Sweet's syndrome: A review from two tertiary hospitals in Malaysia

INTRODUCTION

Sweet's syndrome (SS) also known as acute febrile neutrophilic dermatosis, is an uncommon disease characterised by acute onset of tender, violaceous or erythematous, oedematous papules, nodules or plaques, with fever. It is classified into classic, malignancyassociated, and drug-induced subtypes.The aims of this study is to evaluate the subtypes, clinical features, laboratory profiles, and treatment of patients with SS.

MATERIALS AND METHODS

We did a retrospective medical record review of all patients with SS from July 2014 to July 2018 at Hospital Queen Elizabeth and Hospital Pulau Pinang, both tertiary hospitals in Malaysia.

RESULTS

Twenty-nine patients were included. Approximately half of the patients (15) were females with a mean age of onset of 50.93 (± 11.52) years. The most common subtype was classic (62.0%) followed by malignancy-associated (31.0%) and drug-induced (6.9%). Among the patients with the classic subtype, infective-related causes (50.0%) were the most common. Among the patients with malignancy, eight had haematological malignancy and one had a solid tumour. Two-third of the malignancies were diagnosed within a year after the diagnosis of SS. Eight of our patients in Sabah had mycobacterial infections with three having concomitant haematological malignancies. Patients with malignancy-associated SS had lower mean haemoglobin (p=0.018) and mean platelet count (p=0.031). Itch was associated with the presence of pustules (p=0.038). Histopathological examination of all skin lesions showed dermal neutrophilic infiltrates and 25 (86.2%) of them had papillary dermal oedema. The study was limited by its retrospective design. The sample size was small likely due to the uncommon occurrence of this condition.

CONCLUSION

SS is an uncommon dermatosis with distinctive clinical and histopathological features. Screening for underlying malignancy is essential especially for those who present with anaemia, thrombocytopenia, and pathergy phenomenon. Mycobacterial infection should be considered in this region due to high tuberculosis burden.

Psychosocial burden of patients with atopic dermatitis at two tertiary referral centres in Malaysia

BACKGROUND

Atopic dermatitis (AD) is a chronic pruritic skin disorder that affects up to 20% of children and 10% of adults. The disease course is unpredictable with periods of exacerbation and remission, thus having a significant impact on the mental health and quality of life (QOL). We evaluated the prevalence of anxiety and depression and their association with disease severity, QOL and their associated factors in adolescents (≥ 13 years old) and adults with AD.

METHODS

A cross-sectional study was conducted involving patients aged ≥ 13 years with AD who fulfilled the Hanifin and Rajka diagnostic criteria. These patients were recruited from Hospital Queen Elizabeth, Kota Kinabalu and Hospital Kuala Lumpur between January 2020 to March 2021. Assessment instruments used were Scoring for Atopic Dermatitis (SCORAD), Patient-Oriented Eczema Measure (POEM), Dermatology Life Quality Index (DLQI) and Hospital Anxiety and Depression Scale (HADS).

RESULTS

Of the 217 participants, 75 (34.6%) had mild eczema, 116 (53.5%) moderate eczema and 26 (12.0%) severe eczema with a mean SCORAD score of 30.4 (standard deviation [SD] = 4.70). Twenty-six (12.0%) and 17 (7.8%) had anxiety and depression, respectively. Patients with moderate to severe disease reported higher HADS-A (HADS-anxiety component), HADS-D (HADS-depression component), POEM, DLQI, itch, sleep loss and skin pain scores (p < 0.001 for all). Severe sleep loss (adjusted odd ratio [AOR] 12.41, p < 0.001) and hospitalisation in the past year (AOR 6.44, p = 0.004) were significant predictors for anxiety whereas those aged 41 to 60 (AOR 10.83, p = 0.020), having severe skin pain (AOR 6.12, p = 0.028), DLQI ≥ 10 (AOR 5.27, p = 0.002) and history of hospitalisation in the past year (AOR 12.73, p = 0.002) had increased risk for depression.

