Localised Skin Hyperpigmentation as a Presenting Symptom of Vitamin B12 Deficiency Complicating Chronic Atrophic Gastritis.

Vitamin B12 deficiency is common in developing countries and should be suspected in patients with unexplained anaemia or neurological symptoms. Dermatological manifestations associated with this deficiency include skin hyper- or hypopigmentation, angular stomatitis and hair changes. We report a case of a 28-year-old man who presented to the Sultan Qaboos University Hospital in Muscat, Oman, in November 2013 with localised hyperpigmentation of the palmar and dorsal aspects of both hands of two months' duration. Other symptoms included numbness of the hands, anorexia, weight loss, dizziness, fatigability and a sore mouth and tongue. There was no evidence of hypocortisolaemia and a literature search revealed a possible B12 deficiency. The patient had low serum B12 levels and megaloblastic anaemia. An intrinsic factor antibody test was negative. A gastric biopsy revealed chronic gastritis. After B12 supplementation, the patient's symptoms resolved. Family physicians should familiarise themselves with atypical presentations of B12 deficiency. Many symptoms of this deficiency are reversible if detected and treated early.

A possible case of systemic lupus erythematosus presenting with generalised oedema.

Systemic lupus erythematosus (SLE) is an autoimmune disease of unknown aetiology affecting various systems within the body. We report the case of a patient with generalised subcutaneous oedema as the only presenting feature, which led to the possible diagnosis of SLE without a specific cause. The patient presented to the Sultan Qaboos University Hospital in Muscat, Oman, in April 2013. The oedema had been present for two years before admission. Other potential causes of oedema in patients with SLE were excluded, including SLE of renal origin and SLE due to protein-losing enteropathy or drugs. This was confirmed by the patient's normal serum albumin level and negative proteinuria. Laboratory investigations showed high levels of positive antinuclear antibodies (>1:640), positive anti-double-stranded deoxyribonucleic acid results, high levels of anti-ß2-glycoprotein 1 and immunoglobulin M and low levels of both complement components 3 and 4. The oedema improved immediately in response to steroids and immunosuppressive medications. Physicians should be aware that generalised subcutaneous oedema can be the only manifestation of SLE.

A rare thyroid hormone receptor beta (THRß) gene mutation in a 15-year-old girl with thyroid hormone resistance syndrome: a case report.

INTRODUCTION: Resistance to thyroid hormone is a rare syndrome, where although the level of thyroid hormone is elevated, the level of thyroid stimulating hormone is not suppressed. The patient in our case report is, to the best of our knowledge, the first with this syndrome identified in Oman. CASE PRESENTATION: In one Omani family, a 15-year-old girl of Arabian origin was pre-diagnosed with resistance to thyroid hormone. Blood sample was collected and deoxyribonucleic acid was isolated for molecular genetic testing. The results revealed a rare mutation A268G in the gene for thyroid hormone receptor beta. We believe that this mutation is the cause of the pathology in our patient. CONCLUSION: We report the presence of a rare mutation in the thyroid hormone receptor beta gene for the first time in the Omani population. Due to the rates of consanguinity being high among the Omani population, we are aiming to screen our patient's family members and provide genetic counseling.

Psychosocial impact of breast cancer diagnosis among omani women.

OBJECTIVES: The aim of this study was to explore different psychosocial impacts on Omani women diagnosed with breast cancer. METHODS: Semi-structured individual interviews were conducted with 19 Omani women diagnosed with breast cancer to describe the impact of the disease on their personal and social life. Women were recruited from wards and out-patient clinics at the Sultan Qaboos University Hospital, Muscat. RESULTS: Four main themes emerged. These were: a) factors related to psychological distress of the disease and uncertainty (worry of death, interference with work and family responsibilities, searching for hope/cure, travelling overseas); b) reactions of family members (shocked, saddened, unity, pressure to seek traditional treatments); c) views of society (sympathy, isolation, reluctant to disclose information); and d) worries and threats about the future (side effects of chemotherapy, spread of the disease, effect on offspring). CONCLUSION: Breast cancer diagnosis has several devastating psychosocial impacts on women in Oman. Healthcare professionals working with women with breast cancer should be aware of the different psychosocial impacts of the disease on women's lives. Appropriate measures must be taken by the decision makers whenever needed, including enforcing positive views and support of Oman's society towards women with breast cancer.

