Obstructive Sleep Apnea: An Unusual Cause of Hemorrhagic Stroke.

Stroke is one of the most common causes of mortality and morbidity worldwide. Hemorrhagic stroke comprises 10-20% of strokes. Here, we present a case report of hemorrhagic stroke that may have been secondary to untreated Obstructive Sleep Apnea (OSA) in a young man with no other cardiovascular risk factors or features of metabolic syndrome. A 32-year-old man was admitted for hemorrhagic stroke. An initial thorough workup for the etiology of stroke was inconclusive. Eventually, a polysomnography was done, which demonstrated OSA suggesting that untreated OSA may have contributed to his stroke. OSA may cause hemorrhagic stroke by nocturnal blood pressure surge. So, all physicians should consider doing polysomnography for unexplained hemorrhagic stroke or in patients at risk. Diagnosing and treating OSA would be critical in preventing hemorrhagic stroke and its recurrences.

Brain Tumor Causing Atrial Fibrillation in an Otherwise Healthy Patient.

We report a case of a 57-year-old man who presented with an episode of syncope resulting in an accident. On presentation, he was found to have atrial fibrillation (AF). A brain imaging done to exclude intracranial hemorrhage revealed a brain tumor instead. Recently, AF has been used as a marker for occult cancer. Thus, we hypothesize that AF in our patient was a result of the existing brain tumor and not simply a coincidence. AF may help in diagnosing brain tumors in asymptomatic or oligosymptomatic patients at an early stage, decreasing mortality and morbidity significantly.

Thrombotic Paradox: Ischaemic Stroke in Immune Thrombocytopaenia. A Case Report and Review.

Immune thrombocytopaenia (also known as idiopathic thrombocytopaenic purpura) (ITP) is a chronic condition with isolated low platelet counts. Although it is largely perceived that ITP predisposes to bleeding risks, thrombotic events, such as ischaemic strokes, do happen paradoxically in patients with ITP. A 68-year-old lady presented with right upper limb weakness and was diagnosed with an ischaemic stroke and was started on clopidogrel. She had a history of ITP. Two months later, she again had another ischaemic stroke. Prednisolone was added as her platelet count was below 50 x 109/L. Based on this case and recent case studies, we suggest the administration of antiplatelet or anticoagulant agents judiciously if the platelet count is 50 x 109/L or above with monitoring of bleeding risks. As for the management of ITP, we do agree with the general opinion that treatment is rarely required for patients with a platelet count above 50 x 109/L. We recommend a haematology consult for discussion on treatment initiation if the platelet count is below 50 x 109/L.

Amyloid light-chain amyloidosis presenting as abdominal bloating: a case report.

BACKGROUND: We present a case of amyloid light-chain amyloidosis with occult plasma cell dyscrasia, with the rare initial presentation of gastroparesis. While amyloidosis is known to affect the gastrointestinal system, rarely do patients present with gastrointestinal symptoms as their first symptom. To the best of our knowledge, this is the first such case reported with a definitive diagnosis made on gastroscopy. CASE PRESENTATION: A 52-year-old Malay man with abdominal bloating, early satiety, and weight loss was found to have significant gastroparesis. He had a past medical history of stable non-ischemic cardiomyopathy. Results from initial screening were negative for common causes of gastroparesis, such as diabetes or offending medications. Gastroscopy did not show any mechanical gastric outlet obstruction. Our patient subsequently developed symptoms of postural giddiness, which then prompted further investigations for possible autonomic dysfunction. These finally revealed evidence of systemic involvement, including postural hypotension, speckled myocardium with infiltrative cardiomyopathy on a transthoracic echocardiogram, and multifocal motor neuropathy on nerve conduction studies, from which he had been relatively asymptomatic. These findings were collectively suggestive of infiltrative disease. Retrospective Congo red staining of a gastric biopsy specimen confirmed the diagnosis of gastric amyloidosis. The final diagnosis was amyloid light-chain amyloidosis secondary to plasma cell dyscrasia, which was confirmed by bone marrow examination. Our patients was started on chemotherapy and prokinetic agents, with some improvement in gastrointestinal symptoms on follow-up. CONCLUSION: We present this case to highlight that, although rare, gastroparesis can be the initial sole presentation of amyloidosis. It is important for the internist, gastroenterologist, and hematologist to consider amyloidosis as a differential diagnosis in the investigation of gastroparesis and to be vigilant in monitoring for other systemic involvement.

Predictive value of proteinuria in adult dengue severity.

BACKGROUND: Dengue is an important viral infection with different presentations. Predicting disease severity is important in triaging patients requiring hospital care. We aim to study the value of proteinuria in predicting the development of dengue hemorrhagic fever (DHF), utility of urine dipstick test as a rapid prognostic tool. METHODOLOGY AND PRINCIPAL FINDINGS: Adult patients with undifferentiated fever (n = 293) were prospectively enrolled at the Infectious Disease Research Clinic at Tan Tock Seng Hospital, Singapore from January to August 2012. Dengue infection was confirmed in 168 (57%) by dengue RT-PCR or NS1 antigen detection. Dengue cases had median fever duration of 6 days at enrollment. DHF was diagnosed in 34 cases according to the WHO 1997 guideline. Dengue fever (DF) patients were predominantly younger and were mostly seen in the outpatient setting with higher platelet level. Compared to DF, DHF cases had significantly higher peak urine protein creatinine ratio (UPCR) during clinical course (26 vs. 40 mg/mmol; p<0.001). We obtained a UPCR cut-off value of 29 mg/mmol based on maximum AUC in ROC curves of peak UPCR for DF versus DHF, corresponding to 76% sensitivity and 60% specificity. Multivariate analysis with other readily available clinical and laboratory variables increased the AUC to 0.91 with 92% sensitivity and 80% specificity. Neither urine dipstick at initial presentation nor peak urine dipstick value during the entire illness was able to discriminate between DF and DHF. CONCLUSIONS: Proteinuria measured by a laboratory-based UPCR test may be sensitive and specific in prognosticating adult dengue patients.

Could peak proteinuria determine whether patient with dengue fever develop dengue hemorrhagic/dengue shock syndrome?--a prospective cohort study.

BACKGROUND: Worldwide there is a need to develop simple effective predictors that can distinguish whether a patient will progress from dengue fever (DF) to life threatening dengue hemorrhagic (DHF) or dengue shock syndrome (DSS). We explored whether proteinuria could be used as such a marker. METHODS: We included patients admitted to hospital with suspected dengue fever. Starting at enrollment until discharge, each patient's daily spot urine protein creatinine ratio (UPCR) was measured. We classified those with confirmed dengue infection as DF or DHF (including DSS) based on WHO criteria. Peak and day of onset of proteinuria was compared between both groups. RESULTS: Compared to those with DF, patients with DHF had significantly higher median peak proteinuria levels (0.56 versus 0.08 g/day; p < 0.001). For patients with DHF, the median day of onset of proteinuria was at 6 days of defervescence, with a range of -2 to +3 days after defervescence. There were three patients with DF who did not have proteinuria during their illness; the five remaining patients with DF had a median day of onset of proteinuria of was at 6 days of defervescence with a range of 0 to +28 days. CONCLUSIONS: Peak UPCR could potentially predict DHF in patients with dengue requiring close monitoring and treatment.