Clinical characteristics and outcome of severe malaria in Kapit, Sarawak, Malaysian Borneo

Background & objectives

Severe malaria is a medical emergency and can lead to severe complications and death if not treated promptly and appropriately. Along with Plasmodium falciparum, P. knowlesi is increasingly recognised as a significant cause of fatal and severe malaria.

Methods

We performed a retrospective review on 54 cases of severe malaria in a district hospital in Kapit, Sarawak, from January 2018 to May 2019. The patients' demographics, clinical features, complications based on organ involvement, and treatment outcomes were examined.

Results

There were 54 cases of severe malaria, with the majority being male (70%) and between the ages of 40 and 49 (26%). All patients with severe malaria were febrile or had a history of pyrexia except for one patient. P. knowlesi (81.5%) was the most common species causing severe malaria in our study, followed by P. falciparum (13%), and P. vivax (5.5%). There were no cases of severe malaria caused by P. ovale or P. malariae. Hyperparasitaemia was present in 76% of patients and the median parasitemia value at hospital admission was 33,944 parasites/μL (interquartile range: 19,920-113,285 parasites/μL). Circulatory shock was observed in 17 patients (31.5%). There were eight patients with acute renal failure and six patients with respiratory distress. One patient died as a result of severe malaria with multiorgan involvement (1.9% fatality rate).

Interpretation & conclusion

P. knowlesi is the most common cause of severe malaria in Kapit, Sarawak, Malaysia. Recognizing symptoms of severe malaria and prompt administration of antimalarial are critical for good clinical outcomes.

A Fatal Case Of Persistent Burkholderia Pseudomallei Bacteraemia With Severe Pneumonia And Splenic Abscess

Burkholderia pseudomallei is a Gram-negative bacterium that causes melioidosis. Melioidosis is a potentially fatal disease that is endemic in Southeast Asia and Northern Australia and is being increasingly recognized in other regions worldwide. Melioidosis can affect any organ system and present with a wide range of clinical manifestations including pneumonia, bone, skin/soft tissue, or central nervous system infections. In this report, we describe a diabetic farmer who succumbed to persistent B. pseudomallei bacteraemia with multiorgan involvement despite treatment with meropenem and ceftazidime.

Burkholderia Pseudomallei As The Predominant Cause Of Splenic Abscess In Kapit, Sarawak, Malaysian Borneo

BACKGROUND

Splenic abscess is an uncommon condition, with autopsy studies estimating an incidence rate of 0.14-0.70%. Causative organisms can be extremely diverse. Burkholderia pseudomallei is the most common cause of splenic abscess in melioidosis-endemic areas.

METHODS

We reviewed 39 cases of splenic abscesses in a district hospital in Kapit, Sarawak, from January 2017 to December 2018. The demographics, clinical characteristics, underlying diseases, causative organisms, therapeutic methods, and mortality rates were investigated.

RESULTS

There were 21 males and 18 females (mean age, 33.7±2.7 years). Almost all patients (97.4%) had a history of pyrexia. Diabetes mellitus was present in 8 patients (20.5%). Splenic abscesses were diagnosed using ultrasonography and were multiple in all 39 cases. Positive blood cultures were obtained in 20 patients (51.3%), and all yielded B. pseudomallei. Melioidosis serology was positive in 9 of 19 patients (47.4%) with negative blood cultures. All patients were treated for melioidosis with antibiotics without the need for surgical intervention. All splenic abscesses resolved after anti-melioidosis treatment was completed. One patient died (2.6%) as a result of B. pseudomallei septicaemia with multiorgan failure.

CONCLUSIONS

Ultrasonography is a valuable tool for diagnosing splenic abscesses in resource-limited settings. B. pseudomallei was the most common etiological agent of splenic abscesses in our study.

Bilateral Endogenous Endophthalmitis Secondary to Streptococcus pneumoniae: An Uncommon but Devastating Complication

Endophthalmitis is an infection of the vitreous and/or aqueous humours, caused by bacteria or fungi, and can be either exogenous (resulting from trauma or intraocular procedures) or endogenous (hematogenous in origin). Although less common than exogenous endophthalmitis, endogenous endophthalmitis can have serious, vision-threatening consequences. Streptococcus pneumoniae is a rare cause of endogenous endophthalmitis and is associated with a poor prognosis. In this report, we present a rare case of pneumococcal endogenous endophthalmitis that led to a devastating outcome despite both medical and surgical interventions. Early systemic treatment and prompt identification of the primary source are crucial and potentially life-saving.

