic of Kapit Hospital on Anticoagulation Control
Chin WV1, Siong JYK2 & Theng MI2
1
Medical Department, Kapit Hospital, Sarawak, Malaysia
2
Pharmacy Department, Kapit Hospital, Sarawak, Malaysia
Corresponding Author: Chin Wei Ven ([email protected])
Background: Despite emergence of novel oral anticoagulants (NOAC), warfarin remains a widely
used anticoagulant in view of its easy reversibility of action. Time within Therapeutic Range (TTR),
a measurement used to determine the proportion of time for which the INR is below, within or above
the therapeutic range, can be quantified using Rosendaal linear interpolation method. The major
bleeding and mortality rates are significantly higher among TTR<60% compared to TTR>75%. Thus,
modified RE-LY algorithm had been implemented in Kapit Hospital’s INR clinic since January 2015
with these cases review study conducted to assess the effectiveness of the modified RE-LY algorithm
in term of TTR improvement.
Methods: INR values from June 2014 to June 2015 for all INR clinics’ patients, excluding those
fulfilling exclusion criteria, were studied. TTR for each patient was calculated and the distribution of
TTR for pre-and post-algorithm over six months was analysed. The mean of the TTR for prealgorithm and post-algorithm was compared using paired T-test.
Results: Thirty-eight patients (21 males and 17 females) were included in the study. Fifty-three per
cent (n=20) of them were less than 65 years old and 18 of them were over 60 years old. A majority
(52.6%) of them did not have formal education, while the remainder had primary education (15.8%),
secondary education (28.9%) and only one (2.6%) had tertiary education. The reasons for them being
on warfarin were atrial fibrillation (68.4%), thromboembolism (18.4%), and mechanical valve
replacement (13.2%). The study’s sample size of 38 patients with mean TTR post-algorithm phase
showed significant improvement from 57 to 69 (p=0.011). The percentage of patients with TTR>65%
increases in the post-algorithm phase from 37% to 58%. Besides, the study showed there is no
significant association between the TTR value and socio demographic data collected, such as gender,
age, education level, availability of caretaker and years on warfarin.
Discussion: In this study, the mean TTR in post algorithm showed significant increment from 57%
to 69% with a p value of 0.011. This indicates implementation of modified RE-LY algorithm had
significantly improved the TTR among the INR clinic’s patients. However, this study analysis
showed that there is no significant association between the TTR with the socio-demographic
background among the patients. These findings are inconsistent with studies conducted by others.
The discrepancy of findings with other studies could be due to the small sample size of 38 patients,
short duration of study which is only six months and imbalance of socio demographic data distribution.
Conclusion: With implementation of modified RE-LY algorithm, TTR showed significant
improvement, thus it should be implemented widely in the INR clinics to ensure optimization of TTR
level.
Key Words: International Normalized Ratio (INR); Time within therapeutic range (TTR); warfarin;
anticoagulation; dosing algorithm
NMRR ID: 15-513-25315
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Sarawak Health Journal
Volume 3 2016
Case Record Review on the Effectiveness of Modified Paediatric Early Warning Sign Score in
Shortening the Duration Required for Clinical Intervention in Kapit Hospital
Gan LWˡ, Hii KC1 & Mavis B1
1
Paediatric Department, Kapit Hospital, Sarawak, Malaysia
Corresponding Author: Gan Lee Wan ([email protected])
Introduction: Hospitalised children are at risk of clinical deterioration and some may even develop
cardio-respiratory failure. The survival rate for these children is poor. Many children have a
prolonged physiological deterioration before cardiac arrest. Hence the development of Paediatric
Early Warning Signs (PEWS) score by the National Health Service, United Kingdom in 2006 to
ensure timely identification and prompt medical intervention during this ‘pre-arrest’ phase
(www.institute.nhs.uk/safer_care/paediatric_safer_care/pews_charts.html). Kapit Hospital adapted
and modified original PEWS score for use in paediatric ward in July 2012.
Objective: To evaluate the effectiveness of modified PEWS score in shortening the duration of
intervention from the onset of clinical deterioration and reducing the invasive intervention.
Methods: Case notes for patients admitted to Paediatric Intensive Care Unit (PICU) or High
Dependency Unit and those requiring transfer to Sibu Hospital in years 2010 to 2014 were reviewed.
Transferred cases not attributable to clinical deterioration and patient with incomplete data were
excluded from the study. Vital signs for patient in pre-implementation phase (Jan 2010-June 2012)
were re-charted into the modified PEWS chart. The time frame between the highest PEWS score to
clinical intervention was compared between pre- and post-implementation phase using MannWhitney test. Association between the modified PEWS score implementation and requirement of
invasive intervention was analysed using Chi-square test.
Results and Discussion: A total of 67 patients have been included in this study, 29 from preimplementation and 38 post-implementation. Time frame of intervention pre-PEWS implementation
was 42.64 min. There was significant reduction of the time frame required for clinical intervention
after PEWS implementation (27.41 min, Z statistics, -3.172, p=0.002). There was also a reduction of
requirement of invasive intervention from six cases to one case after PEWS implementation with
statistically significant association between the PEWS implementation and the requirement of
invasive intervention (p<0.05). This finding is consistent with a study conducted by Tucker et al in
2008, which suggests that the PEWS tool provides highly reliable and valid clinical scoring data.
High PEWS are predictive of patients who will require transfer to PICU.
Conclusion: Implementation of PEWS enables earlier prompt medical intervention with earlier
detection of clinical deterioration, thus reducing the requirement of invasive intervention. Thus it
should be implemented widely throughout the paediatric health care system.
Key Words: Paediatric early warning signs score (PEWS); Paediatric intensive care unit (PICU)
References:
1. Haines C, Perrott M& Weir P. Promoting care for acutely ill children: Development and evaluation
of a pediatric early warning tool. Intensive Crti Care Nurs 2006; 22(2): 73-81.
2. Tucker KM, Brewer TL, Baker RB, et al. Prospective evaluation of a pediatric inpatient early warning
scoring system. J Spec Pediatr Nurs 2009 Apr;14(2):79-85.
3. Duncan H, Hutchison J & Parshuram CS. The Pediatric Early Warning Score: A severity of illness
score to predict urgent medical need in hospitalised children. J Crit Care 2006; 21(3): 271-9.
NMRR ID: 15-1009-25887
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Sarawak Health Journal
Physiotherapy in Critically Ill Patients in Sarawak General Hospital
Volume 3 2016
Kuan PX1, Chan WK2 & Fong AYY3
1
Clinical Research Centre, Sarawak General Hospital, Malaysia
2
Anaesthesiology and Intensive Care Unit, Sarawak General Hospital, Malaysia
3
Clinical Research Centre and Cardiology Department, Sarawak General Hospital, Malaysia
Corresponding Author: Kuan Pei Xuan ([email protected])
Introduction: Physiotherapy plays major role in improving short and long term clinical outcomes in
mechanically ventilated patients in the Intensive Care Unit (ICU) setting. It has been shown to be
beneficial for patients with retained secretions, atelectasis and preventing prolonged ventilation.
Main Objectives:
1. To explore the demographic of patients referred for physiotherapy in ICU
2. To determine the relationship between physiotherapy with ventilator dependency and duration
of ICU stay
Methods: Single centre, cross-sectional review of consecutive patients admitted to ICU in October
2014. Data were collected from clinical documentation. Data was entered and analysed in SPSS
version 16.0.
Results: A total of 105 patients were admitted to ICU over a four-week period in October 2014. The
median duration of ventilation was one day. More than half of the patients (52.4%) were intubated
intra-operatively; then admitted post-operatively, mainly for close monitoring and weaning of
mechanical ventilation. Overall, the median length of ICU stay was two days with interquartile range
of 1.5 days. Only 15 (14.3%) patients were referred for physiotherapy, consisting of 6 (40.0%) male
and 9 (60.0%) female patients. Fourteen (93.3%) in this group were ventilated in ICU with 3 (20.0%)
having background lung pathology. The median day-to-initiation of physiotherapy after ventilation
was 2 (25th and 75th centiles: 1, 5). Physiotherapy had significant trend towards shorter duration of
ventilation (p=0.017), and while this is consistent with the study by Malkoc et al (2009), it did not
significantly affect duration of ICU stay (p=0.085).
Discussion and Conclusion: Approximately one-seventh of patients admitted to ICU were referred
for physiotherapy. These were typically females with no lung pathology. We found that early
initiation of physiotherapy was able to reduce the duration of ventilator support but not the duration
of ICU stay. Our results are inconsistent with the published data; therefore further research over
longer term is warranted.
Key Words: ICU; mechanical ventilation; physiotherapy
References:
1. Ambrosino N, Janah N & Vagheggini G. Physiotherapy in critically ill patients. Rev Port
Pneumol 2011; 17(6): 283-8.
2. Malkoc M, Karadibak D & Yıldırım YC. The effect of physiotherapy on ventilator dependency
and the length of stay in an intensive care unit. Int J Rehabil Res 2009; 32(1): 85-8.
3. Stiller K. Physiotherapy in intensive care. Chest 2000; 118: 1801-13.
NMRR ID: 14-1189-22983
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Sarawak Health Journal
Volume 3 2016
Exploration of Analgesic Prescribing Pattern in an Outpatient Setting of a District Hospital in
Sarawak
Kwong CI1, Phan HS1, Pang MSH1, Wong DSH1 & Chai SK1
1
Department of Pharmacy, Bau Hospital, Sarawak, Malaysia
Corresponding Author: Kwong Chea Ing ([email protected])
Introduction: Analgesics are among the most commonly prescribed drugs in hospitals. Rampant use
of analgesics often results in aggravated side effects and drug interactions. Our study was conducted
to explore the prescribing pattern of analgesic use in a district hospital in Sarawak.
Methods: A descriptive cross-sectional study was conducted in the Outpatient Department, Bau
Hospital over a period of seven days with a total sample size of 500 prescriptions containing
analgesics. Relevant information on types of analgesics, indications, concomitant medications, and
past medical conditions were obtained from the prescriptions, home-based card and through patients’
interview. A standardized surveillance form was designed to facilitate data collection. The study
results were analysed using descriptive statistics.
Results and Discussion: Five hundred (56.4%) of the total 887 prescriptions screened contained
analgesics, which included paracetamol (87.2%), non-steroidal anti-inflammatory drugs (NSAIDS)
(12.0%) and tramadol (0.8%). The study findings are consistent with previous research done by AlHomrany et al in a similar setting.1 There were 66.8% of the analgesics prescribed were indicated for
pain and fever. However, 20.4% were given without any specific indications while another 12.8%
were prescribed on patients’ demand. Ninety-nine (57.6%) of 172 patients with chronic illness follow
up received at least three prescriptions with analgesics in their past six visits. Of 60 patients on
NSAIDS, 38.3% (n=23) had co-existing medical conditions that required extra precautions in using
NSAIDs, namely asthma (10.0%), gastritis (25.0%) and cardiovascular disorder (2.0%). Concerning
NSAIDs use associated with increased risk of gastro intestinal bleed, most of the NSAIDs (81.7%)
prescriptions in this study were co-prescribed with gastro-protectants. This finding was relatively
high compared to Sulaiman et al, in which only 10.8% of them were given gastro-protectants.2 Five
per cent were on a combination of NSAIDs, diuretic and angiotensin-converting enzyme inhibitors
which may significantly impair the renal function. It is an adverse effect known as “triple whammy”
as identified by Loboz et al.3
Conclusion: Our study showed the widespread of analgesic prescribing in district hospital, Sarawak.
Rational use of analgesics should be emphasized taking into consideration justifiable indication,
coexisting conditions and drug interactions.
Key Words: Analgesics; prescribing pattern; NSAIDs use; indication
References:
1. Al-Homrany MA & Irshaid YM. Pharmacoepidemiological study of prescription pattern of
analgesics, antipyretics, and nonsteroidal anti-inflammatory drugs at a tertiary health care center.
Saudi Med J 2007; 28(3): 369-74.
2. Sulaiman W, Ong PS & Rosli I. Patient’s knowledge and perception towards the use of nonsteroidal anti-inflammatory drugs in rheumatology clinic northern Malaysia. Oman Med J 2012;
27(6): 505-8.
3. Loboz KK & Shenfield GM. Drug combinations and impaired renal function – the “triple
whammy.” Br J Clin Pharmacol 2005; 59(2): 239-43.
NMRR ID: 14-514-20439
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Sarawak Health Journal
Volume 3 2016
Retrospective Review of Prevention of Mother-To-Child Transmission HIV Programme in
Sarawak General Hospital
Lim HH1, Chai CY1, Niponi S1, Francis C1& Chua HH1
1
Infectious Disease Unit, Sarawak General Hospital, Malaysia
Corresponding Author: Lim Han Hua ([email protected])
Introduction: Improvement of HIV patients care in Malaysia has resulted in a declining trend of
HIV-related mortality in recent years. One of the core HIV prevention programmes that were
introduced is the prevention of maternal-to-child transmission (PMTCT).
Objective: To study the timing and regime of antiretroviral therapy (ART) used, mean CD4 count
during pregnancy and outcome of HIV-positive mothers that underwent PMTCT programme at
Sarawak General Hospital (SGH) from 2004 to 2014.
Methods: Data of all HIV-positive pregnant women who underwent PMTCT programme at SGH
from 2004 to 2014 were reviewed retrospectively.
Results: Among the 45 HIV-positive pregnant women reviewed, a total of four patients did not
receive ART because they presented during labour and were excluded. In the remaining 41 patients,
2 patients were already on ART before pregnancy while the other patients were diagnosed HIV during
ante-natal screening. Patients who were initiated on ART antenatally or were already on ART,
successfully delivered newborns who were free of HIV infection. The only newborn detected HIV
positive, was delivered by a mother, who did not receive ART antenatally due to non-adherence to
follow-up. The demographic characteristics of the patients started on ART are as shown in Table 1.
Discussion: The measures in PMTCT programme include routine antenatal HIV screening, providing
antenatal combination antiretroviral therapy for HIV-positive mothers, prophylaxis for HIV-exposed
infants, ensuring safe mode of delivery and avoidance of breast-feeding. By implementing all the
measures above, the risk of transmission can be reduced to less than 1%.¹ In this review, most (95%)
received zidovudine-based regime as part of the combined ART. The remaining 2 (5%) patients were
on tenofovir-based regime and it has been shown to be non-inferior in PMTCT.² Of those in the first
group, 15 (37%) patients were also on efavirenz combination therapy. There were no cases of foetal
abnormality reported in our study indicating that efavirenz was safe.3 Although the recommendation
is to initiate combined anti-retroviral therapy as early as 14 weeks of gestation, it is never too late as
seen in 38% of our patients who received ART in the third trimester but yet had successful
intervention.
Conclusion: The antenatal HIV screening should be pursued vigorously as the 100% PMTCT success
rate in this hospital means the vertical HIV transmission can be effectively stopped. PMTCT is
effective even if initiated in third trimester of pregnancy. However, 25% (one out of four) of the
patient picked up during labour delivered a child who was infected with HIV.
Key Words: HIV; prevention; mother-to-child
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Sarawak Health Journal
Volume 3 2016
Antibiotic Sensitivity and Spectrum of Bacterial Isolated in Kanowit Hospital: A Retrospective
Study
Loo SC1
1
Pharmacy Unit, Kanowit Hospital, Sarawak, Malaysia
Corresponding Author: Loo Shing Chyi ([email protected])
Aim: To identify the common bacteria isolated in Kanowit Hospital laboratory and to determine the
antibiotic sensitivity patterns of the commonly isolated bacteria.
