Cardiobacterium hominis Endocarditis in a Healthy Adult - Rare but Not to Be Missed

@#Cardiobacterium hominis is part of HACEK group and an atypical cause of infective endocarditis. It may cause similar clinical presentation to other cause of endocarditis. Establishing the diagnosis is challenging as it is a fastidious organism which rarely affects individual without previous cardiac lesion and requires advanced diagnostic tools for identification of species. A 23-year-old previously healthy man presented with intermittent fever for two months associated with palpitations and lethargy. He had undergone a dental procedure four months before the presenting symptoms. Physical examination revealed a pansystolic murmur best heard over the apex. Three aerobic blood culture bottles were positive and Gram stain consistently showed pleomorphic Gram-negative rods. The organism grew as tiny pin-point opaque colonies on sheep blood agar and chocolate agar after 48 hours of incubation but no growth was seen on MacConkey agar. Unsuccessful identification with VITEK 2 NH and VITEK 2 GN was later confirmed by polymerase chain reaction as C. hominis. He was treated with a six-week course of antibiotics.

Diagnostic Pitfall in Fine Needle Aspiration Cytology of Pilomatrixoma with Unusual Clinical Presentation

@#Pilomatrixoma (PMX) is a benign skin adnexal tumour with matrical differentiation. It frequently presents as a painless and slow growing solitary skin nodule primarily at the head, face and neck regions. Although there is increasing understanding on the clinical presentations and morphological features of PMX, difficulties are still expected in establishing the clinical and cytological diagnosis. We report a young girl who presented with a painless post-auricular swelling for one year with sudden increased in size. Computed Tomography (CT) scan and fine needle aspiration cytology (FNAC) findings were suggestive of a malignancy. Diagnosis of PMX was established and confirmed by tissue histopathological examination. The purpose of this study is to demonstrate the diagnostic pitfall of PMX in FNAC specimens, especially in patients with unusual clinical presentations.

Paraneoplastic Bullous Pemphigoid Masquerading as Hand-foot Syndrome: A Case Report of Rare Entity

@#Bullous pemphigoid (BP) is a chronic and the most frequent immune-mediated subepidermal blistering disorder which mainly affects elderly individuals. The autoantibodies produced following T-cell dysregulation are directed against BP180 (BPAg2) and BP230 (BPAg1), hemidesmosomal proteins located in the basement membrane zone (BMZ) of the epidermis. BP may present with polymorphic dermatological features including non-bullous manifestations and blisters. Therefore, a wide range of differential diagnoses such as eczema, urticaria, pemphigus and the differentials for subepidermal blister with eosinophils such as epidermolysis bullosa acquisita (EBA) and bullous drug eruptions should be considered in such cases. The associations of solid organ internal malignancies and BP are quite rare and vary between studies. Here, we present a case of paraneoplastic bullous pemphigoid (PNBP) in a patient with underlying renal cell carcinoma who was initially diagnosed with worsening hand-foot syndrome (HFS) which has led to withdrawal of his oral chemotherapy treatment.

Prevalence, Clinical Manifestations and Predictors of Immune Reconstitution Inflammatory Syndrome among HIV-Infected Patients in Malaysia Infectious Disease Centre: A Retrospective Study

@#Introduction: Immune reconstitution inflammatory syndrome (IRIS) is paradoxical clinical deterioration experienced by some HIV-infected patients in response to antiretroviral therapy (ART). There is still limited published data on IRIS from this region including Malaysia. This study aimed to determine IRIS prevalence, clinical manifestations and possible predictors among HIV-infected patients in an infectious disease centre in Peninsular Malaysia. Method: This retrospective study was conducted in Hospital Sungai Buloh involving secondary data of 256 HIV-infected patients who were initiated on ART in the year 2017. Medical record of each patient was reviewed for up to 12 months following ART initiation to identify IRIS diagnosis which was made by the treating physician. Relevant clinical and laboratory information were retrieved from hospital electronic database. Results: IRIS has occurred in 17.6% of patients. Infections by Mycobacterium tuberculosis (53.3%), Pneumocystis jirovecii (11.1%) and Talaromyces marneffei (6.6%) were the commonest three aetiologies of IRIS. Subacute lupus erythematosus was the only non-infectious IRIS identified. Baseline HIV viral load, CD4+ T-cell count and haemoglobin level between IRIS and non-IRIS patients were significantly different. Risk of developing IRIS was increased seven times in patients with CD4+ T-cell count < 100 cells/µL and four times in patients with HIV RNA viral load > 5.5 log10 copies/ml prior to ART initiation. Conclusion: Mycobacterium tuberculosis infections were the highest IRIS manifestation. Although rare, non-infectious IRIS does occur and should be part of the differential diagnosis. Patients with positive predictors should be appropriately monitored for possible IRIS development once initiated on ART.

