Cow detection and tracking system utilizing multi-feature tracking algorithm.

In modern cattle farm management systems, video-based monitoring has become important in analyzing the high-level behavior of cattle for monitoring their health and predicting calving for providing timely assistance. Conventionally, sensors have been used for detecting and tracking their activities. As the body-attached sensors cause stress, video cameras can be used as an alternative. However, identifying and tracking individual cattle can be difficult, especially for black and brown varieties that are so similar in appearance. Therefore, we propose a new method of using video cameras for recognizing cattle and tracking their whereabouts. In our approach, we applied a combination of deep learning and image processing techniques to build a robust system. The proposed system processes images in separate stages, namely data pre-processing, cow detection, and cow tracking. Cow detection is performed using a popular instance segmentation network. In the cow tracking stage, for successively associating each cow with the corresponding one in the next frame, we employed the following three features: cow location, appearance features, as well as recent features of the cow region. In doing so, we simply exploited the distance between two gravity center locations of the cow regions. As color and texture suitably define the appearance of an object, we analyze the most appropriate color space to extract color moment features and use a Co-occurrence Matrix (CM) for textural representation. Deep features are extracted from recent cow images using a Convolutional Neural Network (CNN features) and are also jointly applied in the tracking process to boost system performance. We also proposed a robust Multiple Object Tracking (MOT) algorithm for cow tracking by employing multiple features from the cow region. The experimental results proved that our proposed system could handle the problems of MOT and produce reliable performance.

Validation and Application of a Molecular Detection System for Fusarium Wilt of Banana in China.

Fusarium wilt of banana is a devastating disease caused by Fusarium oxysporum f. sp. cubense (Foc). It has restricted the development of the banana industry worldwide and is particularly serious in China because of the large planting areas and special planting patterns. However, there is no rapid and accurate approach to detect the Foc strains that specifically occur in China because of the rich genetic diversity observed in this pathosystem. In this study, we evaluated the performance of 10 previously published PCR primer pairs on 103 representative Foc strains in China and neighboring countries and screened out a set of primers (Foc-specific primer pair SIX9-Foc-F/R, Foc R1-specific primer pair SIX6b-210-F/R, Foc R4-specific primer pair Foc-1/2, and Foc TR4-specific primer pair W2987F/R) suitable for the detection of Foc strains in China and the surrounding Southeast Asian countries. Moreover, we developed a molecular detection system to accurately identify the different physiological races of Foc. The findings of this study provide technical support for preventing and controlling the spread of Fusarium wilt of banana in the field in China.

CBL/CAP Is Essential for Mitochondria Respiration Complex I Assembly and Bioenergetics Efficiency in Muscle Cells.

CBL is rapidly phosphorylated upon insulin receptor activation. Mice whole body CBL depletion improved insulin sensitivity and glucose clearance; however, the precise mechanisms remain unknown. We depleted either CBL or its associated protein SORBS1/CAP independently in myocytes and assessed mitochondrial function and metabolism compared to control cells. CBL- and CAP-depleted cells showed increased mitochondrial mass with greater proton leak. Mitochondrial respiratory complex I activity and assembly into respirasomes were reduced. Proteome profiling revealed alterations in proteins involved in glycolysis and fatty acid degradation. Our findings demonstrate CBL/CAP pathway couples insulin signaling to efficient mitochondrial respiratory function and metabolism in muscle.

Molecular Epidemiological Characterization of Staphylococcus aureus and Staphylococcus argenteus Clinical Isolates from a National Tertiary Care Hospital in Myanmar: Co-Isolation of Multiple Clones and Identification of Novel Staphylocoagulase Genotype.