CONCLUSION

The prevalence of anxiety was 12.0% while depression was 7.8% in our cohort. AD renders a significant burden on mental health and QOL with a higher impact on those with more severe disease. The use of screening tools such as HADS and DLQI for assessment of mental health and QOL should be considered to address the multidimensional burden of AD.

A sinister rash in a lady with breast malignancy

Cutaneous metastasis may be the first presentation of an undiagnosed malignancy or a relapse of a previously treated malignancy. We describe a case of a 64-year-old lady with cutaneous metastases from breast carcinoma, who presented with two uncommon rash morphology-carcinoma erysipeloides (CE) and annular erythema. Histopathological examination showed infiltration of neoplastic cells in the dermal lymphatics and staging CT showed distant metastases. She is currently on palliative chemotherapy. A high index of suspicion and early referral to a dermatologist is crucial for early diagnosis for a patient who presents with an inflammatory skin lesion that is refractory to treatment, particularly if the patient has a previous history of malignancy.

Concurrent Influenza A and Pulmonary Melioidosis in pregnancy

Melioidosis is endemic in Sabah. It causes significant morbidity and mortality if diagnosis and treatment is delayed. Important risk factors include diabetes, chronic kidney diseases, chronic lung diseases, thalassaemia, immunosuppressive therapy, and hazardous alcohol consumption. Influenza A is usually a self-limiting disease but is associated with high morbidity and mortality in highrisk populations especially during pregnancy. Both melioidosis and influenza A commonly present in patients with pneumonia. Secondary bacterial pneumonia is a known complication in approximately one third of patients with severe pneumonia due to influenza A, resulting in intensive care unit admissions. However, melioidosis is not commonly recognized as an aetiology in secondary bacterial pneumonia complicating influenza A infection. This is important as empirical antibiotics that are used to treat secondary bacterial pneumonia due to influenza A often do not cover melioidosis. Here we report a rare case of concurrent pulmonary melioidosis and influenza A in a 30- year-old primigravida at 27 weeks of pregnancy in the Queen Elizabeth Hospital, Sabah, Malaysia to highlight the challenge in the recognition and management of both infections in a melioidosis endemic area.

Mid-infrared spectroscopy tracing of channel erosion in highly erosive catchments on the Chinese Loess Plateau

Whether channel erosion or topsoil erosion constitutes the dominant erosion process throughout in the hilly region of the Chinese Loess Plateau (CLP), which suffers perhaps the most severe soil erosion in the world, had been controversial for a long time. The present article attempts to use the mid-infrared (MIR) spectroscopy fingerprinting method to trace sediment sources within nine small catchments in the hilly region of the CLP. Two major categories of sediment sources are identified: channel sediment and topsoil. Sediments trapped by check dams are used as the final sediment transferred by soil erosion. Discriminant analysis shows that MIR spectroscopy can differentiate between the two kinds of source sediments very well. The contributions of channel sediment and topsoil to the total final sediment are quantified using partial least squares regression (PLSR) analyses of MIR spectra to compare the trapped sediment samples with experimental models. The results of the root mean square error of calibration, root mean square error of validation and coefficient of determination for 18 models all show that the MIR-PLSR models boast very high prediction abilities in the nine catchments. A comparison between the geochemical fingerprinting method and the MIR spectroscopy method in one catchment reveals that although the two methods agree well on the channel sediment contributions, the two methods produce a significant difference (R² = 0.4). Overall, the MIR-PLSR results show that channel sediments contribute 19% to 66% of the total sediment with an average of 33 ± 16% in the nine small catchments. Our results indicate that although channel bank sediment is important, topsoil erosion is the predominant process in small dam-controlled catchments on the CLP. Furthermore, the MIR spectroscopy fingerprinting method can provide a useful, non-destructive, rapid and inexpensive tool for tracing sediment sources from different kinds of loess.

