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Gout is a commonly treated inflammatory arthritis that is often managed in the primary care setting. This disease is prevalent among the multi-ethnic Malaysian population. Unfortunately, gout is still frequently managed sub-optimally, even in the hospital and primary care settings. Gout should be considered a major disease since it can potentially lead to multiple disabilities from joint destruction, nephropathy and increased cardiovascular morbidity and mortality. The objectives of this review are to summarise the latest updated information and management of gout in the primary care setting.

Atrial septal defect (ASD) is a congenital heart disease often encountered in the adult population, as it is frequently asymptomatic in childhood. In untreated patients with ASD, some may go on to develop complications such as atrial arrythmias, pulmonary hypertension and Eisenmenger syndrome. Pulmonary hypertension is seen in 6 – 35% of this group of untreated patients in adulthood as a result of left-to-right shunting. Symptoms of pulmonary hypertension include progressive dyspnoea, ascites and syncope. Here, we would like to illustrate a case of ASD presenting with recurrent syncopal attack.

Background Cardiac tamponade is a medical emergency. This study was carried out to determine the etiologies of cardiac tamponade and review the management and outcomes. Methods We retrospectively analysed case records of patients who underwent pericardiocentesis for cardiac tamponade during the two consecutive years (1 January 2018 to 31 December 2019) at Hospital Sultanah Nora Ismail, Batu Pahat, in Johor, Malaysia. Results There were ten patients (eight males, two females; age range 20 to 70 years old, mean age 36 years old) who underwent pericardiocentesis for cardiac tamponade during the said period. Malignancy (40%), tuberculosis (30%), idiopathic (20%), and bacterial (10%) were among the common causes of the pericardial effusion in this center. The commonest symptoms were breathlessness (90%), chest pain (60%), cough (50%), and unexplained fever (20%). Pulsus paradoxus was the most specific sign (100%) for the presence of echocardiographic feature of cardiac tamponade. Two of the patients with tuberculous pericarditis had retroviral disease; one patient had bacterial pericarditis due to salmonella typhi. Conclusion This study has confirmed that there are many etiologies and presentation of cardiac tamponade; clinicians should be alert as urgent pericardiocentesis is lifesaving.

Tuberculous meningitis (TBM) is the most severe form of extra-pulmonary tuberculosis which carries high mortality with 100% mortality without treatment. A neurological complication of TBM includes hydrocephalus, brain abscess and stroke. In this report, we would like to illustrate a case of stroke in a patient with TBM. In this case, a 37-year old man initially presented with fever for 1 week associated with severe headache and occasional vomiting. Computed tomography (CT) of the brain showed leptomeningeal enhancement and lumbar puncture findings consistent with infective in nature. His MARAIS score was 13 and was treated as tuberculous meningitis with anti-tuberculous therapy. While in the ward, he developed right-sided body weakness with evolving CT brain findings. His condition then stabilized with anti-tuberculous treatment which consists of isoniazid, rifampicin, pyrazinamide and streptomycin. Dexamethasone was also initiated. On follow up, his condition further improves and is functionally independent. In conclusion, tuberculous meningitis is an aggressive disease with high morbidity. Stroke can occur as a result of TBM. Timely initiation of treatment is important in improving the outcome of the patients.

Primary cardiac tumor are extremely rare. Incidence is approximately 0.017-0.019% of all primarytumor. An early diagnosis of cardiac tumor may improve the outcome. Bangladesh J Medicine July 2020; 31(2) : 111-113

Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) is a rare disease. It is a maternally inherited multisystem disorder caused by mutations of the mitochondrial DNA. MELAS usually occur during childhood period after a normal early development. Commonly, the patients will have a relapsing and remitting course of illness with stroke like episodes and seizures. It will subsequently lead to progressive neurological dysfunction and memory problems. We would like to present two siblings who presented to us with different age of onset and presentation of their illness. Bangladesh J Medicine July 2019; 30(2) : 96-99

Cardiac tamponade is a medical emergency. This study was carried out to determine the etiologies of cardiac tamponade and review the management and outcomes.We retrospectively analysed case records of patients who underwent pericardiocentesis for cardiac tamponade during the two consecutive years (1 January 2018 to 31 December 2019) at Hospital Sultanah Nora Ismail, Batu Pahat, in Johor, Malaysia.There were ten patients (eight males, two females; age range 20 to 70 years old, mean age 36 years old) who underwent pericardiocentesis for cardiac tamponade during the said period. Malignancy (40%), tuberculosis (30%), idiopathic (20%), and bacterial (10%) were among the common causes of the pericardial effusion in this center. The commonest symptoms were breathlessness (90%), chest pain (60%), cough (50%), and unexplained fever (20%). Pulsus paradoxus was the most speciÿ c sign (100%) for the presence of echocardiographic feature of cardiac tamponade. Two of the patients with tuberculous pericarditis had retroviral disease; one patient had bacterial pericarditis due to salmonella typhi.This study has conÿ rmed that there are many etiologies and presentation of cardiac tamponade; clinicians should be alert as urgent pericardiocentesis is lifesaving.