Objectives:
 Identify the common bacteria that are isolated according to specific culture and sensitivity
 Explore the antibiotic sensitivity of the common isolated bacteria in Kanowit region
Introduction: One of the most serious public health issues around the globe nowadays is
antimicrobial resistance. Although the concerns may be different by region or country, it is clear that
Asian countries are the epicentres of resistance as we could observe that the prevalence of antibiotic
resistance of major pathogens is increasing in these locations. However, the public health infrastructure to combat this problem is very poor1. This prompted us to have a proper monitoring
system on antibiotic sensitivity trends and usage from for our own setting. Antibiotic usage in terms
of Defined Daily Dose (DDD) per 100 admissions has shown that our hospital is the highest, while
DDD for 1000 days patient stay in hospital is the third highest among all district hospitals without
specialist in Sarawak. The commonly used antibiotics parenterally are ampicillin-sulbactam,
ceftriaxone, cefoperazone, and ciprofloxacin, whereas the most commonly used oral antibiotics are
ampicillin, penicillin VK, cloxacillin, erythromycin, and amoxicillin. These indicators alerted us of
the need to monitor our antibiotic usage in Kanowit Hospital. One of the ways to reduce antibiotic
usage is to explore the local microbial culture and sensitivity patterns.
Methods: All positive bacteria growth culture and sensitivity samples from in-patients and outpatients isolated from June 2013 to June 2014 were included for this retrospective study.
Result and Discussion: The antimicrobial resistance patterns of the various bacteria described refer
to the clinical isolates encountered in our hospital laboratory. This study does not differentiate
between the antimicrobial resistance patterns of bacteria in community-acquired and hospitalacquired infections; neither does it cover only the clinically significant isolates. The resistance rates
described here are only based on in vitro tests. A total of 435 specimens with bacterial growth were
recorded in this study. Among these, we found 360 incidents of resistances toward antibiotics. The
highest percentage frequencies of resistance were Ampicillin [143 (39.72%) resistance], Augmentin
[49 (13.61%) resistance], and Co-trimaxazole [48 (13.33%) resistance]. This might due to high usage
of these antibiotics in a peripheral hospital setting.
Conclusion: The most common bacteria isolated from sputum, urine, stool, swab, and pus culture
and sensitivity are Klebsellia sp., Escherichia coli, Escherichia coli, Staphylococcus aureus and
Escherichia coli respectively. These correspond to the National Antibiotic Guidelines 2014. A similar
study is recommended for all hospitals as the bacterial culture and sensitivity patterns in district
hospitals may be different from that in tertiary hospitals.
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Volume 3 2016
Table 1: Summarized total number of bacterial resistance to specific antibiotic (top10)
Antibiotic
Total number
of Resistance
Total number of
bacteria resistant to
specific antibiotic
Percentage of resistant of
bacteria to specific
antibiotic
Ampicillin
360
143
39.72%
Augmentin
360
49
13.61%
Co-trimaxazole
360
48
13.33%
Cefuroxime
360
23
6.39%
Gentamicin
360
16
4.44%
Amoxicillin
360
14
3.89%
Ciprofloxacin
360
12
3.33%
Vancomycin
360
10
2.78%
Penicillin G
360
10
2.78%
Ceftriaxone
360
7
1.94%
Key Words: Antibiotic sensitivity; spectrum of bacterial isolated
Reference:
1. Kang CI & Song JH. Antimicrobial resistance in Asia: Current epidemiology and clinical
implications. Infect Chemother 2013; 45(1): 22-31.
NMRR ID: 15-77-24375
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Sarawak Health Journal
Volume 3 2016
Assess the Effectiveness of Interventions on Knowledge of Nurses towards High Alert
Medications in Kanowit Hospital
Loo SC1
1
Pharmacy Unit, Kanowit Hospital, Sarawak, Malaysia
Corresponding Author: Loo Shing Chyi ([email protected])
Aim: To improve the level of awareness and knowledge of staff nurse toward High Alert Medications
(HAM)Objectives: 1) to assess awareness and knowledge level of Staff Nurse in Kanowit Hospital
toward HAM; 2) to explore the factors affecting the knowledge and awareness level (pre-intervention
scores) of Staff Nurse regarding HAM; 3) To explore the effectiveness of an educational intervention
on Kanowit Hospital Staff Nurse knowledge and awareness regarding HAM.
Introduction: Studies have shown that the administration stage accounts for most medications errors
and the factors associated with the errors are lack of knowledge and awareness.1,2,3 When there are
involvement of dose calculations, rates of infusion of HAM and setting up of infusion pumps, nurses
tend to get confused easily. We would like to explore the nurses’ knowledge and awareness level,
and implement interventions that help to increase the knowledge and awareness.
Methods: Our study will be a comparative cross-sectional study. All respondents will be given a preinterventional test as a baseline. Interventions (HAM logo, educational talk, HAM dilution and HAM
list pocket guide) will be implemented, and a post-intervention test will be given to the same
respondents. Our target is to have all nurses involved. However the minimal sample size is at least 30
participants for paired T-test to be valid.
Result and Discussion: A total of 32 respondents were included in this study. Based on the results
of multiple linear regression, we found that respondents with post-basic qualifications or further
training in midwifery or haemodialysis in our study scored 6.6 marks higher then respondents without
post-basic training. This may be due to their attitude in learning and knowledge. [Adj. b value was
6.6; p=0.04]. Pre-intervention mean score was 69.13 (SD 7.94); post-intervention mean score was
78.53 (SD 8.00). This show significant improvement by 9.40 (95% CI: 6.27, 12.54, t-statistics 6.13,
df 31, p < 0.001) marks after intervention.
Conclusion: Nurses who have further training were the only factors affecting the pre-interventional
score. Interventions carried out in this study showed significant effects in increasing the knowledge
and awareness among staff nurses towards HAM.
Key Words: High Alert Medications (HAMs); nurses; knowledge
References:
1. Lu MC, Yu S, Chen IJ, et.al. Nurses’ knowledge of high-alert medications: A randomized
controlled trial. Nurse Educ Today 2013; 33: 24-30.
2. Bergqvist M, Karlsson EA, Björkstén KS, et.al. Medication errors by nurses in Sweden classification and contributing factors. Open assess scientific report 2012; 1(11): 527.
3. Phillips J, Beam S, Brinker A, et.al. Retrospective analysis of mortalities associated with
medication errors. Am J Health Syst Pharm 2001; 58(19): 1835-41.
NMRR ID: 14-844-20978
14
Sarawak Health Journal
Pyogenic Liver Abscess Review in Sarawak General Hospital 2013 - 2015
Volume 3 2016
Mohd Firdaus AK1, Khairunnissa CG1, Nurazim S1, Siam F1 & Nik Azim NA1
1
Department of General Surgery, Sarawak General Hospital, Malaysia
Corresponding Author: Mohd Firdaus A Karim ([email protected])
Objective: To review demographics and clinicopathological presentations of patients with pyogenic
liver abscess (PLA) treated in Sarawak General Hospital.
Background: PLA is a potentially fatal disease. Understanding of its clinocopathological profile in
a local population allows for a more effective diagnosis and treatment. We present a case series of
PLA treated in Sarawak General Hospital between 2013 and 2015.
Methods: A retrospective review was performed for all patients who presented to Sarawak General
Hospital with a diagnosis of PLA.
Results: Eighty-six patients were admitted with the diagnosis of PLA. Fifty-nine (68%) were male
and 27 were female (32%). The average age of patient presented was 52-year-old with the youngest
being a 15-year-old boy and the eldest an 86-year-old lady. The most common presenting symptoms
were fever and right hypochondrial pain. The right lobe of the liver was involved in 65% of the cases
and 72% of the liver abscesses were solitary. Most patients (65%) had a combination of percutaneous
drainage and antibiotics; 29 had antibiotics alone and one required open drainage as clinical
examination showed peritonitis. Pus culture grew predominantly gram-negative organisms in 49
(57%) patients with Klebsiella pneumoniae being the most common organism isolated. In contrast,
no organism was isolated in 29 (34%) patients. Two patients’ blood cultures were positive for
Burkholderia pseudomallei. There was no in-house mortality seen in this review.
Conclusion: PLA is associated with high mortality and morbidity; the development of sophisticated
imaging system allows early diagnosis and prompt management that result in better outcome.1 It is a
disease that occurs most commonly in the sixth to seventh decade of life2, as reflected in our study,
with the average age of 65 years old. Most PLA are treated with antibiotics and catheter drainage.
Drainage of the abscess helps relieve symptoms and guides the type of antimicrobial management.
Gram-Negative organisms, with Klebsiella pneumonia being the most common, are the main
organism isolated from the blood and abscess fluid which support the findings of previous study.3
Key Word: Pyogenic liver abscess
References:
1. Ruiz-Hernández JJ, León-Mazorra M, Conde-Martel A, et al. Pyogenic liver abscesses:
mortality-related factors. Eur J Gastroenterol Hepatol 2007; 19: 853-8.
2. Lee KT, Wong SR & Sheen PC. Pyogenic liver abscess: an audit of 10 years’ experience and
analysis of risk factors. Dig Surg 2001; 18: 459-66.
3. Rahimian J, Wilson T & Oram V. Pyogenic liver abscess: Recent trends in etiology and mortality.
Clin Infect Dis 2004; 39(11): 1654-9.
15
Sarawak Health Journal
Burn Cases in Intensive Care Unit, Sarawak General Hospital
Volume 3 2016
Mohd Tarmimi M1, Farah R1, Jamaidah J1, Mustaffa Kamil ZA1 & Norzalina E1
1
Department of Anaesthesiology and Intensive Care, Sarawak General Hospital, Malaysia
Corresponding Author: Mohd Tarmimi bin Mustapha ([email protected])
Introduction: Burn patients represent a minor fraction of hospital admissions with significant
amount of morbidity and mortality. The objective of this study is to review the clinical data and
outcome of burn cases admitted to the Intensive Care Unit (ICU), Sarawak General Hospital (SGH).
Methods: This retrospective study was conducted in a 15-bedded multidisciplinary ICU at a 765bedded tertiary medical centre, SGH. All admitted burn patients from 1st April 2013 to 30th March
2015 were included. Data on basic demographics, admission diagnosis, intervention done, length of
stay (LOS) and causes of death were collected.
Results: A total of 52 burn patients requiring ICU support were analysed. Median age was 33 [27,
49] years, predominantly (n=36, 69.2%) males. Mean total burn surface area (TBSA) was 31.9% (21,
44); 63.5% of patients sustained more than 20% TBSA burn. The commonest cause of burn was flame
burn (n=44, 84.6%) predominating in the 20 to 39 years age group; 23 (44.2%) patients had
inhalational injury, requiring ventilation. Twelve out of 52 burn patients underwent emergency
operation (escharectomy / tangential excision). Six (11.5%) patients underwent tracheostomy for
anticipated prolonged ventilation. The median duration of ventilation was two [1, 6] days. The median
length of stay in ICU stay was six [3, 9] days. The mortality rate for burn was 26.9 % (n=14), with
multiorgan failure as the main cause of mortality (n=6, 42.9%). There was no correlation between
age (p=0.300), TBSA (p=0.113) and LOS (p=0.086) with mortality rate as reported in other
literature.2
Discussion: Male foreigners between the ages 20 to 39 were identified as the main contributors for
burn cases admitted to ICU SGH. This may be related to the numerous fire incidents that happened
in plantations and coal mines throughout Sarawak. Our mortality rate is significantly higher compared
to other studies done locally and abroad, which quotes figures from 6.5% to 12%.1,2,3,4 For a state
with a total population 2.4 million people and a total area of 126 million km2, we only have one burn
facility located at SGH to cater for the entire state needs.
Conclusion: Multiorgan failure remains the main cause for mortality in burn patient. Therefore the
burn critical care has to be focused on acute management and prevention of complications.
Key Words: Burn; Intensive Care Unit (ICU); Sarawak General Hospital (SGH)
References:
1. Chan KY, Hairol O, Imtiaz H, et al. A review of burns patients admitted to the Burns Unit of
Hospital Universiti Kebangsaan Malaysia. Med J Malaysia 2002; 57(4): 418-25.
2. Duci SB, Arifi HM, Selmani ME, et al. A retrospective study of 69 patients admitted at the
intensive care unit University Clinical Center of Kosovo during the period 2008 – 2012. Indian
J Burns 2014; 22: 88-92.
3. Ho WS, Ying SY & Burd A. Outcome analysis of 286 severely burned patients: Retrospective
study. Hong Kong Med J 2002; 8: 235-9.
4. Shankar G, Naik VA & Powar R. Epidemiological study of burn injuries admitted in two
hospitals of north Karnataka. Indian J Community Med 2010; 35: 509-12.
16
Sarawak Health Journal
Volume 3 2016
A Review of Complicated Appendicitis and Modified Alvarado Score as a Diagnostic Tool in
Kapit Hospital Year 2014
Sun CCY1, Wong WK2, Hii KC2 & Toh TH3
1
Surgical Department, Kapit Hospital, Sarawak, Malaysia
2
Paediatric Department, Kapit Hospital, Sarawak, Malaysia
3
Paediatric Department and Head of Clinical Research Centre, Sibu Hospital, Sarawak, Malaysia
Corresponding Author: Carine Sun Chung Yine ([email protected])
Introduction: Acute appendicitis is the most common cause of an acute abdomen. Early detection
and intervention is the key to preventing complicated appendicitis, which has a four to five folds
increase in mortality rate compared to the uncomplicated one. The Alvarado Score is a diagnostic
tool that predicts the likelihood of appendicitis; however one of its criteria “shift of white blood cell
count to the left” is not always available during emergency or after-hours in rural hospitals. Thus a
modified Alvarado Scoring System (MASS) with omission of such criteria was adopted in our
hospital.
Objectives:
1. To identify the common forms of complicated appendicitis and the incidence of negative
appendicectomy rate.
2. To evaluate the reliability of MASS in predicting the likelihood of appendicitis.
Methods: We performed a case record review of all patients with suspected appendicitis who
received treatment in Kapit Hospital in the year 2014. Data reviewed included the demographics,
operative findings and the histopathological examination results of the appendicectomy specimen.
The data was then analysed with SPSS v.20.0.
Results and Discussion: A total of 79 patients were included, with majority male (55%) and in age
group of 11 to 20 years old. Both younger and older age groups presented with complicated
appendicitis, most likely due to difficulty in early diagnosis. Sixty-one patients were clinically
suspected to have appendicitis of whom 59 underwent operation while two were treated
conservatively. The overall incidence of complicated appendicitis was 34%, the common forms being
perforation (25.0%), appendicular mass (3.6%), and necrosis (3.6%). Negative appendicectomy rate
was 8.5% overall, but drastically higher in female (14.8%) than male (3.0%) highlighting the
diagnostic difficulties in females presenting with right iliac fossa pain with additional diagnostic
modalities warranted. We suggest a MASS score cut off point of ≥ 6 in our setting as it has a positive
predictive value that is similar to the cut off of 7 i.e. 74%, but with a higher negative predictive value
of 41%. Those with low scores should be re-assessed with other modalities such as ultrasound to
prevent misdiagnosis. Patients with complicated forms of appendicitis were found to have MASS
score of > 7 (OR 3.935, 95% CI: 1.260, 12.607).
Conclusion: MASS > 6 can help to predict the likelihood of appendicitis; however a score of < 6
does not exclude appendicitis. Those with MASS score of > 7 are more likely to have complications.
Key Words: Complicated appendicitis; Modified Alvarado Score; Kapit Hospital; complication rate.