Analysis of evolution and genetic diversity of sweetpotato and its related different polyploidy wild species I. trifida using RAD-seq

BACKGROUND

Sweetpotato (Ipomoea batatas (L.) Lam.) is one of the most important crops from the family of Convolvulaceae. It is widely reported that cultivated sweetpotato was originated from Ipomoea trifida. However, diploid, tetraploid and hexaploid I. trifida were found in nature. The relationship, between them, and among them and sweetpotato, is remaining unclear.

RESULTS

In the present study, we detected the genome diversity and relationship of sweetpotato and different polyploidy types I. trifida using Restriction-site Associated DNA Sequencing (RAD-seq). A total of 38,605 RAD-tags containing 832,204 SNPs had been identified. These tags were annotated using five public databases, about 11,519 tags were aligned to functional genes in various pathways. Based on SNP genotype, phylogenetic relation analysis results confirmed that cultivated sweetpotato has a closer relationship with I. trifida 6× than with I. trifida 4X and I. trifida 2×. Besides, 5042 SSRs were detected in I. trifida 6×, and 3202 pairs of high-quality SSR primers were developed. A total of 68 primers were randomly selected and synthesized, of which 61 were successfully amplified.

CONCLUSION

These results provided new evidence that cultivated sweetpotato originated from I. trifida 6×, and that I. trifida 6× evolved from I. trifida 4X and I. trifida 2×. Therefore, using I. trifida 6× as the model plant of sweetpotato research should be more practical than using I. trifida 2× in the future. Meanwhile, sequence information and markers from the present study will be helpful for sweetpotato and I. trifida studies in the future.

Tubular diskectomy vs conventional microdiskectomy for the treatment of lumbar disk herniation: 2-year results of a double-blind randomized controlled trial

BACKGROUND

Transmuscular tubular diskectomy has been introduced to increase the rate of recovery, although evidence is lacking.

OBJECTIVE

To evaluate the 2-year results of tubular diskectomy compared with conventional microdiskectomy.

METHODS

Three hundred twenty-eight patients with persistent leg pain caused by lumbar disk herniation were randomly assigned to undergo tubular diskectomy (167 patients) or conventional microdiskectomy (161 patients). Main outcome measures were scores from Roland-Morris Disability Questionnaire for Sciatica, Visual Analog Scale for leg pain and low-back pain, and Likert self-rating scale of global perceived recovery.

RESULTS

On the basis of intention-to-treat analysis, there was no significant difference between tubular diskectomy and conventional microdiskectomy in Roland-Morris Disability Questionnaire for Sciatica scores during 2 years after surgery (between-group mean difference [Δ] = 0.6; 95% confidence interval [CI], -0.3-1.6). Patients treated with tubular diskectomy reported more leg pain (Δ = 3.3 mm; 95% CI, 0.2-6.2) and more low-back pain (Δ = 3.0 mm; 95% CI, -0.2-6.3) than those patients treated with conventional microdiskectomy. At 2 years, 71% of patients assigned to tubular diskectomy documented a good recovery vs 77% of patients assigned to conventional microdiskectomy (odds ratio, 0.76; 95% CI, 0.45-1.28; P = .35). Repeated surgery rates within 2 years after tubular diskectomy and conventional microdiskectomy were 15% and 10%, respectively (P = .22).

CONCLUSION

Tubular diskectomy and conventional microdiskectomy resulted in similar functional and clinical outcomes. Patients treated with tubular diskectomy reported more leg pain and low-back pain, although the differences were small and not clinically relevant.