Suppurative BCG Lymphadenitis and the Importance of Microbiology Investigations – A Case Report

@#Suppurative BCG lymphadenitis can easily be overlooked, as it mimics other diseases such as tuberculous lymphadenitis. A case of a three-month old female infant who received the BCG vaccination at birth presented with isolated left axillary mass at two months of age. She was initially treated as lymph node abscess but was referred to the hospital due to the increasing size of the swelling. Needle aspiration was done and the microbiology analysis came out positive for acid-fast bacilli. She was planned for syrup isoniazid; however, the management team withheld treatment until they were certain of the identity of the bacteria. The bacteria was confirmed by the molecular method to be Mycobacterium bovis BCG strain. The case report highlights the importance of the microbiology investigations for appropriate management in this case.

Diabetes-Associated Autoantibodies Among Young Diabetes Mellitus Patients in Malaysia

@#Introduction: Diabetes-associated autoantibodies (DAA) is the hallmark of T1DM and LADA which are frequently tested in young diabetes patients. It was noted that up to 10-15% of patients with initial diagnosis of T2DM also exhibit DAA. Regardless of the classification, the presence of DAA suggests an underlying islet autoimmunity which lead to progressive pancreatic β-cell failure. There is limited data reported on DAA in young diabetes patients in Malaysia. This study aims to determine the frequency of DAA positivity and its association with demographic and clinical characteristics among this cohort. Methods: A retrospective study using secondary data obtained from Allergy and Immunology Research Centre, Institute for Medical Research, Malaysia. This study included 194 diabetes patients who were diagnosed before the age of 40 years old and tested for GADA, ICA, IA2A and IAA. Results: From 194 patients, 91 (46.9%) were positive for least one of the following DAA: ICA (79, 40.7%), GADA (61, 31.4%), IA2A (37, 19.1%) and IAA (9, 4.6%). Multiple positivity was higher (73.6%) compared to single positivity. Highest combination of double positivity was ICA+GADA (54, 59.3%) and triple positivity was ICA+GADA+IA2A (25, 27.5%). Simultaneous positivity of four autoantibodies was seen in only one (1.1%) patient. ICA, GADA and IA2A were associated with age group and ethnicity (all p < 0.001). Only IA2A was associated with gender (p = 0.012). Conclusions: GADA, ICA ad IA2A are more significant in young Malaysian diabetes patients. IAA has a very low frequency in this studied population.

Evaluation of Endothelial Cell Adhesion Molecules and Anti-C1q Antibody in Discriminating between Active and Non-Active Systemic Lupus Erythematosus

Background : Detecting the active state of systemic lupus erythematosus (SLE) is important but challenging. This study aimed to determine the diagnostic accuracy of serum endothelial cell adhesion molecules (ICAM-1 and VCAM-1) and anti-C1q antibody in discriminating between active and non-active SLE. Methods: Using SELENA-SLE disease activity index (SLEDAI), 95 SLE patients (45 active and 50 non-active) were assessed. A score above five was considered indicative of active SLE. The blood samples were tested for serum ICAM-1, VCAM-1 and anti-C1q antibody using enzyme-linked immunosorbent assay (ELISA). Results: The levels of serum VCAM-1 and anti-C1q antibody were significantly higher in active SLE patients. Both VCAM-1 and anti-C1q were able to discriminate between active and non-active SLE ( p -value < 0.001 and 0.005, respectively). From the receiver operating characteristic curves (ROCs) constructed, the optimal cut-off values for VCAM-1 and anti-C1q antibody in discriminating between active and non-active SLE were 30.5 ng/mL (69.0% sensitivity, 60.0% specificity, PPV 58.5%, NPV 66.7%) and 7.86 U/mL (75.6% sensitivity, 80% specificity, PPV 77.3%, NPV 78.4%), respectively. However, serum ICAM-1 level was unable to discriminate between the two groups ( p -value = 0.193). Conclusion: Anti-C1q antibody demonstrated the best diagnostic accuracy in discriminating between active and non-active SLE patients