NMRR ID: 15-327-25124
17
Sarawak Health Journal
Volume 3 2016
Red Cell Alloimmunisation among Multiple Transfused Patients at Sarawak General Hospital
Tay SP1, Ho ZH1, Kong PI1, Ng JCH1, Liew ML1, Ong GB2, Chew LP3 & Gudum HR1
1
Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak (UNIMAS), Malaysia
2
Department of Paediatrics, Sarawak General Hospital, Malaysia
3
Department of Medicine, Sarawak General Hospital, Malaysia
Corresponding Author: Tay Siow Phing ([email protected])
Introduction: Alloimmunisation, the immune response that occurs when an incompatible isoantigen
encounters an immuno-competent host, can occur against red blood cell (RBC), platelet and human
leucocyte antigens. The formation of alloantibodies by recipients against transfused RBC is one of
the complications of blood transfusion. Despite blood transfusion being a life-saving procedure, RBC
alloimmunisation can cause severe and life-threatening consequences. The risk of RBC
alloimmunisation depends on the frequency of transfusions, antigen immunogenicity and the
recipient’s immune response. The alloantibodies in recipients must be systematically identified
before each transfusion to ensure safe and compatible transfusion. In Peninsular Malaysia, the
prevalence of RBC alloantibodies ranged from 0.58% to 3.4%.1,2 However, there is a paucity of
published data on the incidence of RBC alloimmunisation among the multiple transfused patients in
Sarawak.
Objectives: This study aimed to determine the frequency of RBC alloimmunisation among multiple
transfused patients; to determine the association of development of alloantibodies as well as the
haematological parameters with age of first transfusion, frequency and duration of transfusion.
Methods: This was a cross-sectional study involving 60 multiple transfused patients from Sarawak
General Hospital (SGH) with 33 males (55%) and 27 females (45%). The patients comprised
thalassaemia (66.7%), leukaemia (19.9%), myelodysplastic syndromes (6.7%) and other
haematological diseases (6.7%). The blood samples were analysed for full blood count (Haematology
Analyzer Sysmex XS-800i), and the presence of RBC alloantibodies was detected using 3-cell and
11-cell gel card panels (Diamed, Switzerland).
Results: In this study, there was no RBC alloantibodies detected in all the studied patients. Thus, the
association of development of alloantibodies with other studied variable cannot be established in this
study. However, significant correlations were demonstrated between the transfusion frequency with
thrombocytosis (r=0.56; p=0.002) and basophilia (r=0.62; p<0.001). Transfusion duration also
associated significantly with thrombocytosis (r=0.67; p<0.001) and basophilia (r=0.61; p=0.001).
Discussion: Although the comparatively smaller sample size (n=60) could be the reason for this
extremely low frequency (0%), our finding was comparable to the larger scale of studies by University
Malaya (3.4%, n=143,501)1 and Universiti Kebangsaan Malaysia (0.58%, n=24,263)2 medical centres,
which also showed very low prevalence of RBC alloimmunisation. The absence of alloantibodies in
SGH patients was probably due to the homogeneity of our donors’ pool and recipients’ RBC antigens.
It could also be attributed to the routine use of leucodepleted blood for chronically transfused patients
at SGH, which had proven to be effective in preventing alloimmunisation in multiple transfusions.3
In addition, one-third of our patients were haemato-oncological patients who had undergone postchemotherapy and immuno-compromised. This might have contributed to the low frequency of
alloimmunisation in this study. In this study, increased transfusion frequency and duration were
associated significantly with thrombocytosis and basophilia, indicating that long-term multiple
transfusions had triggered the patients’ immune reactivity.
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Sarawak Health Journal
Volume 3 2016
Conclusions: The risk of developing RBC alloantibodies among multiple transfused patients at SGH
was very low. The comprehensive pre-transfusion testing in SGH had successfully eliminated the
risk of alloimmunisation among these patients. Future studies can be extended to other district
hospitals to determine the actual prevalence of RBC alloimmunisation in Sarawak.
Key Words: Red cell alloimmunisation; multiple transfusions
References:
1. Nadarajan VS, Laing AA, Saad SM, et al. Prevalence and specificity of red-blood-cell antibodies
in a multi-ethnic South and East Asian patient population and influence of using novel UT+Mur+
kodecytes on its detection. Vox Sang 2012; 102(1): 65-71.
2. Yousuf R, Abdul Aziz S, Yusof N, et al. Incidence of red cell alloantibody among the transfusion
recipients of Universiti Kebangsaan Malaysia Medical Centre. Indian J Hematol Blood Transfus
2013; 29(2): 65-70.
3. Singer ST, Wu V, Mignacca R, et al. Alloimmunization and erythrocyte autoimmunization in
transfusion-dependent thalassemia patients of predominantly Asian descent. Blood 2000; 96:
3369-73.
NMRR ID: 10-988-13863
19
Sarawak Health Journal
Volume 3 2016
A Review of Clinician-Investigators at Sarawak General Hospital Undertaking Clinical
Research – Industry or Investigator Initiated Studies?
Tiong XT1 & Fong AYY2
1
Clinical Research Centre, Sarawak General Hospital, Malaysia
2
Clinical Research Centre and Cardiology Department, Sarawak General Hospital, Malaysia
Corresponding Author: Tiong Xun Ting ([email protected])
Introduction: Sarawak General Hospital (SGH) is the main public tertiary referral hospital for the
state of Sarawak. SGH has been a site of clinical research for over three decades, undertaking both
industry and investigator-initiated studies. SGH has been recognized as a site for world class clinical
research, and with a steady increase in the number of practising specialists, there is a need to profile
clinician-investigators who have, are, and likely to, undertake clinical research. It is intended that
SGH contributes significantly towards the knowledge economy in the biomedical field, particularly
through clinical research activities and strong collaborative efforts with its partner sites.
Objective: The aim of this research was to identify the type and total number of research done by
clinicians.
Methods: This study was carried out over a month period. It is a cross-sectional data collection
through National Medical Research Register (NMRR) registry. NMRR registry data on investigators
was cross-checked with a list of clinicians available in SGH. Data was entered in Microsoft excel.
Descriptive data analyses were carried out.
Results: Data collected through NMRR from year 2007 to October 2014 for research carried out in
SGH and Heart Centre, SGH were gathered. A total of 851 researchers were registered after duplicate
entries were removed. Total number of investigators (primary investigators, PI and Co-investigators,
Co-I) registered in NMRR database was 2295. Out of 851 researches, 702 researches obtained an
NMRR ID while 149 researches were without an NMRR ID. Based on NMRR registry (n=702), 225
were interventional studies (with mostly clinical trials–223); 358 were observational trials (with
patient registry - 171, clinical epidemiology - 164); while others studies are 119.
Table 1: Funding of researches done in SGH
Source of funding
For all
With NMRR ID
Without NMRR ID
Department operational fund
7
5
2
Government (non-MOH) grant
6
5
1
Industry sponsored
185
178
7
MOH-NIH grant
49
41
8
Others
12
12
0
Self-funding
568
446
122
University research grant
24
15
9
Total
851
702
149
Discussion: Incomplete NMRR registration is present. As SGH is a tertiary hospital equipped with
specialist and a big pool of patients, observational type of studies is more common compared to
interventional studies. Proper classification of studies in the NMRR registry is needed.
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Sarawak Health Journal
Volume 3 2016
Conclusion: SGH conducted a fair amount of researches based on NMRR registry. The main field
of research conducted was clinical trial, followed by patient registry and clinical epidemiology.
Observational type of research is slightly more common. Most research done in SGH is self-funded
(63.6%), followed by industry-sponsored (26.3%), research with grant applications (7%).
Acknowledgement: This work was supported and approved by Clinical Research Centre Network,
National Institutes of Health and Ministry of Health Malaysia. We would like to thank Logos Biomed
Systems Sdn. Bhd. for sponsoring this study and NMRR secretariats for the data source and
management of the NMRR website. The authors declare no conflict of interest with the Sponsor in
this scientific study.
Key Words: Research; Sarawak General Hospital; NMRR
NMRR ID: 14-1190-22973
21
Sarawak Health Journal
Volume 3 2016
Incidence, Risk Factors and Clinical Epidemiology of Melioidosis in Miri Hospital, Sarawak,
Malaysia
Vimal V1, Ling HW1, Cho WM1 & Norhuzaimah J1
1
Department of Anaesthesiology and Intensive Care, Miri Hospital, Sarawak, Malaysia
Corresponding Author: Vimal Varma ([email protected])
Background: Melioidosis is a fatal community-acquired infection caused by the gram-negative
bacteria Burkholderia pseudomallei. The overall mortality of melioidosis approaches 100% if
untreated, but can be reduced to 37-54% with optimal management.
Methods: This retrospective study describes the incidence, risk factors, clinical epidemiology of the
disease by analysing 15 culture-confirmed cases of melioidosis treated in Miri Hospital from Jan 2014
to June 2015.
Results: Patients’ ages ranged from 19 to 78 years old (mean = 49.07). Male patients accounted for
60% of the cases. The overall mortality rate was 53.3%, of whom 62.5% died after 14 days of
admission. Respiratory involvement (33.3%) accounted for the majority of the clinical presentations
followed by fever without definite source of infection (26.7%) and musculoskeletal involvement
(20%). Respiratory involvement carries the highest mortality rate of 80%. Patients with underlying
diabetes mellitus, hypertension and renal impairment on admission were found to have high mortality
rates. As for antimicrobial therapy, most patients received ceftazidime (60%), followed by
meropenem (20%) and imipenem (20%). Based on in-vitro sensitivity testing, antibiotic sensitivity
of clinical isolates was 100%, 90% and 60% to imipenem, ceftazidime and meropenem respectively.
Discussion: The overall mortality rate of culture-positive cases in our study is 53.3%, comparable to
a study done in Pahang (54%).1 Diabetes mellitus has been reported as the most common underlying
disease in melioidosis with an incidence up to 60%2 which is consistent with this study with 53.3%
of the patients having underlying diabetes. Hypertension is not a known risk factor for melioidosis,
however surprisingly in this study, patients with underlying hypertension has 100% mortality rate;
therefore further studies are necessary to investigate this association. White et al demonstrated that
ceftazidime could reduce overall mortality by 50%.3 According to the antibiogram, ceftazidime still
carries 90% sensitivity. For carbapenem group, the sensitivity of meropenem and imipenem towards
Burkholderia pseudomallei were 60% and 100%, respectively. All the patients who received
carbapenem group died despite the antibiotic having high sensitivity towards the pathogen. This
finding may be biased as carbapenem groups were most likely prescribed to severely ill patients,
hence accounting for the higher mortality rate. A further study with a bigger sample size is imperative
to establish a significant relations between the parameters analysed towards the outcome of this
disease.
Conclusion: Melioidosis is an emerging complex socio-ecological health problem in this part of the
region. The wide range of clinical presentations and fatal outcomes of melioidosis require high index
of suspicion for prompt early diagnosis and aggressive treatment to reduce the overall mortality. From
the results of this study, we suggest that, in an endemic area such as our region, melioidosis should
always be included as a working diagnosis in cases presenting with community-acquired infection.
22
Volume 3 2016
Sarawak Health Journal
Table 1: Frequency and mortality rate according to risk factors, initial laboratory results and
antibiotics used
Percentage % (n)
Mortality % (n)
Diabetes Mellitus
53.3 (8)
75 (6)
Hypertension
33.3 (5)
100 (5)
Kidney Disease
20 (3)
66.7 (2)
Liver Disease
13.3 (2)
0
40 (6)
66.7 (4)
Abnormal Platelet Count
46.7 (7)
42.9 (3)
Abnormal White Cell Count
66.7 (10)
60 (6)
Abnormal Capillary Blood Sugar
46.7 (7)
57.1 (4)
High Urea
33.3 (5)
100 (5)
High Creatinine
73.3 (11)
72.7 (8)
High Bilirubin
20 (3)
100 (3)
Low Albumin
60 (9)
55.6 (5)
Ceftazidime
60 (9)
55.6 (5)
Trimethoprim / Sulfamethoxazole
26.7 (4)
50 (2)
Meropenem
20 (3)
100 (3)
Imipenem
20 (3)
100 (3)
Ceftriaxone
46.7 (7)
71.4 (5)
Doxycycline
26.7 (4)
50 (2)
Piperacillin / Tazobactam
20 (3)
66.7 (2)
Amoxicillin / Clavulanic Acid
13.3 (2)
100 (2)
Cloxacillin
13.3 (2)
0
Metronidazole
20 (3)
33.3 (1)
Co-morbid
Initial Laboratory Results
Low Haemoglobin
Antibiotics
Key Words: Melioidosis; risk factors; Miri
References:
1. How SH, Ng KH, Jamalludin AR, et al. Melioidosis in Pahang. Malaysia Med J 2005; 60(5).
2. Cheng AC & Currie BJ. Melioidosis: epidemiology, pathophysiology, and management. Clinical
Microbiol Rev 2005; 18: 383-416.
3. White NJ. Melioidosis. Lancet 2003; 361: 1715-22.
NMRR ID: 15-795-26243
23
Sarawak Health Journal
Volume 3 2016
Demographic and Clinical Features of Leptospirosis in Paediatric and Adolescent Population
in Kapit Hospital
Wong WK1, Tan PW1, Sun CCY1 & Hii KC1
1
Paediatric Department, Kapit Hospital, Sarawak, Malaysia
Corresponding Author: Wong Wai Kit ([email protected])
Introduction: Leptospirosis is a zoonotic disease prevalent mainly in developing countries. It is
caused by infection with spirochetes of genus Leptospira, and is re-emerging with a worldwide
distribution. Acute febrile illness remains one of the most common presentations of leptospirosis in
Kapit Hospital. In our setting, a child with acute febrile illness and leptospirosis serology positive are
often treated clinically for leptospirosis pending microscopic agglutination test (MAT) results.
Objective: To study the clinical and laboratory presentations of leptospirosis MAT-positive subjects
among paediatric and adolescent population in Kapit Hospital.
Methods: Case records of admissions between September 2013 and February 2015 to Kapit Hospital
were reviewed. All hospitalized patients less than 19 years old with positive result of Leptospirosis
Serology and without evidence of other infections were included in this study. More detailed analyses
were done for MAT-positive leptospirosis patients. MAT-positive leptospirosis patients are defined
as those with titres of 1:400 or higher.
Results and Discussions: Forty-four cases tested positive for leptospirosis serology, but only 33
cases were included, as the remainder had other sources of infection. Among 33 cases with
leptospirosis serology positive, only 18 came back with leptospirosis MAT-positive during follow up.
Male-to-female ratio is about 10:1. History of swimming in the river prior to illness was found in 12
(66%) patients, while 5 (28%) had a history of jungle trekking. One 4-year-old child died. The
common symptoms manifested were fever, 17 (94%); vomiting, 9 (50%); diarrhoea, 7 (38%) and
headache, 6 (33%). Cough, 5 (27%) was the only respiratory symptom observed. We had 6 (33%)
subjects who were noted to have conjunctival suffusion, which is pathognomonic of leptospirosis,
with a significant p value of 0.017 compared to leptospirosis MAT-negative group. Other signs
observed included abdominal pain and hepatomegaly. Leptospirosis is characterized by a broad
spectrum of clinical manifestations varying from unapparent infection to fulminant fatal disease.
Children, in particular often bear the brunt of these tropical diseases, and pose the greatest diagnostic
challenges to clinicians. Most of our patients presented with non-specific symptoms. Serology rapid
test is still the most practical diagnostic method of Leptospirosis, with MAT being the “gold standard”
but often requiring a long waiting-period. There was no positive culture for Leptospirae in our study,
thus it was of limited diagnostic value.
Conclusion: A high index of suspicion for leptospirosis should be maintained at all times in a child
with positive leptospirosis serology, presenting with fever, vomiting, diarrhoea, headache and
conjunctival suffusion especially in our setting. The increase in awareness of paediatric leptospirosis
will help guide the appropriate use of healthcare resources in often resource-limited settings.