Successful Treatment of Mucormycosis Caused by Rhizopus arrhizus With Amphotericin B and Itraconazole

Mucormycosis is a serious and often fatal fungal infection that is most commonly observed in immunocompromised individuals. The mortality rate of mucormycosis is high if left untreated, and successful treatment requires a combination of antifungal therapy, surgical intervention, and reversal of the underlying immunocompromised state. The choice of antifungal treatment is crucial and depends on several factors, including the safety profile of the drug, its spectrum of activity, and the species of fungus causing the infection. In this report, we describe a case of a patient who presented with mucormycosis and was successfully treated with a combination of antifungal therapy, surgical excision of affected tissue, and reversal of the underlying immunocompromised state. Our report underscores the importance of early recognition and aggressive treatment of mucormycosis to improve outcomes for affected patients.

Left atrial myxoma causing near-total mitral valve obstruction

Cardiac myxomas are the most common primary cardiac tumors in adults, with the left atrium being the most frequently affected. Echocardiography is the diagnostic modality of choice. The most effective treatment for cardiac myxomas is surgical excision.

Necrotizing Pneumonia Due To Rhodococcus Hoagii In A Patient With Advanced Retroviral Disease

Rhodococcus hoagii is a well-known zoonotic disease, especially in foals. Its occurrence in humans is uncommon and usually occurs in immunocompromised patients. We present a case of Rhodococcus hoagii infection resulting in necrotizing pneumonia in a patient with advanced retroviral disease who had defaulted treatment. Effective treatment of Rhodococcus hoagii infection requires a combination of antibiotics. We also highlighted the importance of effective communication between clinicians and microbiologists so that prompt treatment can be initiated to improve patient outcomes.

Clinical severity of COVID-19 with omicron variant predominance in relation to vaccination status, age, comorbidities- a single center in Selangor, Malaysia

INTRODUCTION

Recently, the rapid surge of reported COVID-19 cases attributed to the Omicron variant of severe acute respiratory syndrome coronavirus (SARS-CoV-2) created an immediate concern across nations. Local information pertaining to the new variant of concern (VOC) is lacking. We aimed to determine the clinical characteristics of COVID-19 during a period of Omicron prevalence among patients hospitalised from February 1 to 21, 2022 at Sungai Buloh Hospital and to estimate the risks of disease progression presumably caused by this variant in association with gender, age, comorbidity, and vaccination status.

MATERIALS AND METHODS

In this retrospective, singlecentered, retrospective cohort study, all hospitalised adults with laboratory-confirmed COVID-19, aged 18 and above, were recruited from February 1 to 21, 2022. Clinical characteristics, investigations, and outcomes were assessed.

RESULTS

A total of 2279 patients aged 18 years and above with laboratory-proven COVID-19 were recruited and analysed, excluding 32 patients owing to incomplete data. Majority of the study population had a mean age of 41.8 ± 17.7, was female-predominant (1329/2279, 58.6%), had completed a primary series of vaccination with a booster (1103/2279, 48.4%), and had no underlying medical conditions (1529/2279, 67.4%). The risk of COVID-19-related disease progression was significantly lower in hospitalised patients under the age of 50 who were female, had no comorbidity, and had completed two doses of the primary series with or without a booster. [respectively, OR 7.94 (95% CI 6.16, 10.23); 1.68 (1.34, 2,12); 2.44 (1.85, 3.22); 2.56 (1.65, 3.97), p< 0.001].

CONCLUSION

During the period of Omicron prevalence, a favourable outcome of COVID-19 was strongly associated with female gender, age below 50, a comorbidity-free condition, and having completed immunization. With this new observation, it could help improve public health planning and clinical management in response to the emergence of the latest VOC.

Enterococcus hirae bacteremia associated with perinephric collection and renal abscesses in a diabetic woman

Enterococcus hirae infection accounts for about 1% of all enterococcal infections. This number is likely to be underestimated because of inadequate identification. Human infection due to E. hirae is rarely reported. We present the case of a young woman with diabetes mellitus who developed symptoms of pyelonephritis and diabetic ketoacidosis. Renal computed tomography scan revealed the presence of subcapsular perinephric collection and renal abscesses. Her blood culture yielded E. hirae. Our patient was successfully treated with antimicrobials based on the susceptibility result. To our knowledge, this is the first reported case of perinephric collection and renal abscesses associated with E. hirae bacteremia.

Lung abscess caused by Rhodococcus equi in a patient with advanced retroviral disease

Rhodococcus equi is a Gram‐positive coccobacillus bacterium commonly found on dry surface soil of farming and livestock properties. This organism is a rare cause of subacute, necrotizing infection, and mostly causes cavitary pneumonia and lung abscess, especially in immunocompromised hosts with advanced human immunodeficiency virus (HIV) infection.