Palpitations caused by a Seizure with Autonomic Features.

Palpitations are a common symptom of presentation in medical practice. They are usually caused by cardiac arrhythmias, psychiatric problems or other miscellaneous causes, such as anaemia or endocrine causes. They are rarely due to autonomic seizures. We report a 55-year-old woman who presented at Sultan Qaboos University Hospital, Oman, with recurrent episodes of palpitations. Her associated symptoms included breathlessness and excessive sweating, followed by a sensation of dizziness. During subsequent episodes, she experienced symptoms of rising abdominal pain followed by a loss of consciousness. Positive electroencephalogram findings, as well as the response of the symptoms to antiepileptic drugs, were strongly suggestive of temporal lobe epilepsy as the possible diagnosis. The fact that the cardiac investigations, performed during an interictal period, were unremarkable also supports the hypothesis that the palpitations were linked to seizures. Epilepsy should be considered as a differential diagnosis of palpitations, especially if the palpitations are episodic.

Factors Affecting the Quality of Diabetic Care in Primary Care Settings in Oman: A qualitative study on patients' perspectives.

OBJECTIVES: The quality of services delivered to type 2 diabetic patients in primary health care has an important impact on long-term outcomes. The aim of this study is to explore diabetic patients' views of factors affecting quality of diabetic services delivered in primary care in Oman, a developing country with a high burden of diabetes. METHODS: Semi-structured face to face interviews were conducted with 19 type 2 diabetic patients recruited from four selected primary healthcare centres (PHCs) in Muscat region, the capital city of Oman. A framework approach was used to analyse the qualitative data. RESULTS: PARTICIPANTS IDENTIFIED SEVERAL FACTORS WHICH COULD AFFECT THE QUALITY OF DIABETIC SERVICES PROVIDED IN PHCS: delays in the follow-up process; lack of continuity of care; diabetes educational materials unavailable in waiting areas; shortage of Omani nurses able to speak the patients' language; inadequate explanations from the attending primary care physician (PCP); under involvement of dieticians in patient management; delays in provision of laboratory results; inadequate supplies of diabetic medication between appointments, and long waits to see ophthalmologists. CONCLUSION: Several factors were identified by diabetic patients that may influence the quality of diabetic services provided in the PHC setting in Oman. Health care professionals and decision makers in the Ministry of Health (MOH) and other health care sectors in Oman should consider patients' views and concerns in order to improve the quality of diabetic care services in primary health care.

Menopausal symptoms among healthy, middle-aged Omani women as assessed with the Menopause Rating Scale.

OBJECTIVE: The aim of this study was to analyze the prevalence and severity of climacteric symptoms and associated risk factors among a cohort of healthy, middle-aged Omani women. METHODS: In this cross-sectional study, 472 healthy Omani women between 40 and 60 years old from the representative regions of Omani society were surveyed using the Menopause Rating Scale. The scores obtained were plotted against their demographic data and menopausal stage. RESULTS: Overall, 39.6% of the participants were premenopausal, 15.2% were perimenopausal, and 43.6% were postmenopausal. The Menopause Rating Scale scoring showed that somatic and psychological symptoms occurred more frequently than did urogenital symptoms in all three stages. Muscle and joint pain was the most common symptom (73.3%), followed by mental and physical exhaustion (47.2%) and anxiety (46.6%). An increase in the mean scores for both somatic and psychological symptoms and their severity was observed when the following factors were present: progression of menopausal stage (mean ± SD, 22.5 ± 2.6, 3.6 ± 2.9, 4.5 ± 3.2), old age (4.2 ± 3.2) versus young age (2.9 ± 2.6), single (4.3 ± 3.3) versus married (3.3 ± 2.9), illiterate (3.9 ± 3.1) versus educated (2.7 ± 2.6), and sexually inactive (4.4 ± 3.4) versus sexually active (3.1 ± 2.7). CONCLUSIONS: Omani women were found to exhibit highly atypical symptoms of menopause. Increased severity of symptoms was found to be related to age, advanced stage of menopause, and lower educational level.