24
Sarawak Health Journal
Table 1: Laboratory findings of lepto MAT positive
Volume 3 2016
Key Words: Paediatric leptospirosis; adolescent leptospirosis; Kapit Hospital; lepto MAT;
leptospirosis serology
References:
1. Libraty DH, Myint KS, Murray CK, et al. A comparative study of leptospirosis and dengue in
Thai children. PLoS Negl Trop Dis 2007; 26:111.
2. Tullu MS & Karande S. Leptospirosis in children: A review for family physicians. Indian J Med
Sci 2009; 63(8): 368-78.
NMRR ID: 15-994-26301
25
Sarawak Health Journal
Volume 3 2016
Prevalence of Antibiotic Resistance in Burkholderia Pseudomallei Cases Presented to Miri
General Hospital
Yong KY1, Tang ASO1, Teh YC1, Fam TL1 & Chua HH2
1
Department of Medical, Miri Hospital, Malaysia
2
Department of Medical, Sarawak General Hospital, Malaysia
Corresponding Author: Yong Kar Ying ([email protected])
Background: Melioidosis is caused by the gram-negative bacilli, called Burkholderia pseudomallei.
It is an endemic infection in Southeast Asia.1 There is a wide spectrum of disease manifestation and
associated with high mortality rate.2 Antibiotic resistance has been emerging and it poses significant
challenges in our practices. We conducted a cross-sectional study to determine the prevalence and
resistance rate of Burkholderia pseudomallei in Miri Hospital from January 2011 to May 2015.
Methods: Patients’ demographic data, types of culture specimens and resistance rate to common
antibiotics as well as all cases with positive cultures identified from the bacteriology laboratory were
reviewed. Cultures sensitivity on antibiotics was determined by using disc diffusion method.
Results and Discussion: In this study, 58 cases known to have positive cultures for Burkholderia
pseudomallei were identified. Most of the samples identified were from blood cultures. Majority of
the patients were males and less than 40 years old. There was no resistance to ceftazidime; but, the
rate of resistance to imipenem, meropenem, trimethoprim-sulfamethoxazole (TMP-SMX) and
amoxycillin / clavulanate (AMC) were varied. Resistance rate to meropenem (25% to 85.7%) was
higher compare to imipenem (0% to 14.3%). TMP-SMX, was commonly used as oral medication for
melioidosis eradication treatment with a mean resistance rate of 38.1%. The resistance rate for AMC
ranged from 25% to 68.2%.
Table 1: Percentage of resistance rate of Burkholderia pseudomallei (from 2011 till June 2015)
Type of Antibiotic
Ceftazidime
Meropenem
Imipenem
Trimethoprim / Sulfamethoxazole
Amoxycillin / Clavulanate
2011 (%) 2012 (%) 2013 (%) 2014 (%) 2015 (%)
0
0
0
0
0
0
25.0
45.5
85.7
28.1
0
0
0
14.3
0
16.7
0
36.4
100
37.5
50.0
25.0
68.2
16.7
53.1
Conclusion: Burkholderia pseudomallei remains sensitive to ceftazidime despite its usage as a firstline antibiotic for melioidosis treatment over the years. The true resistance rate to imipenem,
meropenem, AMC and TMP-SMX should be determined by using e-Test technique for better
accuracy of antibiotic of choice.3
Key Words: Burkholderia pseudomallei; meliodosis; antibiotic resistance
References:
1. Cheng AC & Currie BJ. Melioidosis: Epidemiology, pathophysiology, and management. Clin
Microbiol Rev 2005; 18(2): 383-416.
2. How SH & Ng KH. Meliodosis in Pahang, Malaysia. Med J Malaysia 2015; 60(5): 606-13.
3. Tan AL & Tan ML. Melioidosis: Antibiogram of cases in Singapore 1987-2007. Trans R Soc
Trop Med Hyg 2008; 102(S1): 101-2.
NMRR ID: 15-925-26358
26
Sarawak Health Journal
Volume 3 2016
Public Health
Observational
Research
Public Health Observational Research
27
Sarawak Health Journal
Volume 3 2016
Iodine Nutritional Status amongst School Children after Five Years of Universal Salt Iodisation
in Sarawak
Jeffery S1, Jambai E1, Kiyu A1 & Zulkifli J 1
1
Sarawak State Health Department, Kuching, Sarawak, Malaysia
Corresponding Author: Jeffery Stephen ([email protected])
Introduction: Iodine deficiency is a public health problem worldwide. Globally, the WHO estimates
31% or two billion people are iodine-deficient. Iodine deficiency has many consequences such as
goitre, cretinism, intellectual impairments, growth retardation, neonatal hypothyroidism neurological
disorders and impairment in physical development; pregnant mothers and children are especially
susceptible. Sarawak is endemic for iodine deficiency disorders (IDD). Many intervention
programmes have been implemented to eliminate the IDD including the establishment of saltiodisation plants, water iodisation system for longhouse communities, free distribution of iodised
table salt to local communities with priority to antenatal mothers, implementation of legislation
requiring the iodization of fine table salt in certain highly-goitrous areas as well as universal salt
iodisation (USI) programme.
Objective: To determine the iodine status amongst school-aged children in Sarawak after five years
of USI programme.
Methods: We analysed the Sarawak State IDD Survey (2014) Database and the findings were
compared with the National IDD Survey results which were done in 2008. Urinary iodine
concentration (UIC) was used as the impact indicator. AWHO/ICCIDD/UNICEF criterion was used
to classify iodine status into different degrees of public health significance as well as for monitoring
of IDD elimination progress.
Results and Discussion: The median UIC in 2014 was 114.9 µg/L – that was a significant increase
from 102.1 µg/L in 2008 (p<0.001). The median UIC in rural areas significantly improved from 91.9
µg/L (mild iodine deficiency) in 2008 to 113.6 µg/L (optimal) in 2014 (p<0.001). The median UIC
in urban areas increased significantly from 109.3 µg/L (optimal) in 2008 to 120.8 µg/L (optimal) in
2014 (p<0.001). Overall, the percentages of children who were iodine-deficient (median UIC less
than 100 µg/L) were lower in 2014 (41.2%) compared to 2008 (49.3%). The Bumiputera’s median
UIC also improved from 95.0 µg/L in 2008 to 123.0 µg/L in 2014 (p<0.00).
Conclusion: There was significant reduction in the proportion of school-aged children who were
iodine-insufficient in 2014 compared to 2008. Median UIC for rural areas improved significantly
from 91.9 µg/L (iodine insufficient) in 2008 to 113.6 µg/L (not iodine-deficient) in 2014. Significant
improvement in iodine status was observed amongst Bumiputera children. Monitoring and evaluation
of the availability of adequately iodised salt and household iodised salt consumption should be
strengthened. Health education on the benefits of adequate iodine intake should be carried out
continuously to the public. After 5 years of USI implementation in Sarawak, the iodine status of the
school aged children in 2014 has improved compared to 2008.
Key Words: Iodine deficiency; universal salt iodisation; school-aged children; Sarawak
NMRR ID: 15-956-26509
28
Sarawak Health Journal
Volume 3 2016
Pendekatan Program Community Feeding Dalam Memulihkan Kanak-Kanak Kekurangan Zat
Makanan Di Long Urun, Belaga
Lai SF1, Nicholas AG2 & Hasrina H3
1
Klinik Kesihatan Kapit, Sarawak, Malaysia
2
Klinik Kesihatan Belaga, Sarawak, Malaysia
3
Pejabat Kesihatan Bahagian Kapit, Sarawak, Malaysia
Pengarang Koresponden: Lai Sher Fang ([email protected])
Pengenalan: Perkhidmatan kesihatan kerajaan telah diperluaskan ke kawasan Long Urun pada tahun
2012 dan dididapati peratus kanak-kanak kekurangan zat makanan (KZM) bawah 5 tahun di Daerah
Belaga meningkat daripada 13.1% (2011) kepada 15.9% (2012). Keadaan ini merunsingkan kerana
tren telah menunjukkan penurunan purata 2.1% sejak 2009. Dengan itu, Program Community Feeding
(PCF) telah diperkenalkan di Long Urun mulai Disember 2013 untuk memperkasakan Program
Pemulihan Kanak-kanak KZM (PPKZM).
Objektif: Kajian ini bertujuan untuk menilai keberkesanan pelaksanaan PCF dalam meningkatkan
status pemakanan kanak-kanak KZM berbanding dengan PPKZM sahaja.
Kaedah: Senarai nama kanak-kanak KZM bawah tujuh tahun daripada komuniti Penan yang
berdaftar dalam PPKZM serta kombinasi PCF dan PPKZM, yang berada dalam program sekurangkurangnya 12 bulan telah diperolehi daripada Laporan Bulanan KPIKZM101 sejak 2012. Kes-kes
yang mempunyai masalah perubatan (contoh: congenital heart disease) serta gagal ditimbang berat
badan lebih daripada dua bulan berturut-turut telah dikecualikan daripada kajian ini. Purata kenaikan
berat badan (g) antara kes-kes yang berdaftar bawah PPKZM (n=26) serta kombinasi PCF dan
PPKZM (n=18) telah dianalisa dengan merujuk kepada berat badan semasa bermula bantuan dan
berat badan pada bulan ke-12 berada dalam program. Peratus kes yang menunjukkan kenaikan status
makanan antara kes yang berdaftar bawah kedua-dua program telah dianalisa dengan merujuk kepada
z-score berat-untuk-umur semasa bermula bantuan dan z-score berat-untuk-umur pada bulan ke-12
berada dalam program. Peratus kes yang meningkat berat badan juga dianalisa dengan merujuk
kepada data berat badan setiap bulan selama 12 bulan berada dalam program.
Keputusan: Kombinasi PPKZM dan PCF berjaya meningkatkan berat badan kes dengan 355.6 g lagi
lebih daripada PPKZM. Selain itu, kombinasi program PCF dan PPKZM juga menunjukkan 10.2%
lebih berkesan dalam meningkatkan status pemakanan kes ke satu kategori yang lebih baik
berbanding dengan PPKZM sahaja. Peratus kes yang meningkat berat badan dari kombinasi PCF dan
PPKZM adalah lebih tinggi (72.2%) berbanding dengan PPKZM sahaja (7.7%).
Kesimpulan: Kombinasi PPKZM dan PCF merupakan pendekatan yang lebih berkesan dalam
meningkatkan status pemakanan kanak-kanak KZM. Ia mungkin disebabkan oleh penjagaan yang
lebih rapi serta pemberian bantuan makanan yang lebih kerap. Namun, ini memerlukan kajian yang
lebih lanjut untuk mengkaji faktor penyumbang keberkesanan program. Dengan itu, kombinasi
PPKZM dan PCF diharap dapat diperluaskan ke lokaliti lain di bahagian Kapit yang mempunyai kes
KZM yang ramai pada masa akan datang.
Kata Kunci: Program Community Feeding; kanak-kanak kekurangan zat makanan; Long Urun
Rujukan:
1. Garis Panduan Program Community Feeding. Bahagian Pemakanan, KKM 2014; 1.
2. Garis Panduan Program Pemulihan Kanak-kanak Kekurangan Zat Makanan. Bahagian
Pemakanan, Kementerian Kesihatan Malaysia 2014; 6-7.
29
Sarawak Health Journal
Volume 3 2016
Dengue Fever Outbreak in the Long House: What is the Responsibility of Divisional Health
Office?
Shafizah AS1, Tze SN1, Phua AL1 & Azlee A1
1
Divisonal Health Office Bintulu, Sarawak, Malaysia
Corresponding Author: Shafizah Ahmad Shafei ([email protected])
Introduction: Cumulatively, Sarawak has registered 871 dengue cases this year which is an increase
(162.3%) compared to 539 cases only last year. Meanwhile, Bintulu Division recorded 42 dengue
cases cumulatively up to epid week 14/2015 compared to 28 cases within the same period last year,
which is a 50% increase in the number of cases. Bintulu Divisional Health Officer (DHO) has
declared a dengue fever outbreak in Rumah Suhaili, 25th Mile Bintulu-Miri road on 12 April 2015
upon receiving a second notification from the same locality on 11 April 2015. The first case was
recorded on 8th April 2015.
Objective: To identify the epidemiology of the outbreak, the source of infection and the appropriate
action for prevention and control
Methods: The case was investigated within 24 hours of notification using the investigation form for
dengue fever case PBV (DF / DDB / JE / CHIKU) Amendment 301 4/13. Validation is done through
serological test case. Epidemic control measures that have been implemented include thermal fogging,
destruction of breeding grounds (PTP) and active case detection. The effectiveness of control
activities especially fogging was evaluated through 48 hours ovitrap survey.
Results: The outbreak of dengue fever was caused by the Aedes albopictus mosquito as shown from
the entomological survey. Both confirmed cases of dengue fever have positive serological test (Case
1: positive for NS1 antigen, Case 2: positive for NS1 antigen, IgM and IgG). Ovitrap index examined
after the control activities were carried out was 0%.
Discussion: The main cause of the incident was caused by the absence of clean water supply that
encouraged residents to use 45-gallon (205-litre) drums as water containers. The absence of a proper
waste disposal system also has resulted in the outbreak in that area. Control measures have been done
together with the local authorities and residents and were reflected well with the decrease of amount
of potential containers and the reduction of Aedes Index, Breteau Index and Container Index.
Commitment from the Local Authorities in providing better waste disposal system has contributed to
the effectiveness of the control activities.
Conclusion: The outbreak of dengue fever that occurred in the longhouse was due to the absence of
a clean water supply and an improper waste disposal. Control measures have been carried out in
accordance with the guidelines and standards set by the Ministry of Health (MOH).
30
Sarawak Health Journal
Volume 3 2016
Table 1: Summary of activities carried out to assess Aedes breeding activity levels
Date
09.04.2015 12.04.2015
Total houses visited
Total
19.04.2015
30
30
30
90
Total houses
inspected
30
30
30
90
Outside
30
30
30
90
Inside
25
25
25
75
Aed. Aeg
0
0
0
0
Aed. Alb.
2
0
0
2
Locked
2
2
2
6
Vacant
3
3
3
9
No. of houses +ve
2
2
2
2
Aedes Index* (%)
6.7
0
0
2.2
Inside
20
27
10
57
Outside
51
28
16
95
Total
71
55
26
152
Inside
0
0
0
0
Outside
2
0
0
2
Total
2
0
0
2
Breteau Index**%
6.7
0
0
2.2
Container Index***
2.8
0
0
1.3
Inspected
Number
of
houses Positive for
Aedes
Number of containers
inspected
Number of containers
positive
* Aedes IndexAedes Index (AI) or House (premises) Index (HI): Percentage of houses or premises positive
for Aedes larvae
** Breteau index (BI): number of positive containers per 100 houses inspected.
*** Container index (CI): percentage of water-holding containers infested with larvae or pupae.
Key Words: Dengue fever; treated water
References:
1. Heymann DL. Control of Communicable Diseases Manual. American Public Health
Association 2008.
2. Jabatan Kesihatan Negeri Sarawak. Buletin Mingguan Epidemiologi Denggi Minggu Unit
Penyakit Bawaan Vektor. Epid 14/2015.
3. Kementerian Kesihatan Malaysia. Garis Panduan Halatuju Baharu Kawalan Denggi.
Kementerian 2014.
4. Kementerian Kesihatan Malaysia. Surat Pekeliling Ketua Pengarah Kesihatan Malaysia Bil.
29/2010. Tindakan Susulan Keputusan Mesyuarat Jawatankuasa Peringkat Kebangsaan
Mengenai Denggi dan Mesyuarat Jemaah Menteri: Pengaktifan Jawatankuasa Wabak Denggi
Peringkat Daerah. Kementerian 2010.
5. World Health Organization. Dengue: Guidelines for Diagnosis, Treatment, Prevention and
Control. New Edition. The Organization 2009.