Acute Liver Injury, Rhabdomyolysis, and Acute Kidney Injury Following Mass Envenomation by Wasps in Malaysia

A wasp sting is not uncommon in rural areas, especially in developing countries. While severe allergic reactions to wasp sting are well known, many are unaware of its dangerous systemic toxic reactions. In addition, these systemic toxic reactions occur more gradually as compared to anaphylaxis reactions, which occur rapidly. These deadly systemic reactions can be deceiving, as the local reactions may seem benign and harmless. In an untrained eye with a low index of suspicion, these systemic toxic reactions may be missed without repeated laboratory evaluations and may prove fatal without the timely institution of supportive treatments.

Invasive salmonella enteritidis infection complicated by colonic perforations and pancytopenia: A case report

Salmonellosis caused by bacterial genus Salmonella is associated with a high morbidity and mortality rate. Salmonellae can be divided into typhoidal serotypes (S. enterica ser. Typhi and S. enterica ser. Paratyphi A) and nontyphoidal Salmonella (NTS) serotypes. The two most common NTS serotypes isolated from human sources were S. enterica ser. Typhimurium and S. enterica ser. Enteritidis. NTS infection can present with diverse clinical manifestations, including gastroenteritis, bacteraemia, septic arthritis, osteomyelitis, and endovascular infection. Intestinal perforation is an extremely rare and potentially fatal complication of severe salmonella infection. Herein, we report a case of invasive S. Enteritidis infection complicated by colonic perforation and pancytopenia. Following a colonic resection, the patient received a prolonged course of antimicrobial therapy and eventually recovered.

Acute abdomen revealed Streptococcus gordonii infective endocarditis with systemic embolism

Infective endocarditis can result in potentially fatal complications such as heart failure, systemic embolization, mycotic aneurysm and neurological complications. Staphylococci and streptococci are the most common causative agents of infective endocarditis, with Streptococcus gordonii being a rare cause. We present a case of infective endocarditis in a young patient who presented with an acute abdomen 2 months after being diagnosed with cerebrovascular accident. An abdominal computed tomography revealed superior mesenteric artery thrombosis, and infarct in the right kidney and spleen as a result of systemic septic embolism. Echocardiography showed numerous vegetations at the aortic and mitral valves. Infective endocarditis was diagnosed based on echocardiographic findings and positive blood cultures for S. gordonii. He was treated with intravenous benzylpenicillin and was also referred for surgical intervention.

Rhino-orbital Mucormycosis in a COVID-19 Patient: The First Case in Malaysia

Mucormycosis is an aggressive and potentially fatal fungal infection caused by fungi of the order Mucorales. There has been an increase in the number of cases of rhino-orbital mucormycosis in people with COVID-19, particularly in India. Rhino-orbital-cerebral mucormycosis is the most common manifestation of mucormycosis associated with COVID-19. We report the first case of rhino-orbital mucormycosis in a diabetic patient with SARS-CoV-2 infection in Malaysia. The diagnosis of mucormycosis was confirmed by histopathological examination, but the fungal culture and PCR results were negative. He was treated with antifungal therapy and had extensive debridement. Treatment of mucormycosis requires a multidisciplinary approach that includes addressing underlying risk factors, effective antifungal therapy, and surgical debridement.

Cryptococcus gattii meningitis complicated by immune reconstitution inflammatory syndrome in an apparent immunocompetent host in Malaysia

Cryptococcosis is a systemic fungal infection caused by Cryptococcus neoformans or Cryptococcus gattii. Cryptococcus causes a wide range of diseases, ranging from asymptomatic pulmonary lesions to disseminated disease involving the central nervous system, particularly meningoencephalitis. C. gattii infection has rarely been reported in Malaysia. We present a case of C. gattii meningitis with pulmonary cryptococcosis complicated by immune reconstitution inflammatory syndrome in an apparently immunocompetent person with no prior travel history.

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Cryptococcosis is a fungal infection causing significant morbidity and mortality.

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Cryptococcus gattii can present with meningitis and pulmonary cryptococcosis.

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CSF examination is the cornerstone of diagnosis in cryptococcal meningitis.

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IRIS is a rare complication of C. gattii infection that can be treated with steroids.