570 Background: Gemcitabine-based chemotherapy is an approved therapy for treatment-naïve metastatic pancreatic ductal adenocarcinoma (PDAC). Inherent resistance to gemcitabine inevitably leads to cancer progression and shorter survival. It has been demonstrated that bacteria are a component of the PDAC tumor microenvironment and may play a critical role in mediating resistance to chemotherapy. Hence, the coadministration of an antibiotic to chemotherapy may potentiate antitumour drug responses. We conducted a pilot study to assess the efficacy and safety of ciprofloxacin plus gemcitabine-based chemotherapy in patients with treatment naïve metastatic PDAC. We also aimed to study gut microbiome changes during treatment with ciprofloxacin. Methods: This was a single arm study conducted at the National University Cancer Institute, Singapore. Patients (pts) with histologically confirmed metastatic PDAC were treated with nab-paclitaxel (125 mg/m2) and gemcitabine (1000 mg/m2) on days 1, 8, and 15 every 4 weeks, in combination with oral ciprofloxacin 500 mg twice daily. Treatment was continued until disease progression or intolerable toxicity. DNA extraction, 16S rRNA amplification and sequencing for bacteria were performed on pre- and post-treatment stool samples. Primary endpoint of this study was response rate and safety of the treatment combination. Secondary endpoints included progression free survival (PFS), overall survival (OS) and microbiome changes after treatment with ciprofloxacin. Results: From Mar 2019 – Feb 2021, 8 pts were recruited. Median age was 71 years old. Best response was stable disease in 5 (62.5%) pts and 3 pts had progressive disease (PD). Median PFS and OS were 4.3 and 15.4 months, respectively. 2 pts developed grade 4 neutropenia and 1 pt had grade 3 febrile neutropenia. Rash was common with 50% of pts developed grade 1/2 rash. No additional toxicities from ciprofloxacin were observed. Preliminary stool analysis showed significant differences in individual bacterial strains across all timepoints in the PD vs. SD groups. There was also an increased abundance in gammaproteobacteria resistant to ciprofloxacin treatment in pts with PD. Conclusions: Gemcitabine-based chemotherapy plus ciprofloxacin demonstrated clinical activity and acceptable safety profile in PDAC. Our study also highlighted that gut microbiome may play a critical role in mediating resistance to chemotherapy. Clinical trial information: NCT04523987.

Bacterial meningitis has a potentially devastating outcome if there is any delay in diagnosis and treatment. There are multiple routes at which bacteria could migrate into the subarachnoid space. Lumbar puncture bypasses the natural defense barrier of central nervous system and therefore carries a risk of transmitting infection to the meninges. We report a case of post spinal bacterial meningitis in a post partum lady who underwent spinal anaesthesia for emergency lower segment caesarean section. She developed signs and symptoms of meningitis twenty-eight hours post procedure. Her cerebrospinal fluid (CSF) analysis was suggestive of bacterial meningitis and she made a full recovery.

Sarcoidosis is a multisystemic, chronic granulomatous disease of unknown aetiology that often affects the lungs. Diagnosis and treatment of sarcoidosis can be strenuous. Patients may be asymptomatic or experience cough, dyspnoea, fatigue, unintentional weight loss or night sweats. Computed tomography is valuable in the diagnosis of sarcoidosis. The typical histopathological lesion of sarcoidosis is granuloma without caseous necrosis in the involved organs. As tuberculosis is endemic in our region, clinicians should not forget this great mimicker. The cornerstone of treatment of sarcoidosis is corticosteroids but newer agents such as steroid-sparing agents and biological agents are available. We report a case of pulmonary sarcoidosis presenting with chronic cough.

Inflammatory myopathies (IM) is a rare inflammatory muscle disorder, which can be broadly divided into 5 subgroups. The accurate diagnosis of subtype of IM can be challenging due to a diverse presentation of the disease. On the other hand, skeletal muscle complication is common in patients with systemic lupus erythematosus (SLE) in the form of myalgia or myopathy. Inflammatory myopathy is a rare association of SLE and the diagnosis and treatment can be quite challenging. A 43-year-old lady with underlying systemic lupus erythematosus (SLE), presented with subacute onset progressively worsening muscle weakness involving upper limbs and lower limbs. Neurological examination showed findings consistent with proximal myopathy, with proximal power of 3/5 and distal power of 4/5. She has elevated creatinine kinase, ALT and AST level. Her myositis-specific autoantibodies were positive for anti-Ku antibodies. Her electromyography showed evidence of active myopathy of the upper and lower limb. Here, we would like to report a case of polymyositis in a patient with SLE.

Kocuria kristinae is a gram-positive cocci bacteria of the family Micrococcaceae . Kocuria species are bacteria commonly found in the environment and human skin flora. They are usually regarded as non-pathogenic bacteria, thus rarely associated with human infections. We report a case of K. kristinae related continuous ambulatory peritoneal dialysis (CAPD) peritonitis. The clinical presentation resembles that of usual CAPD peritonitis and diagnosis was made via routine laboratory and microbiological investigation. However, mortality occurred in our case due to severe sepsis with multi-organ failure.