31
Sarawak Health Journal
Food Poisoning Outbreak at the Ocean: A Case Report
Volume 3 2016
Shafizah AS1, Connie AA1, Nurdiana S1 & Azlee A1
1
Divisional Health Office Bintulu, Sarawak, Malaysia
Corresponding Author: Shafizah Ahmad Shafei ([email protected])
Introduction: A food poisoning outbreak among offshore workers occurred on an accommodation
vessel in South China Sea near Bintulu shore. The Communicable Disease Control (CDC) Unit of
Bintulu Divisional Health Office received a notification of food poisoning outbreak on 22nd August
2014 involving offshore workers from JC Company who stayed in an accommodation vessel in the
South China Sea of Bintulu shore. JC Company was one of the many companies responsible for
building oil rigs for a multinational company based in Kuala Lumpur. All of the construction workers
from all these different companies resided in an accommodation vessel that was attached to the oil
rig platform. Altogether, there were 284 persons on board the accommodation vessel.
Objective: To determine the epidemiology of the outbreak and its control measures.
Methods: Cases sent onshore were investigated using the standard form FWBD/UMU/BG/007. The
remaining workers who experienced the symptoms were investigated with the help of the Safety and
Health Officer of the affected company using a questionnaire developed based on the standard form
with additional questions on types of meals eaten by the workers. The food that caused the outbreak
was identified by determining the food attack rate which was calculated based on the list of menu
given. Investigation by Hazard Analysis Critical Control Point was also conducted.
Results: Thirty-five workers reported of having gastrointestinal symptoms. Almost all cases had
diarrhoea, while 94.2% experienced abdominal pain and 68.5% had fever. Only 60% had nausea and
48.5% had vomiting and headache. The incubation period ranged from 15 to 53 hours. Fried chicken
with dried tofu scored the highest food attack rate of 10.3% and was identified as the culprit, and
followed by chicken curry and fried noodles at 8.5% and 7.4%, respectively. Refer to Figure 1 for the
epidemic curve of food poisoning among workers (page 60).
Discussion: The food poisoning outbreak involving 35 workers aged between 18 to 54 years old
occurred at the accommodation vessel. The affected workers experienced mainly lower
gastrointestinal (GI) symptoms with overall attack rate of 12.3%. The aetiological agent responsible
for the outbreak was most likely Salmonella spp. based on the incubation period, signs and symptoms
of cases and food taken at that moment. The incubation period correlated with the incubation period
of Salmonella spp. as well as the suspected menu that was based on chicken. The limitation for case
investigation was mainly due to tight security since it involved heavy industry related to the oil
industry in the sea.
Lesson Learnt: Food poisoning can occur anywhere. Heavy industries must practise food safety and
hygiene. This can be done in their routine safety practice especially those who work offshore.
Innovative and alternative methods of investigation need to be implemented when normal procedures
cannot be applied. Coordination with related agencies needs to be optimized to ensure timeliness of
control measures.
Key Words: Food poisoning; Salmonella spp.
Reference:
1. Kementerian Kesihatan Malaysia. Garis Panduan Pengurusan Wabak Keracunan Malaysia di
Malaysia. Putrajaya. Kementerian Kesihatan Malaysia 2006.
32
Sarawak Health Journal
Case Reports
and
Case Series
Reports and Case Series
33
Volume 3 2016
Sarawak Health Journal
Volume 3 2016
Inferior Epigastric Artery Injury – A Complication of Femoral Line Insertion despite Under
Ultrasound Guidance
Chan WK1, Ng PN1 & Norzalina E1
1
Anaesthesiology and Intensive Care Unit, Sarawak General Hospital, Malaysia
Corresponding Author: Chan Weng Ken ([email protected])
Introduction: Accidental arterial puncture is a complication of central venous catheter (CVC)
insertion with reported incidence ranging from 4.2% to 9.3%.1. The National Institute for Health and
Care Excellence (NICE) 2002 guideline advocates ultrasound-guided CVC placement to reduce this
complication.2 We present a case of inferior epigastric artery (IEA) injury sustained during CVC
insertion into the femoral vein despite being under ultrasound guidance.
Case Presentation: A 62-year-old gentleman with underlying diabetes mellitus, chronic kidney
disease and other comorbidities including a recent stroke presented with acute parapharyngeal abscess
requiring Intensive Care Unit (ICU) admission. He was planned for incision and drainage. Preoperative blood investigations showed leucocytosis and uraemia (34.2 mmol/L). Right femoral CVC
was inserted under ultrasound guidance uneventfully. On the left however, two attempts were needed
using 7 Fr CVCs. Post insertion, he underwent haemodialysis for four hours uneventfully before being
sent to the operating theatre. Vital signs remained stable with no obvious haematoma at the CVCs
site. Post-operatively, upon arrival at ICU, it was noted that he developed significant bilateral scrotal
haematoma extending up to lower abdominal wall with haemodynamic instability requiring fluid
resuscitation and high vasopressor support. His haemoglobin level had dropped more than 4 g/dL and
patient developed lactic acidosis. Urgent femoral angiogram showed left IEA leakage, which was
embolised by the interventional radiologist. He required massive blood transfusions. Subsequently,
his condition improved. A repeated angiogram two days later showed no more haemorrhage.
However, patient continued to be managed in ICU as he had acute respiratory distress syndrome,
delayed wound healing and hospital-acquired infection. Unfortunately, patient succumbed to
aspiration pneumonia three months later.
Discussion: IEA injuries occur more commonly among the patients with coagulopathy, and
embolisation is an effective measure for haemorrhage control.3 Despite ultrasound guidance,
iatrogenic complication can still occur. In order to reduce the risk, it is crucial to visualise the tip of
the needle at all times. This skill is operator-dependent and requires some training and is best learnt
through a simulation model which is sold commercially and should be made available to all training
centres. Some authors have advocated static or dynamic ultrasound techniques but this minor
difference in ultrasound guiding techniques which often involves both the so-called static and
dynamic methods is negligible.4
Conclusion: Arterial injury is a known complication of central venous access. Ultrasound guidance
may reduce inadvertent arterial puncture and potential life threatening haemorrhage. However,
clinicians need to learn this technique correctly.
Key Words: Dynamic ultrasound; central venous access complications; inferior epigastric artery
34
Sarawak Health Journal
Volume 3 2016
Diffuse Large B-Cell Lymphoma of the Terminal Ileum Mimicking Appendicular Mass in a Young
Adult
Devanraj S1, Suriaraj K1, Premjeet S1 & Soon KC2
1
Miri Hospital, Sarawak, Malaysia
2
Sarawak General Hospital, Sarawak, Malaysia
Corresponding Author: Devanraj A/L Selvam ([email protected])
Introduction: Lymphomas of the gastrointestinal (GI) tract are the most common primary extranodal
lymphomas, of which 15-20% of these manifests as primary intestinal lymphoma.1 The presentations for
GI lymphomas are usually non-specific and clinically indistinguishable from other benign and malignant
GI conditions.
Case Report: We report a 20-year-old lady with primary lymphoma of the terminal ileum who presented
initially to our centre with one day history of pain and a mass at the right iliac fossa. The blood results
were of no significance but the computed tomography (CT) scan of the abdomen was suggestive of an
appendicular mass (Figure 1). From the outset, a conservative regime was planned for her with antibiotics,
fluids and rest, and a subsequent follow-up in the surgical clinic. However after four weeks, her pain
recurred and she then underwent an emergency surgery during which it was noted that there was a small
bowel mass at the terminal ileum along with multiple mesenteric lymphadenopathies. A right
hemicolectomy (Figure 2) was performed and she was discharged well. Histo-pathological examination
of the terminal ileum revealed it to be of the Diffuse Large B-Cell type of lymphoma with the involvement
of only one out of the 23 mesenteric lymph nodes. A staging CT thorax, abdomen and pelvis showed
evidence of para-aortic and mesenteric lymphadenopathy without affecting the supra-diaphragmatic
lymph nodes. Chemotherapy was commenced for her shortly after that.
Discussion: Extranodal lymphomas are lymphomas that arise from tissues other than lymph nodes.
Lymphoma constitutes 15-20% of all small intestine neoplasms with the most common site of
involvement being the ileum (60-65%).2 Ileo-caecal lymphoma commonly presents with abdominal pain,
altered bowel habits and weight loss, along with the finding of an abdominal mass. Nevertheless, primary
intestinal lymphoma is usually only diagnosed after exploratory laparotomy such as in our patient.
Treatment of primary intestinal lymphoma differs according to the extent of the disease. Surgical resection
should always be attempted for localized disease.1 This, combined with systemic chemotherapy, appear
superior to any other treatment combination in localized disease. On the other hand, in disseminated cases,
chemotherapy alone or in combination with surgery was the treatment modality associated with the
highest complete remission and five-year survival. Diffuse large B-cell lymphoma (DLCL) of the intestine
is usually treated with aggressive poly-chemotherapy, which is usually combined with a monoclonal
antibody such as Rituximab.3 The major prognostic factors for survival are the size of the primary tumour,
the likelihood of radical surgical resection, its degree of extension to adjacent structures, the amount of
residual disease after surgery, stage and histological subtype.4
Conclusion: Albeit lymphoma at the ileo-caecal junction is relatively uncommon, it should always be
considered as a pertinent differential of a right iliac fossa mass in a young adult, especially when
conservative management fails.
Key Words: Lymphoma; terminal ileum; appendicular mass
36
Sarawak Health Journal
Volume 3 2016
Figure 1: Heterogeneous mass seen at the right iliac fossa which was initially suggestive of an appendicular
mass
Figure 2: Gross specimen of the right hemicolectomy with multiple mesenteric lymphadenopathies
References:
1. Zinzani PL, Magagnoli M, Pagliani G, et al. Primary intestinal lymphoma: Clinical and therapeutic
features of 32 patients. Haematologica 1997; 82(3): 305-8.
2. Schottenfeld D, Beebe-Dimmer JL & Vigneau FD. The epidemiology and pathogenesis of neoplasia
in the small intestine. Ann Epidemiol 2009; 19: 58-69.
3. Ghimire P, Wu GY & Zhu L. Primary gastrointestinal lymphoma. World J Gastroenterol 2011; 17(6):
697-707.
4. Weingrad DN, Decosse JJ, Sherlock P, et al. Primary gastrointestinal lymphoma: A 30-year review.
Cancer 1982; 49: 1258-65.
NMRR ID: 15-802-26254
37
Sarawak Health Journal
Volume 3 2016
Silantek Burn Disaster 2014: Critical Care Experience and Lesson Learned
Farah R1, Yusopian Y1, Natasha N1, Fakhzan M1& Norzalina E1
1
Department of Anaesthesiology and Intensive Care, Sarawak General Hospital, Malaysia
Corresponding Author: Natasha Mohd Noh ([email protected])
Introduction: Burn disaster is uncommon and management after a casualty is important. On 22nd
November 2014, a coal mine exploded in Silantek Pantu, Sri Aman, Sarawak.
Case Presentation: The Intensive Care Unit (ICU) in Sarawak General Hospital (SGH) is 15-bedded
and it was converted to 20-bedded during the incident. Thirty patients were brought to SGH. Fifteen
of them who were admitted to ICU were foreigners from North Korea, Myanmar, Indonesia, and
China. Their ages were between 21 to 44 years old. Most had full-thickness burns and more than 40%
Total Body Surface Area (TBSA). The Burn Unit ventilated four patients, while the general ward
ventilated ten patients. Of those in the ICU, two had inhalational injury, one with intracranial bleed,
and two with fractures. Other hospitals in Sarawak (including private medical centres) with ICU
facilities were identified. During the first 24 hours, six patients were transferred to two private
hospitals in Kuching for ventilator support, and they were transferred back to SGH at day-five postincident. A total of eight patients were transferred to Sabah and West Malaysia for facilities up to 72
hours post-incident. Patients ventilated in general wards were later transferred to ICU. Four operating
rooms were dedicated for burn cases for the first week. Mortality rate in ICU was 40% (n=6).
Discussion: The purpose of this report is to review our recent experience and lessons learned with
burn disaster with respect to the planning and management from the anaesthesiology and intensive
care perspectives. As the incident occurred over the weekend, staff were called back to work and most
had to stay overnight in the hospital. The critical shortages of ventilators and ICU beds became our
main problem. Those patients transferred away were the ones intubated with minor injuries. Planning,
communication, and documentation are the most important element in managing a casualty. There
must be a disaster plan in place in the hospital with a proper framework. Communication must be
established by defining the role of the leader and others for an effective disaster response. Triage is
essential as burn victims need immediate medical care and to prevent overload at a burn centre
especially in the ICU. Personnel shortages and organization of work through formation of teams is
required. Supplies and equipment such as medications, ventilators and transport monitors are
potentially scarce when critical care capacity is expanded; hence the list should be updated. The
timely transfer of patients to other identified hospitals or regions in the country is crucial and this
may include aeromedical evacuation.5 Acute hours of life-saving resuscitation and surgery include 24
hours post-disaster whereby patients may need surgery.
Conclusion: The challenges faced were manpower and limitation of ICU resources to accommodate
mechanically-ventilated patients in ICU, Burn Unit and general ward. Transfer decision is a priority
to ensure optimum care of the critically-ill patients. Effective planning and communication is needed
to ensure that the sudden onset of a crisis situation at an unexpected time does not overwhelm hospital
manpower and resources.
Key Words: Disaster management; Silantek; burn
38
Sarawak Health Journal
Endocrine Disorder Masquerading as Blood Malignancy: A Case Report
Volume 3 2016
Lee WH1, Leong TS1 & Chew LP1
1
Haematology Unit, Medical Department, Sarawak General Hospital, Malaysia
Corresponding Author: Lee Wan Hui ([email protected])
Introduction: Hypercalcemia is a commonly encountered medical problem in our practice, which
can be attributed to a myriad of aetiologies. We present a case that was evaluated for hypercalcaemia,
anaemia and multiple lytic lesions with a strong suspicion of blood malignancy which eventually
turned out to be an endocrine disorder.
Case Presentation: A 68-year-old lady presented to us with generalized body weakness, nausea,
headache, confusion, and abdominal pain. Blood investigation showed normochromic normocytic
anaemia and hypercalcemia. Skeletal survey revealed multiple lytic lesions. Multiple myeloma was
suspected. However, bone marrow aspiration revealed a dry tap and trephine biopsy did not show
plasma cells. Hence, we encountered a diagnostic dilemma and we were hesitant to start treatment
for multiple myeloma, considering the high cost and potential life-threatening side effects of the
treatment. Fortunately, the intact parathyroid hormone level came back on time and noted to be
markedly raised. The diagnosis of primary hyperparathyroidism was considered and the case was
referred to an endocrinologist.
Outcome / Follow-up: Ultrasound of the neck revealed a right retrothyroid lesion. Sestamibi scan
was suggestive of hyperfunctioning parathyroid tissue. Subsequently the patient underwent parathyroidectomy where a right parathyroid adenoma of 2 cm x 1.5 cm was resected. A follow-up four
weeks later revealed a stable calcium level with haemoglobin of 11 (without any blood transfusion).
As expected, serum and urine protein electrophoresis were negative for paraprotein, not suggestive
of any blood malignancy.
Discussion: Hyperparathyroidism may be a precipitating factor important to the development of
anaemia which might progress into myelofibrosis. However, there had been only a few reported cases
on anaemia and myelofibrosis secondary to primary hyperparathyroidism. It is suggested that
parathyroid hormone (PTH) interferes with normal erythropoiesis by down- regulating the
erythropoietin (EPO) receptors on erythroid progenitor cells in the bone marrow; hence anaemia
ensues. This effect is observed with very high concentrations of PTH. Hypercalcaemia and anaemia
are expected to resolve once the source of high PTH is removed. This is clearly illustrated in our case
scenario.