A Fatal Case of Dengue-Associated Hemophagocytic Lymphohistiocytosis and Retroperitoneal Hematoma in a Patient With Autoimmune Hemolytic Anemia

Hemophagocytic lymphohistiocytosis (HLH) is a rare but potentially life-threatening complication of dengue infection which necessitates early diagnosis and treatment to improve patient outcomes. Severe dengue infection complicated by HLH may require interventions such as systemic corticosteroids, intravenous immunoglobulin, or chemotherapy. Here, we report a case of concurrent dengue-induced HLH and flare of underlying autoimmune hemolytic anemia (AIHA). The disease was refractory to treatment including corticosteroids and intravenous immunoglobulin. The course of illness was later complicated by dengue shock syndrome, severe liver dysfunction, and a large retroperitoneal hematoma. Unfortunately, the patient succumbed on day 10 of illness.

Streptococcus sanguis brain abscess as an initial manifestation of pulmonary arteriovenous malformation

Pulmonary arteriovenous malformation is a vascular anomaly that predisposes to complications of paradoxical embolization including stroke and brain abscess. Here, we present a case of brain abscess associated with pulmonary arteriovenous malformation.

Dengue fever complicated by hemophagocytic lymphohistiocytosis: Report of 2 cases and bone marrow findings

Hemophagocytic lymphohistiocytosis is a rare but severe complication of dengue infection which carries a high mortality. This report highlights the importance of early recognition of this condition as prompt appropriate treatment improves outcomes.

CT-guided bone marrow aspirations and biopsies: retrospective study and comparison with blind procedures

PURPOSE

To compare the pathology results of CT-guided and blind bone marrow aspirations and biopsies.

METHODS

Ninety-eight consecutive CT-guided biopsies and 98 age- and gender-matched blind (non-CT-guided) posterior iliac crest bone marrow aspirations and biopsies performed in 2017 were reviewed for adequacy of core biopsies and aspirate smears. CT procedure images and CT abdomen/pelvis images were reviewed to evaluate anatomic features of the posterior ilium and soft tissues. Statistical analysis was performed using a T test, Fisher exact test, and Kruskal-Wallis test.

RESULTS

There was no significant difference in the age and gender of the two groups (p > 0.05). However, the CT-guided group had a higher BMI (p = 0.0049) and posterior soft tissue thickness (p = 0.0016). More CT-guided biopsy samples (CT 93 (95%); blind 77 (79%); p = 0.0006) and aspirate smears (CT 90 (92%); blind 78 (80%); p = 0.042) were categorized as adequate. The CT-guided group had longer core lengths (CT 1.4 ± 0.6 (range 0.3-3.5) cm; blind 1.0 ± 0.60 (range 0-2.6) cm; p = 0.0001). Overall, 131/164 (80%) of the cases had at least one of the described features (slanted posterior ilium (angle > 30°), 30%; rounded posterior ilium, 20%; thick posterior ilium cortex, 13%; focal lesion in posterior ilium, 12%; prior procedure in posterior ilium, 5%; posterior soft tissue thickness > 3 cm, 40%).

CONCLUSION

CT-guided bone marrow procedures were more likely to result in both adequate aspirate smears and biopsy samples and longer core lengths when compared with blind procedures.

Disseminated melioidosis in early pregnancy - an unproven cause of foetal loss

Background

Melioidosis is a potentially life-threatening infection caused by the Gram-negative bacterium Burkholderia pseudomallei. Melioidosis is difficult to diagnose due to its diverse clinical manifestations, which often delays administration of appropriate antibiotic therapy.

Case presentation

Melioidosis is uncommon in pregnancy but both spontaneous abortion and neonatal melioidosis have been reported. We report a case of bacteraemic melioidosis in a young woman with a subsequent spontaneous abortion, with B. pseudomallei cultured from a high vaginal swab as well as blood.

Conclusion

It remains unclear in this and previously reported cases as to whether the maternal melioidosis was sexually transmitted.

Periorbital cellulitis and eyelid abscess as ocular manifestations of melioidosis: A report of three cases in Sarawak, Malaysian Borneo

Melioidosis is an infection caused by the Gram-negative bacterium Burkholderia pseudomallei. Melioidosis can affect any organ and result in a broad spectrum of diseases. Ocular involvement in melioidosis is rare but can potentially lead to devastating outcomes. We describe ocular manifestations in 3 patients diagnosed with culture-confirmed melioidosis in Kapit, Sarawak, Malaysian Borneo. Melioidosis affecting the eye can present as periorbital cellulitis and eyelid abscess. High clinical suspicion and early empirical treatment were crucial to a successful outcome. Surgical drainage of the abscess was an important part of management beyond standard antimicrobial therapy.