After the Indian Ocean tsunami: Singapore's contribution to the international disaster victim identification effort in Thailand

This paper describes the international disaster victim identification (DVI) response mounted in Thailand, with particular reference to Singapore's contribution to this process, in the wake of the Asian tsunami of 26 December, 2004, which devastated parts of more than 10 countries in and around the Indian Ocean and claimed more than 200,000 lives. Although Singapore was unscathed by this natural calamity, over 30 Singaporean visitors were counted amongst the thousands of deceased victims, mostly in Thailand. The systematic application of forensic pathology, forensic dentistry, DNA profiling, and fingerprinting to human identification, especially of the bodies of various nationalities that were in advanced states of putrefaction, was crucial to the entire DVI process. The authors perceive that the resource implications arising from such a disaster, which is unprecedented in both its scale and reach in the international history of DVI, are immense. Forward planning, adequate funding and international cooperation are essential to mounting an effective response to any major mass disaster of the future.

Neurofibromatosis type 2 diagnosed in the absence of vestibular schwannomas. A case report and guidelines for a screening protocol for children at risk

A 5-year-old girl presented with multiple tumours of the central nervous system. As on the first MRI scan bilateral vestibular schwannomas were not detected due to their small size, she initially did not meet the criteria for neurofibromatosis type 2 (NF2), although her clinical symptoms were highly suggestive for the diagnosis. Using molecular studies, a mutation in the NF2 gene was found confirming the clinical suspicion at an early age and indicating the value of molecular analysis. Follow-up MRI 3 years later demonstrated bilateral vestibular schwannomas more clearly, since they had increased in size.

CONCLUSION

In children, magnetic resonance imaging can be inconclusive for the diagnosis of neurofibromatosis type 2, since very small vestibular schwannomas may be missed. In these cases molecular studies may provide additional evidence for the diagnosis. We propose guidelines for a screening protocol for children at risk for having neurofibromatosis type 2.

Antibacterial activity of antibiotic-soaked polyvinylpyrrolidone-grafted silicon elastomer hydrocephalus shunts

If shunts, inserted for the relief of hydrocephalus, are pretreated with antimicrobials, the incidence of shunt-associated infections (SAI) may be reduced. The duration of the antibacterial activity of shunts, made from conventional silicon elastomer (SE) or from SE grafted with the hydrogel polyvinylpyrrolidone (SEpvp), which had been soaked in various antibiotics, was assessed in vitro. For any antibiotic or combination, using an arbitrary breakpoint (aBP), SEpvp remained antibacterially active for longer periods than SE. Bacterial adherence to either shunt was prevented during the period of antibacterial activity. Thus, the aBP is a good indicator of the capacity of antimicrobial-treated shunts to prevent bacterial colonization in vitro. Hydrogel-grafting of shunts may be useful in preventing SAI.

Irradiation induced osteosarcoma in the posterior cranial fossa six years after surgery and radiation for medulloblastoma

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Analysis of the D1S80 locus by amplified fragment length polymorphism technique in the Chinese, Malays and Indians in Singapore

The distributions of the D1S80 alleles and genotypes in the Chinese, Malays and Indians in Singapore were determined by amplified fragment length polymorphism (AMP-FLP) analysis. The distributions of the observed genotypes for the three races conformed to Hardy-Weinberg expectations. The system was applied to 19 families whose paternity had been established by restriction fragment length polymorphism (RFLP) analysis. In all cases, Mendelian inheritance of the alleles at the D1S80 locus could be demonstrated. D1S80 typing on DNA recovered by differential extraction of forensic specimens which included vaginal swabs, urethral swabs and seminal stains yielded consistent results.

The development of DNA profiling database in an HAE III based RFLP system for Chinese, Malays, and Indians in Singapore

Deoxyribonucleic acid (DNA) restriction fragment length polymorphism (RFLP) profiles were obtained for blood specimens from the three population groups--Chinese, Malays and Indians--in Singapore. The population databases were collected from Hae III digested high molecular weight DNA hybridized with four variable number of tandem repeats (VNTR) loci--D2S44, D10S28, D4S139 and D1S7. The data were analyzed statistically using the fixed bin system. Comparison of ratio of bin frequencies of these population data with published data on whites, blacks, and hispanics shows that the alleleic distribution at these loci is not seriously different among the six groups. This has important implications to the statistical significance of forensic DNA applications.