Conclusion: In the presence of anaemia, hypercalcaemia and radiographic evidence of multiple lytic
lesions, primary hyperparathyroidism should always be kept in differential diagnosis and should be
looked into after other causes such as (blood) malignancy has been excluded. A high index of
suspicion will lead to an early diagnosis and appropriate treatment.
Key Words: Hypercalcaemia; anaemia; multiple myeloma; primary hyperparathyroidism
39
Sarawak Health Journal
Cutting the Queue: Young Myocardial Infarction
Volume 3 2016
Kang WJ1 & Ng SG1
1
Emergency and Trauma Department, Sarikei Hospital, Sarawak, Malaysia
Corresponding Author: Kang Wen Ji ([email protected])
Introduction: How young is actually young? Standard teaching imparts that myocardial infarction
(MI) occurs mainly in patients older than 45 years. But in reality, 3% of MI occurs in patients between
15 and 34 years old, which is rarely highlighted.1 This group of patients has a wide range of
aetiologies, which poses a management challenge. Here, we share a case of a young MI.
Case Presentation: A 24-year-old gentleman, smoker with no co-morbid presented with typical chest
pain. He had no family history of heart disease and denied any recreational drug abuse. On
examination, vital signs were stable. His lungs were clear and heart sounds were normal.
Electrocardiogram (ECG) showed ST elevation in the anteroseptal leads. Bedside echocardiogram
revealed anteroseptal wall hypokinaesia and troponin T level was raised. Blood sugar and lipid
profiles were normal. He was immediately thrombolysed with intravenous streptokinase and ECG
post-thrombolysis showed good resolution. This patient subsequently stopped taking his medications.
He landed in a heart centre with severe chest pain and developed ventricular fibrillation. He was
resuscitated and primary percutaneous coronary intervention (PCI) was done, showing occlusion of
the proximal segment of left anterior descending (LAD) and was stented successfully.
Echocardiogram was done: ejection fraction of 25-35% with regional wall motion abnormalities over
the anteroseptal.
Discussion: When a young patient presents with chest pain and ECG shows ST elevations, we should
consider the different aetiologies and risk factors of coronary artery disease (CAD) in young adults
before rushing for thrombolysis. In general, the aetiologies of young MI can be divided into two
categories: (a) atheromatous CAD and (b) non-atheromatous CAD.4
(a) Atheromatous CAD
The atheromatous process was linked to the conventional risk factors as in older adults, which are
cigarette smoking, lipid abnormalities, insulin resistance, hypertension, obesity and positive
family history of premature CAD.1,2,3,4 In our patient, the risk factors were cigarette smoking. The
relative risk for CAD was 3 times higher in smokers1. Repeated exposure to cigarettes results in
damaged endothelial cells, leading to injury of the vascular intima.
(b) Non-atheromatous CAD
Recreational drug use (e.g. cocaine) was found to be associated with MI by causing coronary
vasospasm and the effects can present up to 76 hours.4 Hypercoagulable states e.g.
antiphospholipid syndrome, nephrotic syndrome are associated with recurrent vessels thrombosis.
Congenital coronary artery anomalies and coronary embolisation of septic vegetation are other
rare causes of MI in young adults.
Although rare, all the above causes must be considered in every young patient presenting with MI
while chasing time. Primary PCI was done and showed occlusion of LAD. Young patients are more
likely to have single vessel disease as compared to their older counterparts1 and the LAD was the
most susceptible site of atherosclerotic occlusion in younger patients with MI2.
Lessons Learnt:
1. The causes of a young patient presenting with MI should be weighed and evaluated due to the
wide range of aetiologies.
2. Young MI is rare but possible. If the diagnosis is definite, do not hesitate to thrombolyse them.
Remember, time is myocardium.
40
Key Words: Young myocardial infarction
Sarawak Health Journal
Volume 3 2016
References:
1. Klein LW & Nathan S. Coronary artery disease in young adults. J Am Coll Cardiol 2003; 41(4):
529-31.
2. McGill HC Jr, McMahan CA, Tracy RE, et al. Relation of a postmortem renal index of
hypertension to atherosclerosis and coronary artery size in young men and women.
Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Research Group. Arterioscler
Thromb Vasc Biol. 1998; 18: 1108-18.
3. Kannel W, McGee D & Castelli W. Latest perspectives on cigarette smoking and cardiovascular
disease. The Framingham Study. J Card Rehabil 1984; 4: 267-77.
4. Egred M, Viswanathan G & Davis GK. Myocardial infarction in young patients. Postgrad Med
2005; 81: 741-5.
41
Sarawak Health Journal
An Early Experience of Treating Paediatric Neck of Femur Fracture
Volume 3 2016
Kesavan R1, Hafiz D1, Norzatulsyima N1 & Isymth AR1
1
Miri Hospital, Sarawak, Malaysia
Corresponding Author: Kesavan Ramachandran ([email protected])
Introduction: Femoral neck fractures are rare in children and usually occur in high energy trauma
settings. These fractures pose a challenge for orthopaedic surgeons, because of its potential
complications and the high degree of expertise needed in its management.
Case Report: We report a 5-year-old girl who presented with a closed left femoral neck fracture. The
mechanism of injury in our case was that of a high-impact trauma from motor vehicle accident. Upon
arrival at hospital, the left lower limb was externally rotated with no obvious deformity seen.
Attempted manoeuvre around the hips was painful. The frontal pelvic radiograph (Figure 1) showed
a left cervico–trochanteric (Type III) femoral neck fracture. She was operated within 24 hours. Closed
reduction was attempted on the left side under an image intensifier and the fracture was fixed with
two partial treaded cannulated 7.0 mm screws. Post-operatively, the patient was on spica
immobilization for six weeks. The follow up review showed that the fracture had healed with no sign
of femoral head avascular necrosis (Figure 2). The range of movements of both hip joints was full
and painless with no limb length discrepancy noted.
Discussion: Femoral neck fractures in children are nearly always the result of high energy trauma
because the femoral neck of children is relatively denser and harder compared to adult femoral neck.2
Occasionally, they can occur due to underlying metabolic disorders.1 The mechanism of injury in our
case was due to direct high impact force. Other mechanisms of injury that have been described include
indirect abduction and external rotation which cause the femoral neck to hinge against the acetabular
rim.3 Avascular necrosis (AVN) is the most dreaded complication following these fractures, reported
to be 18% to 30%.4 There is a higher incidence of AVN up to 41% when hip decompression is not
done, compared with 8% in those treated with early hip decompression. In our case, AVN has not
been observed up to 6 months post injury. The main factors influencing AVN rates are the initial
fracture displacement, the degree of initial insult, and the timing of surgical fixation together with hip
decompression. Operative fixation should be carried out preferably within 48 hours of fracture.
Conclusion: It is important not to miss this femoral neck fractures in children involved in high impact
trauma as early correct management involving surgical intervention can lead to good outcome.
Key Words: Paediatric; neck of femur; fracture
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Volume 3 2016
Figure 1: Anteroposterior radiograph of pelvis showing left neck of femur fracture
Figure 2: Radiograph showing left neck of femur fracture healed with implant in-situ
References:
1. Saied A& Jalili A. Bilateral femoral neck fractures in a child. Eur J Orthop Surg Traumatol
2009; 19: 349-51.
2. Quinlan WR, Brady PG & Regan BF. Fracture of the neck of the femur in childhood. Injury
1980; 11(3): 242-7.
3. Upadhyay A, Maini L, Batra S, et al. Simultaneous bilateral femoral neck fractures in children
- mechanism of injury. Injury 2004; 35: 1073-5.
NMRR ID: 15-966-26537
43
Sarawak Health Journal
A Rare Disease Encounter: Hitting Hard May Not Be the Answer
Volume 3 2016
Leong TS1, Lee WH1 & Chew LP1
1
Haematology Unit, Medical Department, Sarawak General Hospital, Malaysia
Corresponding Author: Chew Lee Ping ([email protected])
Introduction: Cutaneous T-cell lymphoma is the most common type of skin lymphoma but the case
we are presenting is an uncommon presentation of a rare form of T-cell skin lymphoma. We hope to
present a new “treatment” to this rare skin lymphoma, with minimal side effects and better quality of
life.
Case Presentation: A 20-year-old female, presented with pyrexia of unknown origin for one month.
She had microcytic hypochromic anaemia and lymphopenia. Her LDH of 2343 mmol/L was
unusually high. However, all septic work up and autoimmune screening were negative. Bone marrow
examination did not show any obvious abnormality. However, she started noticing a right breast lump
that grew rapidly. CT scan showed a large cystic mass occupying the right breast. Biopsy revealed
subcutaneous panniculitis-like T-cell lymphoma (SPTCL), a rare form of blood malignancy.
Treatment / Outcome: She was started on chemotherapy CHOP, which was escalated to DAEPOCH as new satellite lesions were growing around the breast lump. Despite that, she started
developing red plaque-like tender lesions at both her lower limbs. Treated as a refractory disease, she
was given Bendamustine + Ara C high dose (BAC). Histopathologic examination (HPE) of the skin
showed perivascular pleomorphic skin infiltrate but inconclusive of panniculitis T- cell lymphoma.
Her conditions continued to deteriorate with pancytopenia, fever and peripheral neuropathy. The only
consolation was the breast lump healed totally, leaving a small scar. Out of desperation, based on
anecdotal evidence, she was started on a combination of milder oral chemotherapeutic drug, namely
prednisolone, cyclosporine and methotrexate. To our surprise, her condition improved. Her fever
settled, cytopenia resolved and the skin plaque eventually disappeared. She was able to resume back
her activities of daily living subsequently.
Conclusion: Subcutaneous panniculitis-like T-cell lymphoma (SPTCL), is a subtype of Peripheral
T-cell lymphoma (PTCL)1, which usually presents with subcutaneous nodules at trunk and
extremities.2 Involvement of lymph nodes and dissemination to other organs are rare.3 Our patient
presented with extracutaneous manifestation of SPTCL i.e. B symptoms, breast tumour, cytopenias,
pleural effusion, lymphadenopathy, hepatitis and later bilateral peripheral neuropathy. Multiorgan
involvement may mask the diagnosis of this cutaneous lymphoma, making diagnosis difficult.
Currently, no standard treatment has been established for SPTCL due to its low incidence and lack of
clinical trials. From the various trials published, combination chemotherapy e.g. CHOP-like therapy
is not successful in treating this disease, with five years median survival of 80%.4 High-dose
chemotherapy followed by auto/allogenic stem cell transplant has been suggested as an option in
patients with refractory or recurrent SPTCL.5 This case illustrates a real-world experience where
intensive chemotherapy may not always be the answer, especially for a rare disease that many people
are not familiar with. Perhaps a more gentle and individualized therapy should be adopted to manage
this rare form of lymphoma.
Key Words: T-cell lymphoma; treatment; skin lesion
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Sarawak Health Journal
Volume 3 2016
References:
1. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. 4th ed. 2008; 2945.
2. Gonzalez CL, Medeiros LJ, Braziel RM, et al. T-cell lymphoma involving subcutaneous tissue.
Am J Surg. Pathol 1991; 15: 17-27.
3. Willemze R, Jaffe ES, Burg G, et al. EORTC classification for Primary cutaneous lymphoma.
Blood 2005; 111: 838-45.
4. Go RS & Wester SM. Immunophenotypic and molecular features, clinical outcomes, treatments,
and prognostic factors associated with subcutaneous panniculitis-like T-cell lymphoma: a
systematic analysis of 156 patients reported in the literature. Cancer 2004; 101(6): 1404-13.
5. Alaibac M, Berti E, Pigozzi B, et al. High-dose chemotherapy with autologous blood stem cell
transplantation for aggressive subcutaneous panniculitis-like T-cell lymphoma. J Am Acad
Dermatol 2005; 52: 121-3.
45
Sarawak Health Journal
Does Low Platelet Count Equate to Immune Thrombocytopenic Purpura?
Volume 3 2016
Leong TS1, Lee WH1 & Chew LP1
1
Haematology Unit, Medical Department, Sarawak General Hospital, Malaysia
Corresponding Author: Leong Tze Shin ([email protected])
Introduction: Thrombocytopenia is commonly treated as immune thrombocytopenic purpura (ITP),
especially when longstanding. We report the case of a family with a rare inheritable form of platelet
disorder. They were initially treated for ITP.
Case Presentations:
Case One: Ms A was a 26-year-old female, diagnosed as “ITP” at the age of five years. She was noncompliant to steroids. During her first pregnancy, she went into labour with platelet of less than
10,000, needing platelet transfusion and delivered a healthy baby boy. Estimated blood loss was 200
ml.
Case Two: Mr B was a 23-year-old male, also diagnosed with ITP when he was 3 years old. He was
treated for dengue fever, when he had fever and platelet count of 3 x 103/dl. However at day 14 of
illness, platelet count remained 9k. He was treated as ITP but did not respond to steroid.
Outcome/Follow-up: Peripheral blood film showed presence of giant platelets with Dohle inclusion
bodies in the neutrophils. Based on further history from Mr B’s mother, we identified probably the
first documented pedigree of May Hegglin Anomaly in Kuching after examining the relatives’ blood
films. Ms A and Mr B are actually first-degree cousins. Related family members’ bloods were sent
to Australia for genetic mutation testing for May-Hegglin anomaly.
Figure 1: Pedigree of May-Hegglin Anomaly
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Volume 3 2016
Discussion: May-Hegglin anomaly is a type of autosomal dominant genetic disorder characterized
by large platelet, thrombocytopenia and variable degree of bleeding tendencies. It involves mutations
in the MYH9 gene encoding for the non-muscle myosin heavy chain IIA of platelet. May-Hegglin
anomaly is a rare disorder that has been under-recognised and misdiagnosed as ITP and leads to
inappropriate treatment such as corticosteroids (with numerous side effects) and splenectomy.
Conclusion:
These cases illustrate the potential clinical pitfalls in our approaches in managing thrombocytopenia.
Family history taking and peripheral blood film will lead to the correct diagnosis.
Key Words: Thrombocytopenia; low platelet; Dohle inclusion body; May-Hegglin anomaly
47
Sarawak Health Journal
Clinical Suspicion of Pulmonary Leptospirosis — Treat or Die!
Volume 3 2016
Norhayani Y1, Ng SG1, Ngoi YS1, Hnin NC1 & Mohd Zaim AZ1
1
Emergency & Trauma Department, Sarikei Hospital, Sarawak, Malaysia
Corresponding Author: Norhayani bt Yahya ([email protected])
Introduction: Pulmonary leptospirosis is recognised increasingly as a major and lethal complication
of leptospirosis. Mortality remains significant, mostly related to delays in diagnosis due to inadequate
clinical suspicion even in endemic regions. The incidence of pulmonary involvement in leptospirosis
has been reported to be increasing affecting up to 70% of the patients.
Case presentation: A 14 year-old-boy presented to the Emergency Department with two days history
of shortness of breath and fever; no leptospirosis risk factors. Upon arrival, he was conscious,
tachypneoic with respiratory rate of 60 bpm, febrile, tachycardic and oxygen saturation under highflow oxygen was 92%. There was generalized crepitation of the lungs. His arterial blood gases
showed type I respiratory failure, non-invasive ventilation was applied but after 30 minutes, he started
to cough out blood and was unable to maintain oxygen saturation; he was intubated subsequently.
Chest X-ray showed diffuse nodular infiltration with periphery involvement. Blood investigations
revealed white cell count 19,000/L, platelet 349 x 103/dl, creatinine kinase 216 U/L, urea 12.5
mmol/L, creatinine 130 mol/L with normal liver function test. Our initial diagnosis was pulmonary
leptospirosis and he was started with intravenous Rocephine and methylprednisolone. He required
high ventilator setting to maintain adequate oxygen saturation. After discussion with anaesthesia team,
he was started on lung recruitment strategy with prone position and successfully extubated after three
days.
