Sticky Throat.

A 46-year old woman from Hlaing Thar Yar Township presented to the medical ward of Insein General Hospital with acute onset of fever, dyspnoea and coma. She had one year history of tiredness and feeling of sticky sensation in the throat while swallowing meals. Tiredness was especially marked in the evenings and after heavy work. The feeling of sticky sensation was felt intermittently but it was more remarkably felt during dinner and after having a heavy meal. On admission, she was cyanosed, respiration was depressed and autonomic disturbances were observed. She was treated in the intensive care unit with assisted ventilation. Upon further investigation along with clinical assessment and nerve conduction studies the diagnosis was confi rmed as generalized myasthenia. This is an example of myasthenia presenting with vague signs and symptoms that fi nally lead to a health crisis. The delay in diagnosis occurred due to lack of detailed analysis of the symptoms, lack of suspicion and the unique presentation of the case with vague symptoms. The lesson to be learnt from this case is that neuromuscular disorders should always be considered in cases presenting with throat problems.

The prognostic utility of bedside assessment of adults hospitalized.

Background: Data collected in clinical trials have been used to develop scoring systems that identify adults with malaria at greatest risk of death. One of these, the RCAM score, can be simply determined by measuring a patient’s Glasgow Coma Score and respiratory rate on admission to hospital. However the safety of using the RCAM score to define high-risk patients has not been assessed outside of the clinical trial setting. Methods: A retrospective audit of medical records of all adults admitted with a diagnosis of malaria to two tertiary referral hospitals in Lower Myanmar in 2013 was undertaken. An RCAM score was calculated in all patients and related to their subsequent clinical course. Results: The recent decline in malaria hospitalizations at both sites continued in 2013. During the year 90 adults were hospitalized with malaria; 62 (69%) had Plasmodium falciparum monoinfection, 11 (12%) had Plasmodium vivax mono-infection, 17 (19%) had mixed infection. All seven (7.7%) deaths occurred in patients infected with P. falciparum. An admission RCAM score < 2 identified all the patients that would survive to discharge (positive predictive value (95% confidence interval (CI)) 100% (94.9-100%) and also predicted a requirement for less supportive care: 9/70 (13%) patients with an admission RCAM score < 2 required supportive care (blood transfusion, vasopressor support or oxygen supplementation) during their hospitalization compared with 12/20 (60%) patients with an admission RCAM score ≥ 2 (p < 0.0001). No patient with P. vivax monoinfectionrequired supportive care during their hospitalization. Patients with an oxygen saturation ≤ 95% on room air on admission were more likely to die before discharge (odds ratio 17.3 (95% CI: 2.9-101.2) than patients with a higher oxygen saturation (p = 0.002). Conclusions: Even outside a clinical trial setting the RCAM score reliably identifies adults with malaria who are at greatest risk of death and can be safely used in the initial triage and management of these patients.

Beyond the hit.

A 53-year old saw mill worker from Mingalardon presented to the medical ward of Insein General Hospital with acute confusion and fever. He noticed diplopia, eye pain, headache,protrusion of the right eye 2 months after injury to left eye. He was taking antipsychotics for mutism and behavioural changes of recent onset. Examination revealed fever, proptosis, right III and VI nerve palsy and rigidity. Baseline investigations show mild anaemia, thrombocytosis, increased inflammatory markers. MRI head revealed enlarged right superior ophthalmic vein dilatation consistent with carotico-cavernous fistula. He was treated for raised intracranial pressure and antibiotics. Anti-psychotics were discontinued. Recovery was uneventful. Mood returned to normal. Only right VI nerve palsy remained. Two lessons were learnt from this case - complex but happy ending. One is rare case of cavernous sinus syndrome and second is the iatrogenic neurological presentation.

Efficacy and safety concerns with thrombolysis in acute myocardial infarction in Insein General Hospital (ESCORT-IGH).

Background - Although patients with ST elevation myocardial infarction should be ideally treated with primary coronary intervention (PCI), due to limited availability of PCI capable hospitals, thrombolysis remains the mainstay treatment in Myanmar. It is imperative that evidence is necessary to prove the efficacy and safety of thrombolysis in district hospital setting in Myanmar. Methods - Patients with acute myocardial infarction were studied during a period of 21 months in the medical ward of Insein General Hospital (IGH), a (300 bedded) hospital which has no facilities for PCI. Streptokinase was used for thrombolysis. Study was set up to achieve “call to needle time of 25 minutes”. Primary endpoint was ST resolution at 90 minutes post-thrombolysis and secondary endpoint was 7 days survival post-thrombolysis. Adverse reactions including haemorrhage were recorded. Results - One hundred and eighteen patients (78%) out of one hundred and fifty one study cases were eligible for thrombolysis. Among the thrombolysis patients, male to female ratio was 1.63 and mean age was 60 years (22 - 86 yr). Median time of thrombolysis since onset of pain was 4.7 hours. Primary end point of ST resolution at 90 min was achieved in 58% (69/118) in thrombolysis group and 0% (0/33) in non-thrombolysis group. Secondary end point of 7 day survival was achieved in 89% (105/118) in thrombolysis group and 6% (2/33) in non-thrombolysis group. Thrombolysis favours ST resolution (p < 0.0001) and 7 day survival (p < 0.0001) better than non-thrombolysis. Statistically non-significant minor bleeding (gum bleeding and epistaxis) was observed in 3% (4/118) (p = 0.52) in the treatment group but there was no fatal bleeding and anaphylaxis. Conclusion - Thrombolysis using streptokinase is safe and highly effective in acute ST-elevation myocardial infarction in district hospital setting.

A forgotten disease of Myanmar origin.

A 16-year old student from Taungoo presented to medical ward, Insein General Hospital with one month-long fever, weight loss and multiple abscesses and ulcers at the face, limbs and trunk. Examination revealed pallor, remittent fever and hepatosplenomegaly. Imaging showed multiple splenic abscesses. Wound swab cultures from ulcers revealed gram negative coccobaccilli with characteristic of Burkholderia pseudomallei. The diagnosis was melioidosis. Defeverese time was 13 days after treatment with intravenous ceftazidime and amikacin. Recovery was uneventful. This case warrants the clinician, in case of recalcitrant septicaemia, to consider melioidosis-originally discovered in Myanmar but uncommon now.

Observational study of co-morbidities among patients with Tuberculosis.

Background- Many co-morbid conditions can influence the susceptibility, treatment options and outcome in tuberculosis. This study was aimed to determine five co-morbid conditions - HIV, HBV or HCV co-infection, diabetes mellitus or alcohol misuse in tuberculosis patients of medical ward, Insein General Hospital. Methods- An observational study among tuberculosis patients of medical ward, Insein General Hospital conducting for 12 months' period. Diagnosis of tuberculosis was determined by clinical and standard laboratory tests and imaging. Confirmed cases were categorized and assessed the 5 comorbid conditions - HIV, HBV or HCV co-infection, diabetes mellitus and alcohol misuse in clinical grounds and standard laboratory tests. Those with HIV infections or drug experienced cases were further assessed by Gene Xpert. Data was analysed by Microsoft Excel. Results- Of a total of 281 TB patients, 60% had co-morbid conditions. Leading co-morbidity was alcohol abuse (25.62%), and HIV co-infection (20.64%) and diabetes mellitus (15.3%) were significant co-mobidities. Conclusion- The study warrants the significance of determining alcohol use, HIV co-infection and diabetes mellitus among TB patients.