The Elusive Primary: Metastatic Adenocarcinoma of the Breast Presenting Solely as a Hard Sternal Mass.

BACKGROUND Carcinoma of unknown primary (CUP) is a diverse category of malignancies diagnosed in patients who have metastatic disease but without an identifiable primary tumor at initial presentation. CASE REPORT We report a case of CUP which was later diagnosed to be metastatic adenocarcinoma of the breast in a 62-year-old woman. The patient initially presented to a primary care clinic with an incidental finding of a small hard mass in the middle of the sternum, with no other clinical findings in the breast or axillary lymph nodes. Chest X-ray, ultrasound, and CT scan of the sternum suggested a benign sternal lesion, and a mammogram was normal. Due to the persistence of the mass, a biopsy was performed. The histopathological findings revealed a metastatic adenocarcinoma, most likely from breast origin, with positive estrogen receptor (ER) and mammaglobin on immunohistochemistry studies. The patient subsequently underwent PET scan, repeat mammogram, and MRI of the breast. Following high uptake in the rectum on PET, a colonoscopy was performed, revealing a suspicious rectal mass. The mass was surgically excised, and the final histopathological examination concluded the mass was a second primary adenocarcinoma of the rectum. Genetic analyses for BRCA1 and BRCA2 were negative. CONCLUSIONS This is a rare case of an isolated bone-like lesion on the sternum due to metastatic adenocarcinoma of the breast in a patient with no prior history of breast cancer and lacking any clinical or radiological evidence of breast or axillary lymph node lesions on presentation. The patient was also subsequently diagnosed with 2 primary carcinomas. Thorough clinical examination, extensive radiological investigations, laboratory investigations, histopathological examination, and a multidisciplinary approach are essential in managing CUP.

Early Presentation of Pityriasis Rubra Pilaris Mimicking Tinea Corporis: Diagnostic Challenges of a Rare Skin Condition.

BACKGROUND Pityriasis rubra pilaris (PRP) is a rare chronic inflammatory skin condition characterized by follicular, papulosquamous, reddish-orange scaling, palmoplantar keratoderma, and erythema with islands of sparing. Its heterogeneous clinical presentation makes the diagnosis of PRP quite challenging, especially at the initial presentation, as it can mimic common skin conditions. CASE REPORT We present a case with an early presentation of PRP in a 61-year-old Malay woman with underlying uncontrolled diabetes, and discuss evolving clinical course of her disease. She presented to a primary care clinic with a 3-week history of itchy, ring-like skin lesions that started on her neck and chest but subsequently spread widely on her chest, back, and upper extremities. She was first treated as having extensive tinea corporis but responded poorly to multiple courses of antifungal treatment. An initial skin biopsy that was taken at the dermatology clinic revealed features suggestive of erythema annulare centrifugum. However, despite topical steroid treatment, her skin condition evolved further and she developed generalized erythroderma along with follicular hyperkeratosis and palmoplantar keratoderma. A repeat biopsy finally confirmed the diagnosis of PRP. CONCLUSIONS Making the diagnosis of PRP is challenging for clinicians. However, clinicians should approach any common skin problem that does not respond to treatment appropriately, with consideration of other uncommon skin disorders. A repeat skin biopsy may be considered if there are any doubts about the diagnosis. A clinical and histopathological correlation is important to aid in the diagnosis of PRP.

Rickets Due to Severe Vitamin D and Calcium Deficiency During the COVID-19 Pandemic in Malaysia.

BACKGROUND Rickets is the deficiency in mineralization of the bone associated with lack of sunlight exposure and inadequate dietary calcium and/or vitamin D in children. Important efforts to eradicate rickets include appropriate sunlight exposure advice and fortification of food and milk with vitamin D. However, there is a growing concern that the current Coronavirus Disease 2019 (COVID-19) pandemic will increase the incidence of rickets due to inadequate sunlight exposure resulting from movement restriction measures imposed by governments across the world. CASE REPORT A 22-month-old girl presented to our primary care clinic in Selangor, Malaysia with abnormal gait and bowing of the legs during the COVID-19 pandemic. She had a history of inadequate sun exposure as she lived in an apartment and there was a Movement Control Order in place because of the pandemic. Calcium intake was also poor as she could not tolerate formula milk and did not consume any other dairy products. Investigations revealed severe hypocalcemia and low vitamin D level. She was diagnosed with nutritional rickets and was referred for admission to correct the hypocalcemia. She was subsequently discharged with oral calcium and vitamin D supplementation. Her calcium and vitamin D levels improved and at her 6-month review, her bilateral bowed legs had improved significantly. CONCLUSIONS This case highlights the importance of having a high degree of suspicion for vitamin D deficiency and rickets in young children growing up during the COVID-19 pandemic. Public health messages on preventing the spread of COVID-19 should also be interlaced with messages addressing the possible effects of our new norms such as inadequate sunlight exposure.

Why women chose unassisted home birth in Malaysia: a qualitative study.

BACKGROUND: Incidences of unassisted home birthing practices have been increasing in Malaysia despite the accessibility to safe and affordable child birthing facilities. We aimed to explore the reasons for women to make such decisions. METHODS: Twelve women participated in in-depth interviews. They were recruited using a snowballing approach. The interviews were supported by a topic guide which was developed based on the Theory of Planned Behaviour and previous literature. The interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis. RESULTS: Women in this study described a range of birthing experiences and personal beliefs as to why they chose unassisted home birth. Four themes emerged from the interviews; i) preferred birthing experience, ii) birth is a natural process, iii) expressing autonomy and iv) faith. Such decision to birth at home unassisted was firm and steadfast despite the possible risks and complications that can occur. Giving birth is perceived to occur naturally regardless of assistance, and unassisted home birth provides the preferred environment which health facilities in Malaysia may lack. They believed that they were in control of the birth processes apart from fulfilling the spiritual beliefs. CONCLUSIONS: Women may choose unassisted home birth to express their personal views and values, at the expense of the health risks. Apart from increasing mothers' awareness of the possible complications arising from unassisted home births, urgent efforts are needed to provide better birth experiences in healthcare facilities that resonate with the mothers' beliefs and values.

Isolated Bilateral Pinna Swelling: A Rare Initial Presentation of Leprosy.

BACKGROUND: Leprosy or Hansen disease is a chronic infectious disease that causes social stigma due to its deforming bodily appearance and physical disability. It has a wide spectrum of presentation affecting diagnosis. CASE REPORT: A 21-year-old man who presented with chronic isolated bilateral pinna swelling as a result of leprosy is reported. The bilateral pinna swelling started as multiple shiny papules with an erythematous background and progressively became hyperpigmented and lobular over two years. This rare presentation of leprosy poses initial diagnostic difficulties, leading to misdiagnoses by various health care professionals. Diagnoses ascribed include eczema, insect bite and perichondritis. A suspicion of leprosy was raised when hyperaesthetic hypopigmentation of skin started to appear on the body after two years, with worsening of the pinna swellings. This was confirmed by identification of Mycobacterium leprae in slit skin smear test and skin biopsy. CONCLUSION: Isolated involvement of pinna in a patient without lesions in other body parts is an unusual initial presentation of leprosy. However, leprosy should be kept as a rare differential diagnosis of isolated lesions on the ear in patients not responding to conventional treatment.