Discussion: This is a young, healthy patient with a short history of febrile illness with pulmonary
manifestation requiring high-flow oxygen and deteriorated rapidly requiring intubation within 1 hour
of presentation. The spectrum of pulmonary manifestation of leptospirosis is wide and ranging from
mild respiratory symptoms to the presence of ARDS. Dry cough, dyspnea and hemoptysis are the
most common pulmonary symptoms that usually appear between day 3 and 6 of disease and may lead
to death in less than 72 hours.1 The only risk factor in this patient was cigarette smoking. Garcia et
al. actually found that cigarette smoking was a risk factor for the development of respiratory
involvement in Leptospirosis.2 Shenoy et al. demonstrated that corticosteroid reduces mortality and
change its outcome significantly. Stat dose of methylprednisolone given within the first 12 hours of
onset of respiratory involvement is life-saving in severe pulmonary leptospirosis.3 However, this is a
small scale study, larger randomised control study is needed.
Lesson Learnt: Leptospirosis is endemic in Sarawak. Due to its geographical setting, high index of
suspicion towards leptospirosis, particularly pulmonary leptospirosis, is required in patient with fever
and no obvious sources of infection with or without risk factors. Evolution of pulmonary leptospirosis
may be rapid and fatal, thus prompt initiation of treatment is crucial.
Key Words: Pulmonary; leptospirosis
References:
1. Dolhnikoff M, Mauad T, Bethlem EP, et al. Leptospiral pneumonias. Curr Opin Pulm Med.
2007; 13: 230-5.
2. Martinez Garcia MA, de Diego Damia A, Menendez Villanueva R, et al. Pulmonary
involvement in leptospirosis. Eur J Clin Microbiol Infect Dis 2000; 19(6): 471-4.
3. Shenoy VV, Nagar VS, Chowdhury AA, et al. Pulmonary leptospirosis: An excellent response
to bolus methylprednisolone. Postgrad Med J. 2006; 82: 602-6.
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Sarawak Health Journal
Volume 3 2016
Unusual Presentation of Intussusception in Henoch-Schonlein Purpura - A Case Report
Nursheila Izrin AZ1, Premjeet S1 & Suraj PB1
1
Department of General Surgery, Miri Hospital, Sarawak, Malaysia
Corresponding Author: Nursheila Izrin Abu Zaki ([email protected])
Introduction: Henoch-Schonlein Purpura (HSP) is a self-limited, systemic, nongranulomatous,
autoimmune complex, small vessel vasculitis, with multiorgan involvement. It is the commonest
cutaneous vasculitis in children compromising up to 90% of cases, with gastrointestinal symptoms
occurring in about two-thirds of patients.2 Intussusception is a rare complication and is the most
common surgical indication of HSP and occurs in 0.7 to 13.6% of patients.3
Case presentation: A 3-year-old Iban girl presented with a three-day history of fever and palpable
skin rash over her extremities. During admission she developed vomiting and intermittent colicky
abdominal pain and distension, localised to the right iliac fossa. Abdominal ultrasound showed
thickening of the terminal ileum with dilated small bowels. There was no sonographic evidence of
intussusception. Suspicion of appendicitis dictated her treatment. She had open appendicectomy after
no improvement from antibiotics. Intraoperatively, appendix was normal with dilated small bowels
secondary to an ileo-ileal intussusception 5 cm from the ileocecal junction. After manual reduction,
10 cm of gangrenous small bowel was resected with primary anastomosis performed.
Discussion: Gastrointestinal symptoms in HSP include abdominal pain that worsens after meals,
similar to bowel ischemia, resulting from inflammation, oedema or haemorrhage in the intestinal
wall.2,3 It is uncommon in adults and those less than three years of age, and may occur at any stage
of the illness.4 The sites of intussusception with HSP are most commonly ileo-ileal (51%), followed
by ileo-colic (39%).1,3 Bowel wall oedema or submucosal bleeding is typically identified as the lead
point in intussusception with HSP. Ultrasonography is the imaging of choice to assess patients of
HSP presenting with abdominal pain for complications such as intussusception, with sensitivity of
98-100% and specificity of 88%.5 Contrast or air enema reduction is ineffective in majority of
intussusceptions with HSP because they are confined to the small bowel.1,3 Surgical intervention is
required in non-reducible intussusception by air or contrast enema, or with no spontaneous reduction
of ileoileal type for over 24 hours or in the case of intestinal perforation.3
Conclusion: In patients of HSP with gastrointestinal symptoms, abdominal ultrasound is
recommended for early diagnosis of intussusception and to exclude bowel perforation. A negative
ultrasound finding does not rule out intussusception and patients need to be monitored closely.
Key Words: Intussusception; Henoch-Schonlein; paediatrics; purpura; case
References:
1. Choong CK, Kimble RM, Pease P, et al. Colo-colic intussusception in Henoch-Schonlein
purpura. Pediatr Surg Int 1998; 14: 173-4.
2. Glasier CM, Siegel MJ, McAlister WH, et al. Henoch-Schonleiun syndrome in children:
gastrointestinal manifestation. AJR Am J Roentgenol 1981; 136: 1081-5.
3. Ebert EC. Gastrointestinal manifestations of Henoch-Schonlein purpura. Dig Dis Sci 2008; 53:
2011-9.
4. Martinez-Frontanilla LA, Haase GM, Ernster JA, et al. Surgical complications in HenochSchonlein purpura. J Pediatr Surg 1984; 19: 434-6.
5. Hu SC, Feeney MS, McNicholas M, et al. Ultrasonography to diagnose and exclude
intussusception in Henoch-Schonlein purpura. Arch Dis Child 1991; 66: 1065-7.
NMRR ID: 15-816-26307
49
Sarawak Health Journal
Case Report: Leiomyoma of the Anterior Abdominal Wall
Volume 3 2016
Ong ECW1 & Siow SL1
1
Department of General Surgery, Sarawak General Hospital, Malaysia
Corresponding Author: Ernest Ong Cun Wong ([email protected])
Case Report: A 72-year-old Bidayuh gentleman presented with lower abdominal pain for one year,
associated with constipation, loss of weight and appetite for the past two months. On examination,
there was a palpable mass at the left iliac fossa which was firm, tender and mobile, measuring about
5 cm x 5 cm. There was no palpable cervical or axillary lymph node. Tumor markers and initial
investigations for tuberculosis (sputum for acid-fast bacilli, Mantoux test, erythrocyte sedimentation
rate and chest radiograph) were negative. Colonoscopy revealed an extraluminal compression of the
sigmoid colon. Computed tomography (CT) scan of the abdomen and pelvis (Figure 1) revealed a
calcified mesenteric mass measuring 37 mm x 47 mm x 45 mm at the left iliac fossa region.
Figure 1: Preoperative computed tomography images of the abdomen and pelvis
Diagnostic laparoscopy revealed a tumour arising from the anterior abdominal wall (Figure 2). The
tumour was laparoscopically excised, and the patient was discharged well on the second postoperative
day, and remained well 6 months later. Histology revealed a tumour with proliferating smooth muscle
cells arranged in interlacing bundles, showing mild pleomorphism and hyperchromatic nuclei. Some
of the cells showed mild pleomorphism and hyperchromatic nuclei. The smooth muscle cells were
positive for smooth muscle actin, and negative for CD117 and CD34.
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Sarawak Health Journal
Volume 3 2016
Figure 2: Intraoperative picture of bivalve tumour
Discussion: The exact aetiology for the development of a leiomyoma in an area which primarily
consist of skeletal muscle tissue is unknown. Possibilities in this patient include secondary
leiomyomatous metaplasia or smooth muscle tumour arising from blood vessels.1,2,3 In the assessment
of a peritoneal tumour, it is sometimes difficult to differentiate between mesenteric, omental and
peritoneal tumours on CT and ultrasound (US). MRI is sometimes used in conjunction with CT to
characterize a mesenteric mass.4 Surgical excision is considered to be the first choice of the treatment
for leiomyoma and long‑term follow‑up of minimum one-year duration is recommended for
surveillance of any tumour recurrence.
Conclusion: Leiomyoma of the anterior abdominal wall is a rare condition that may pose diagnostic
difficulties, especially in the presence of clinical features of malignancy. A diagnostic laparoscopy is
advocated for the management of any suspicious intraabdominal mass.
Key Words: Leiomyoma; anterior abdominal wall; laparoscopic surgery
References:
1. MS S, Manna V & RL. Leiomyomas of the spleen. Internet J Pathology 2010; 12(1).
2. Wu Q, Liu C, Luo X, et al. Neurology India ISSN 2013; 61(6): 686-7.
3. Harnanan D, Hariharan S et al. Acta Obstetricia et Gynecologica Scandinavica 2012; 91(10):
1233-6.
4. Park JY, Kim KW, Kwon HJ, et al. Peritoneal mesotheliomas: clinicopathologic features, CT
findings and differential diagnosis. AJR Am J Roentgenol 2008; 191(3): 814-25.
51
Sarawak Health Journal
A Rare Case of Spontaneous Renal Artery Rupture
Premjeet S1, Devanraj S1, Nursheila Izrin AZ1, Suraj PB1
1
Department of General Surgery, Miri Hospital, Sarawak, Malaysia
Volume 3 2016
Corresponding Author: Premjeet Singh ([email protected])
Introduction: Traumatic artery rupture, accidental injury of arteries during manipulation
intraoperatively, and even rupture of fairly common aneurysms like abdominal aorta or berry
aneurysms are commonly encountered during clinical practice. However, spontaneous rupture of an
artery is rare and only few cases have been reported. We are presenting a rare case of spontaneous
renal artery rupture presenting with acute abdomen and peritonitis and would like to highlight the
importance of prompt investigations and intervention. A battery of investigations were ordered
including a CT (Computerized Tomography) scan, and subsequently immediate intervention
(exploratory laparotomy and vessel repair) was carried out, saving the life of this patient.
Case Report: This previously well 40-year-old gentleman presented to us with acute abdomen and
clinical examination revealed peritonitis. Erect chest X-ray showed no free air and a CT scan (Figure
1) was subsequently ordered which showed haemoperitoneum, and active bleeding seen around the
greater curvature, lesser sac and mesentery. Patient was acidotic, however, and was sent for surgery
after resuscitation. Intra-operative findings revealed 5 L of blood with active bleeding noted from left
renal artery. The vessel was repaired with prolene and haemostasis was secured. Patient’s condition
improved and was discharged on post-operative day 6. We planned for a post-operative CT
Angiogram and further workup like connective tissue disease screening but patient defaulted follow
up.
Discussion: The spontaneous rupture of a renal artery is indeed rare. Only one case has been reported
by Lincoln, back in January 1918 where a 64-year-old previously-well gentleman, presented with
peritonitis and hypovolemic shock. Intraoperatively, a hematoma was found at the retroperitoneal
space around the right kidney. When evacuated, there was profuse bleeding from the renal artery
which was ligated one inch away for the renal pelvis after which patient recovered well.1 However,
many cases have been reported of ruptured renal artery aneurysms and pseudo-aneurysms which have
an overall incidence range between 0.01% and 1%.2 For instance, a case report published in January
2015 in Korea of a giant renal artery pseudo-aneurysm (9.4 cm in diameter) with severe left flank
pain and a syncopal attack in a 32-year-old with uncontrolled hypertension3. A case of a previously
healthy 46-year-old man presenting with flank pain and gross haematuria which later was diagnosed
as having a ruptured renal artery aneurysm in 2010 was reported in America.4 Spontaneous renal
artery rupture has also been reported in patients with underlying connective tissue diseases. A 12year-old with Ehlers Danlos Syndrome Type IV, presented with peritonitis and was found
intraoperatively to have a ruptured right renal artery with the wall of the vessel being friable and
weak.5
Conclusion: Rare and unexpected causes of acute abdomen such as a ruptured artery should always
be kept in mind in clinical practice and prompt investigation and intervention should be carried out
for a successful outcome. Clinical suspicion of a ruptured artery together with an early CT scan is
mandatory on the survival of this patient with this rare condition. It may be possible to reduce the
incidence of renal artery rupture through imaging and autoimmune screening if clinically indicated.
Keywords: Renal; artery; rupture; rare; haemoperitoneum
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Sarawak Health Journal
Volume 3 2016
Figure 1: CT abdomen pelvis
Figure 2: CT abdomen pelvis
References:
1. Lincoln WA. Spontaneous rupture of the renal artery. J Am Med Assoc 1918; 70(2): 80-2.
2. Giannopoulos A, Manousakas T, Alexopoulou E, et al. Delayed life-threatening haematuria from
a renal pseudoaneurysm caused by blunt renal trauma treated with selective embolization. Urol
Int 2004; 72: 352-54.
3. Kim MS, Lee YB, Lee JH, et al. Spontaneous rupture of a renal artery pseudoaneurysm in a
previously hypertensive patient. Clin Hypertens 2015, 21:4.
4. Wason SEL & Schwaab T. Spontaneous Rupture of a Renal Artery Aneurysm Presenting as
Gross Hematuria 2015. Rev Urol 2010 Fall; 12(4): e193-e196.
5. Øyen O, Clausen OP, Brekke IB, et al. Spontaneous rupture of the renal artery in a patient with
Ehlers-Danlos syndrome type IV. Eur J Vasc Endovasc Surg 1997; 13(5): 509-12.
NMRR ID: 15-797-26245
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Sarawak Health Journal
A Rare Case of Pure Miller Fisher Syndrome: A Case Report
Volume 3 2016
See WYN1,2 & Yew YH2
Department of Ophthalmology, University Malaya, Kuala Lumpur, Malaysia
2
Department of Ophthalmology, Sarawak General Hospital, Malaysia
1
Corresponding Author: Wendy See Yen Nee ([email protected])
Introduction: Miller Fisher syndrome (MFS) is a rare, acquired nerve disease that is considered to
be a variant of Guillain-Barre syndrome (GBS)3 with estimated annual incidence of 1 in 1,000,0001.
It is named after Dr. C. Miller Fisher in 1956 as a limited variant of ascending paralysis.4
Case Report: A 55 year old housewife presented to t he E ye Department with sudden onset of
double vision with no preceding trauma. Initial examination revealed binocular diplopia in all gazes
with ophthalmoplegia in left eye on upward and horizontal gazes, which was not consistent with
any cranial nerve palsies. Otherwise, all other ocular examinations were normal with visual acuity
of 6/9 in both eyes. She presented again the next day with progressive worsening of
ophthalmoplegia (Picture 1) involving both eyes. She also had bilateral knee weakness, fingertips
numbness and areflexia in all limbs. There was no ptosis, fatigability or dyspnoea. Later, she
developed total ophthalmoplegia in both eyes and ataxic gait after admission. Computed tomography
of the brain and orbit were normal. She underwent lumbar punctures twice, which were normal. A
nerve conduction study was performed and it showed evidence of underlying diffuse mild sensorymotor demyelination. She was diagnosed with Miller-Fisher syndrome and started only on T.
Neurobion. During subsequent follow-up, her diplopia, ophthalmoplegia a n d a l l n e u r o l o g i c a l
d e f i c i t s spontaneously resolved within six weeks (Picture 2).