Shunting normal pressure hydrocephalus: the predictive value of combined clinical and CT data

The value of an ordinal global scale derived from combined clinical and CT data (clin/CT scale) to predict the clinical outcome in 112 patients shunted for presumed normal pressure hydrocephalus (NPH) was analysed. The clinical data were retrospectively collected, all CT scans were re-evaluated, and the clin/CT scale was determined blind to the results of further ancillary tests and to the post-surgical outcome. The scale ranked three classes of prediction: on the basis of clinical and CT characteristics, improvement after shunting was probable, possible, or improbable. The predictive value of the clin/CT scale for the subgroup of communicating NPH was established for two different strategies, depending on the strictness of selection criteria for shunting. In the subgroup of patients with presumed communicating NPH, the prevalence of shunt responsiveness was 29%; the best strategy was to shunt only patients with probable shunt-responsive NPH: the sensitivity was 0.54, the specificity 0.84, and the predictive accuracy 0.75, with a limited number of ineffective shunts (11%) and missed improvements (13%). The study illustrates its need to assess the pre-test probability of NPH based on combined clinical and CT data, before establishing the clinical usefulness of an ancillary test.

The application of restriction fragment length polymorphism to disputed paternity

The Hae III restriction fragment length polymorphism (RFLP) system with four variable number tandem repeats (VNTR) loci has been used to resolve disputed paternity. The system exhibits an average power of exclusion of 99.96% and a mean probability of paternity of 99.96%. In all the casework examined, three VNTR loci provided a minimum 98.11% of probability of paternity. With four VNTR loci, the minimum probability of paternity was 99.69%. The alleged fathers in these cases were of different races: Chinese, Malay, Indian, Caucasian and Black, suggesting that the RFLP system is not biased for any race. This RFLP system has also been used to resolve disputed paternity cases involving related alleged fathers and cases of "motherless children". To date, we have not observed any mutation or recombination on either the maternal or paternal alleles. These results suggest that the RFLP system with four VNTR loci can decisively resolve the biological relationship in disputed paternity cases.

Normal-pressure hydrocephalus. Is cisternography still useful in selecting patients for a shunt?

The clinical usefulness of cisternography in selecting patients with presumed normal-pressure hydrocephalus for shunting was investigated in 76 patients. The predictive value of a scale based on combined clinical and computed tomographic criteria was first established, followed by an assessment of the predictive value of cisternography. Predictions based on cisternograms were identical to those of the clinical/computed tomographic scale in 43%, better in 24%, and worse in 33%. Our findings suggest that cisternography does not improve the diagnostic accuracy of combined clinical and computed tomographic criteria in patients with presumed normal-pressure hydrocephalus.

Shunting normal-pressure hydrocephalus: do the benefits outweigh the risks? A multicenter study and literature review

We performed a multicenter retrospective study in 166 consecutive patients shunted for presumed normal-pressure hydrocephalus (NPH) in the four neurosurgical departments of Amsterdam. Overall improvement occurred in 36%, substantial improvement in 21%. In the subgroup of idiopathic NPH (N = 127), marked improvement was only 15%. The incidence of shunt-responsive NPH in our area was 2.2/million/year. The rate of severe and moderate shunt-related complications was 28%, leading to death or severe residual morbidity in 7%. The substantial benefit/serious harm ration in the whole group was only three (21%/7%), decreasing to 1.7 in idiopathic NPH. By excluding patients at high surgical risk, this ratio might have risen to 10 in the whole group and to six in idiopathic NPH. Our experience is much less favorable than that encountered in the literature, reporting overall improvement in 74% and marked improvement in 55% of the shunted patients. We conclude that NPH is probably a very rare and still overdiagnosed syndrome and that the overall morbidity rate for each patient demonstrating meaningful improvement is high.