Control of Hypertension among Type II Diabetics.

OBJECTIVES: Numerous studies have confirmed the high prevalence of hypertension among type 2 diabetics, and that intensive hypertensive treatment is more beneficial to diabetics than non diabetics. The aim of this study is to assess blood pressure control in patients with type 2 diabetes mellitus and to study the types of antihypertensives used. METHODS: A retrospective study was conducted on hypertensive diabetics followed at a health center in Oman within a year. Patients' age, sex, duration of diabetes, hypertension and the type of antihypertensive used were noted. Patients were classified according to the degree of systolic and diastolic BP control into 4 groups. RESULTS: 210 patients with a mean age of 53.7±9.1 years were included with a 2:5 male to female ratio. The mean duration of diabetes was found to be 9 years and 7 years for hypertension. 10% of the subjects were in the systolic group I, 23% in group II, 23% in group III and 41% in group IV. While 56% were in diastolic group I, 19% in group II, 16% in group III, and 7% in group IV. Angiotensin converting enzyme-inhibitors (ACE) were used in 50% of the subjects followed by a combination of angiotensin receptor blockers (ARB) with diuretics in 40%. B blockers were used in 38% of the patients. Calcium channel blockers were used in 18%, while diuretics were used in 16% of the patients. CONCLUSION: Only 30% of the BP of the hypertensive diabetics met the recommended BP for diabetes. More effort should be dedicated to control the BP in diabetics. Physicians should be careful in the selection of hypertensive medications, because in some combinations, they are not useful.

Belching as a presenting symptom of angina pectoris.

Symptoms of angina pectoris can present with the typical specific symptoms, which are easy to recognize, or vague symptoms like chills, nausea, dizziness, belching and mild chest pain. Both the typical and atypical forms of angina symptoms may rarely be associated with or masked by predominantly extra cardiac manifestations, which are occasionally referred to the abdomen. We report here an unusual presentation of angina. A 62 years old male who had been healthy all his life, presented at Sultan Qaboos University, Oman, with a two month history of belching episodes as the chief and the only complaint. He was found to have angina pectoris, although there were no classical symptoms or signs to suggest it. He was treated successfully by surgery. It is concluded that belching can be a presenting symptom of angina.

Clinical presentation of hypothyroidism.

OBJECTIVE: This study was to review the common and unusual symptoms of hypothyroidism. METHOD: A retrospective study was done of forty thousand patients attending Sultan Qaboos University Health Center (SQU), within a period of three years. Sixty-three patients proved to have either clinical or subclinical hypothyroidism and were screened for the different symptoms & signs of hypothyroidism. RESULTS: The well-known symptoms and signs of hypothyroidism reported in the medical textbooks were uncommon in this study. Symptoms such as dysarthria and dysphagia not usually mentioned in the medical textbooks were reported. CONCLUSION: Early diagnosis by screening both middle-aged as well as older patients is advantageous.

Hypothyroidism presenting with dysarthria.

Hypothyroidism is a common endocrine disorder with characteristic clinical symptoms and signs. Typical symptoms of hypothyroidism are lethargy, cold intolerance, slowing of intellectual and motor activity, decreased appetite, weight gain, and dry skin. A 39-year-old female presented to the clinic with dysarthria as the chief symptom. Subsequent questions revealed that other symptoms were confined to the otolaryngeal region, which were episodes of mild dysphonia, dysphagia, sleep apnea, and snoring. Laboratory data revealed marked hypothyroidism and positive tests for antithyroglobulin and antimicrosomal antibodies. After administration of thyroxin, the dysarthria and the other symptoms rapidly disappeared. Dysarthria may be the presenting symptom of hypothyroidism and can be resolved after hormone replacement therapy.