Picture 1: Limited eye movements in both eyes, inconsistent with cranial nerve palsies
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Sarawak Health Journal
Volume 3 2016
Picture 2: Complete resolution of ophthalmoplegia in both eyes
1,4
Discussion: Pure MFS characterised by a triad of ataxia, arreflexia and ophthalmoplegia, as
described in our case, is uncommon. Acute onset of external ophthalmoplegia is a cardinal feature of
MFS. Ophthalmologists may be the first physician to encounter such patients due to double vision
or rapid drop of vision. MFS symptoms can be a signal of GBS development, with breathing
difficulties. Thus most patients are admitted for observation. Generally, a pure MFS affects nerve
group of the head first, resulting in loss of extraocular muscles control and coordination, whereas the
other forms of GBS typically begins in the legs. Fortunately, most MFS is usually self-limiting with
spontaneous recovery within two to four months from onset of symptoms.4 High- dose
immunoglobulins or plasma exchanges are reserved for severe cases. Recurrence occurs in less than
3% of cases.3
Conclusion: Kozminski stated that clinicians need to be aware of symptoms and clinical findings
consistent with MFS so a s n o t to misdiagnose them with GBS, myasthenia gravis or those
of ischemic events such as stroke and transient ischemic attack, especially in patients older than 40
years of age.2
Keywords: Miller Fisher Syndrome; ophthalmoplegia; binocular diplopia; areflexia
References:
1. Aranyi Z, Kovacs T, Sipos I, et al. Miller Fisher syndrome: Brief overview and update with a
focus on electrophysiological findings. Eur J Neurol. 2012; 19(1): 15-20.
2. Kozminski MP. Miller Fisher of Gullain Barre syndrome: A case report. J Am Osteopath Assoc
2008; 108 (2).
3. National Institute of Neurologic Disorder and Stroke: Miller Fisher syndrome Information Page
(2015). Available from: http://www.ninds.nih.gov/disorders/miller_fisher/miller_fisher .htm
4. Matthew Hansen. Miller Fisher Syndrome. Gullain Barre Syndrome and Chronic Inflammatory
Demyelinating Polyneuropathy Foundation International (2012). Available from:
https://www.gbs-cidp.org/wp-content/uploads/2012/01/MillerFisherSyndrome.pdf
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Sarawak Health Journal
Volume 3 2016
Cryptogenic Invasive Klebsiella Pneumoniae Liver Abscess Syndrome – A Case Report
Yogessvaran K1, Seak CK1, Anna Fitriana AR1, Siam F1& Nik Azim NA1
1
Sarawak General Hospital, Malaysia
Corresponding Author: Yogessvaran Krishnan ([email protected])
Introduction: Klebsiella pneumoniae (KPN) is a pathogen with worldwide distribution. Cryptogenic
invasive Klebsiella pneumoniae liver abscess (CIKPLA) Syndrome is an emerging distinct clinical
syndrome in Southeast Asia characterized by bacteraemia, liver abscess and metastatic infections.
Case report: We report a case of a 44-year-old man with underlying diabetes mellitus who presented
with fever and right upper quadrant pain for one week. Blood investigations were normal except for
deranged liver enzymes. Ultrasound and Computed Tomography (CT) Abdomen showed solitary
liver abscess (measuring 7.6 cm x 7.8 cm) which was drained percutaneously at right lobe, segment
VII/ VIII. He was put on a 6-week course of antibiotics and discharged well. However, three weeks
later, he presented again with left calf swelling and new onset of fever. Lower limb sonography
showed left gastrocnemius myositis with abscess formation. Open drainage was done and complete
destruction of left gastrocnemius-soleus complex noted intraoperatively. During the same admission,
patient developed left eye endopthalmitis and a large anterior chest wall abscess with deep extension
to the neck and intrathoracic cavity. Intravitreal antibiotics were administered and drainage of chest
wall abscess done. All specimens sent for culture grew mono-microbial KPN with an identical
antibiogram.
Discussion: CIKPLA syndrome is a rare entity characterized with KPN-associated mono-microbial
solitary liver lesion and metastatic septic seeding. It is most commonly reported in Taiwan with
emerging number of cases being reported in South East Asia. KPN serotypes isolated in Taiwanese
patients are invasive strains that demonstrate hypervirulence which may explain the prevalence of
this condition in Taiwan. There is a 20-fold increased risk of metastatic septic spread in patients with
underlying diabetes mellitus. Common metastatic septic seeding includes endophthalmitis, CNSrelated infections such as meningitis and abscesses manifesting in other organs. Recent reports
showed that catastrophic disability due to ocular or neurological complications from CIKPLA could
lead to poor long-term prognosis. Mainstay of therapy is percutaneous drainage of abscess with
systemic antibiotics which has good vitreous and cerebrospinal fluid penetration.
Figure 1: Chest wall abscess
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Volume 3 2016
Figure 2: Liver abscess
Conclusion: CIKPLA syndrome is a rare insidious syndrome that needs to be considered especially
in diabetic patients with solitary liver abscess because if treated inadequately, this condition can be
associated with ocular and CNS complications.
Key Words: Cryptogenic invasive Klebsiella pneumoniae liver abscess syndrome (CIKPLA);
Klebsiella pneumonia (KPN); metastatic liver abscess
References:
1. Braiteh F& Golden MP. Cryptogenic invasive Klebsiella pneumoniae liver abscess syndrome.
Int Journal of Infect Dis 2007; 11: 16-22.
2. Yu VL, Hansen DS, Ko WC, et al. Virulence characteristics of Klebsiella and clinical
manifestations of K. pneumonia bloodstream infections. Emerg Infect Dis 2007; 13: 986-93.
3. Anstey JR, Fazio TN, Gordon DL, et al. Community-acquired Klebsiella pneumoniae liver
abscesses - an “emerging disease” in Australia. Med J Aust 2010; 193: 543-5.
4. Ko WC, Paterson DL, Sagnimeni AJ, et al. Community-acquired Klebsiella pneumoniae
bacteremia: global differences in clinical patterns. Emerg Infect Dis 2002; 8: 160-6.
57
Case Report: Lesson from the Serpent’s Kiss
Sarawak Health Journal
Volume 3 2016
Zyneelia H1, Kandasamy V1& Chan HC1
1
Department of Emergency and Trauma, Sarawak General Hospital, Malaysia
Corresponding Author: Zyneelia Husain ([email protected])
Introduction: Snake bite is a well-known occupational hazard amongst farmers, plantation workers,
herdsmen and other outdoor workers. Worldwide, it is estimated that more than 5 million persons per
year are bitten by snakes, out of which approximately 100,000 develop severe sequelae.1,2 In Malaysia,
there are 400 to 650 snakebites per 100,000 populations per year which carries a mortality rate of
0.04% per year.2,3 Hence, identification of the species of the offending snake is important for optimal
clinical management. However, in most instances, precise identification of the offending snake is not
possible and this may result in suboptimal treatment delivered by the inexperienced healthcare
providers. We describe two cases of unidentified snake bites that were presented to rural healthcare
facilities in Sarawak in which both patients developed complications arising from local and systemic
envenomation.
Case 1: A 32-year-old farmer was bitten on his right shin and subsequently sustained severe pain and
swelling over the bitten part. First aid supportive treatment was given when he attended the rural
clinic. He started to develop episodes of vomiting and hence was transferred to the nearest hospital.
Unfortunately, the patient, en route to the hospital, developed cardiorespiratory arrest. Return of
spontaneous circulation was achieved after five minutes of cardiopulmonary resuscitation and
successful endotracheal intubation. The only available vial of antivenom was given and the patient
was subsequently transferred to the tertiary care centre for the completion of antivenom course and
continuation of multidisciplinary care. He underwent multiple wound debridement for his infected
bite wound which eventually led to limb amputation. He was discharged from hospital in a vegetative
state and on a tracheostomy.
Figure 1: Enlargement of necrotic patch with presence of bullae over the mid-shin and the foot at day 3
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Volume 3 2016
Figure 2: Wound debridement at day 6
Case 2: A 43-year-old security guard was bitten on his left ankle and sustained severe pain and
swelling over the bitten part. En route to the clinic, he developed difficulty in breathing, vomiting and
bilateral lower leg weakness. Upon arrival to the clinic, he complained of generalised body weakness
accompanied with slurred speech. First aid supportive treatment was given and the patient was
promptly transferred to the hospital. The patient was later intubated for airway protection in view of
shallow laboured breathing. The available six vials of antivenom were administered. After one hour
of antivenom administration, he showed good neurological recovery and was subsequently
extubated .The swelling of the bitten part had gradually reduced in size during his admission in the
hospital. No surgical intervention was needed. He was discharged well to home.
Conclusion: Two case reports as illustrated above show that adequate and timely administration of
antivenom is vital in preventing the development of serious sequelae of snakebite injury. The
awareness about clinical manifestations of snake bite helps the healthcare providers to determine the
appropriate treatment modalities and antivenom administration. In addition, continuous training
programmes should be provided to healthcare providers at all levels in order to enhance the
knowledge and confidence in managing snake envenomation.
Key Words: Snake bite; envenomation; neurotoxicity; antivenom; tropical disease
References:
1. Swaroop S & Grab B. Snakebite mortality in the world. Bulletin of the World Health
Organization 1954; 10(1): 35-76.
2. Chippaux JP. Snake-bites: appraisal of the global situation. Bulletin of the World Health
Organization 1998; 76(5): 515-24.
3. Kasturiratne A, Wickremasinghe AR, de Silva N, et al. The Global Burden of Snakebite: A
literature analysis and modelling based on regional estimates of envenoming and deaths. Winkel
K, ed. PLoS Medicine 2008; 5(11).
59
Figure 1: Epidemic curve of food poisoning among workers (for abstract by Shafizah et al on page 32)
Sarawak Health Journal
60
Volume 3 2016
Key Note Address
Towards Better Clinical Outcomes
Datu Dr Zulkifli Jantan
1
The New Clinical Research Centre at Sarawak General Hospital – A Review and Update
Dr Alan Fong Yean Yip
2
Hospital Observational Research
Procedure Duration Estimation & Accuracy: A New Key Performance Index?
4-5
Chan WK, Kuan PX, Teo SC & Norzalina E
Effectiveness of the Introduction of Modified RE-LY Warfarin Dosing Algorithm in
International Normalized Ratio Clinic of Kapit Hospital on Anticoagulation Control
6
Chin WV, Siong JYK & Theng MI
Case Record Review on the Effectiveness of Modified Paediatric Early Warning Sign Score in
Shortening the Duration Required for Clinical Intervention in Kapit Hospital
7
Gan LW, Hii KC & Mavis B
Physiotherapy in Critically Ill Patients in Sarawak General Hospital
8
Kuan PX, Chan WK & Fong AYY
Exploration of Analgesic Prescribing Pattern in an Outpatient Setting of a District Hospital in
Sarawak
9
Kwong CI, Phan HS, Pang MSH, Wong DSH & Chai SK
Retrospective Review of Prevention of Mother-To-Child Transmission HIV Programme in
Sarawak General Hospital
10-11
Lim HH, Chai CY, Niponi S, Francis C & Chua HH
Antibiotic Sensitivity and Spectrum of Bacterial Isolated in Kanowit Hospital: A Retrospective
Study
12-13
Loo SC
Assess the Effectiveness of Interventions on Knowledge of Nurses towards High Alert
Medications in Kanowit Hospital
14
Loo SC
Pyogenic Liver Abscess Review in Sarawak General Hospital 2013 - 2015
15
Mohd Firdaus AK, Khairunissa CG, Nurazim S, Siam F & Nik Azim NA
Burn Cases in Intensive Care Unit Sarawak General Hospital
16
Mohd Tarmimi M, Farah R, Jamaidah J, Mustaffa Kamil ZA & Norzalina E
A Review of Complicated Appendicitis and Modified Alvarado Score as a Diagnostic Tool in
Kapit Hospital Year 2014
Sun CCY, Wong WK, Hii KC & Toh TH
ii
17
Red Cell Alloimmunisation among Multiple Transfused Patients at Sarawak General Hospital
18-19
Tay SP, Ho ZH, Kong PI, Ng JCH, Liew ML, Ong GB, Chew LP & Gudum HR
A Review of Clinician-Investigators at Sarawak General Hospital Undertaking Clinical
Research – Industry or Investigator Initiated Studies?
20-21
Tiong XT & Fong AYY
Incidence, Risk Factors and Clinical Epidemiology of Melioidosis in Miri Hospital, Sarawak,
Malaysia
22-23
Vimal V, Ling HW, Cho WM & Norhuzaimah J
Demographic and Clinical Features of Leptospirosis in Paediatric and Adolescent Population
in Kapit Hospital
24-25
Wong WK, Tan PW, Sun CCY & Hii KC
Prevalence of Antibiotic Resistance In Burkholderia Pseudomallei Cases Presented to Miri
General Hospital
26
Yong KY, Tang ASO, Teh YC, Fam TL & Chua HH
Public Health Observational Research
Iodine Nutritional Status amongst School Children after FiveYears of Universal Salt Iodisation
in Sarawak
28
Jeffrey S, Jambai E, Kiyu A & Zulkifli J
Pendekatan Program Community Feeding Dalam Memulihkan Kanak-Kanak Kekurangan Zat
Makanan Di Long Urun, Belaga
29
Lai SF, George NA & Hasrina H
Dengue Fever Outbreak in the Long House: What is the Responsibility of Divisional Health
Office?
30-31
Shafizah AS, Tze SN, Phua AL & Azlee A
Food Poisoning Outbreak at the Ocean: A Case Report
32
Shafizah AS, Connie AA, Nurdiana S & Azlee A
Case Report and Case Series
Inferior Epigastric Artery Injury – A Complication of Femoral Line Insertion Despite under
Ultrasound Guidance
34-35
Chan WK, Ng PN & Norzalina E
Diffuse Large B-Cell Lymphoma of the Terminal Ileum Mimicking Appendicular Mass in a
Young Adult
36-37
Devanraj S, Suriaraj K, Premjeet S & Soon KC
Silantek Burn Disaster 2014: Critical Care Experience and Lesson Learned
Farah R, Yusopian Y, Natasha N, Fakhzan M & Norzalina E
iii
38
Endocrine Disorder Masquerading as Blood Malignancy: A Case Report
39
Lee WH, Leong TS & Chew LP
Cutting the Queue: Young Myocardial Infarction
40-41
Kang WJ & Ng SG
An Early Experience of Treating Paediatric Neck of Femur Fracture
42-43
Kesavan R, Hafiz D, Norzatulsyima N & Isymth AR
A Rare Disease Encounter: Hitting Hard May Not Be the Answer
44-45
Leong TS, Lee WH & Chew LP
Does Low Platelet Count Equate to Immune Thrombocytopenic Purpura?
46-47
Leong TS, Lee WH & Chew LP
Clinical Suspicion of Pulmonary Leptospirosis - Treat or Die!
48
Norhayani Y, Ng SG, Ngoi YS, Hnin NC & Mohd Zaim AZ
Unusual Presentation of Intussusception in Henoch-Schonlein Purpura - A Case Report
49
Nursheila Izrin AZ, Premjeet S & Suraj PB
Case Report: Leiomyoma of the Anterior Abdominal Wall
50-51
Ong ECW & Siow SL
A Rare Case of Spontaneous Renal Artery Rupture
52-53
Premjeet S, Devanraj S, Nursheila Izrin AZ & Suraj PB
A Rare Case of Pure Miller Fisher Syndrome: A Case Report
54-55
See WYN & Yew YH
Cryptogenic Invasive Klebsiella Pneumoniae Liver Abscess Syndrome – A Case Report
56-57
Yogessvaran K, Seak CK, Anna Fitriana AR, Siam F & Nik Azim NA
Case Report: Lesson from the Serpent’s Kiss
58-59
Zyneelia H, Kandasamy V & Chan HC
Food Poisoning Outbreak at the Ocean: A Case Report (Figure 1: Epidemic curve of food
poisoning among workers)
Shafizah AS, Connie AA, Nurdiana S & Azlee A
iv
60