Spread of antimicrobial resistance and virulence factors among Staphylococcus aureus/Staphylococcus argenteus poses a potential public health concern in Myanmar. In this study, a total of 226 clinical isolates of S. aureus (n = 211) and S. argenteus (n = 15) collected in Yangon General Hospital during a two-year period were analyzed for their antimicrobial susceptibility and genetic features. Methicillin-resistant S. aureus (MRSA) accounted for 19% of S. aureus isolates, associated with mostly staphylococcal cassette chromosome mec (SCCmec) type IV, or V. Panton-Valentine leukocidin (PVL) genes were detected in methicillin-susceptible S. aureus (MSSA) at significantly higher rate (39%) than in MRSA (22%). Among MRSA, ST361 (clonal complex [CC] 361), ST772 (CC1), and ST239 (CC8) were frequently identified, while the most common clone in MSSA was ST2990 (CC1), followed by ST121 and CC8 comprising five STs. Novel coagulase gene genotype XVI was identified in four MSSA isolates. All the S. argenteus isolates were assigned to ST2250 and mecA negative, including only one PVL-positive isolate. MSSA and S. argenteus were co-isolated from two patients, while two different MSSA clones were simultaneously identified in eight patients. This study revealed clonal diversity and genetic characteristics of current MRSA/MSSA/S. argenteus clinical isolates in the national tertiary care hospital in Myanmar.

Spatial and temporal assessment of human-water interactions at the Inle Lake, Myanmar: a socio-hydrological DPSIR analysis.

Freshwater resources as a key aspect of socio-economic development, provide a large number of services in human and environmental systems. Nevertheless, human appropriation of these water resources and the modification of landscapes lead to potential threats on water availability and quality from local to global scales. The Inle Lake in Myanmar is an economically, traditionally, and ecologically important freshwater ecosystem that faced severe degradation from the 2000s. In its catchment area, a Driver-Pressure-State-Impact-Response (DPSIR) framework is applied for an assessment period of 30 years from 1990 to 2020. The analysis results are complemented with a socio-hydrological survey, water quality assessment, a land use classification based on ground truth and satellite data, and hydrologic models. The resulting land use changes, - 13% forest, + 13% agriculture, and + 5% urban areas, lead to increased water yield, decreased evapotranspiration, and increased sediment yield. Together with other drivers and pressures such as climate change and anthropogenic pollution, these human activities are major threats for freshwater resources and the ecosystem. However, the existing awareness of the local population for the environmental degradation is obstructed by national and international crises and responses to negative developments can accelerate degradation if they are unplanned and short-term solutions. Our study shows that environmental degradation processes have a complex nature and can only be tackled in a coordinated way with a long-term perspective. DPSIR is a suitable approach to assess human-water dynamics and disentangle the complex interconnectedness of social and environmental systems in freshwater ecosystems, even in data-scarce regions.

Therapeutic efficacy of chloroquine for uncomplicated Plasmodium vivax malaria in southeastern and western border areas of Myanmar.

BACKGROUND: In the Greater Mekong Subregion of Southeast Asia, Plasmodium vivax malaria is endemic and causes significant morbidity. In this study, the efficacy of chloroquine for treating uncomplicated P. vivax malaria at the eastern and western borders of Myanmar was investigated. METHODS: A total of 197 participants with microscopically confirmed P. vivax infection were enrolled from three townships of the southeastern (Thanbyuzayat and Kawthoung) and western (Kyauktaw) borders of Myanmar. Patients were treated with chloroquine according to the national malaria treatment guidelines and followed for 28 days. RESULTS: Among the 197 enrollments, 172 completed the 28-day follow-up. Twelve recurrent P. vivax infections, all occurring in the third and fourth week, were detected, resulting in an overall cumulative rate of recurrence of 4.7% [95% confidence interval (CI) 1.5-7.8]. The incidence rate of recurrence varied among the three sites. In Thanbyuzayat township, no patients had recurrent parasitemia between days 7 and 28. In contrast, Kyauktaw township had a day 28 cumulative incidence rate of recurrence of 7.2% (95% CI 0.6-13.9%) compared to 6.9% (95% CI 0.6-13.2) in Kawthoung township. CONCLUSION: While this study confirmed the relatively high clinical efficacy of chloroquine for treating P. vivax in Myanmar with modest rates of recurrent infections within 28 days of the treatment, it also revealed considerable geographical heterogeneity of chloroquine efficacy, which warrants continuous surveillance efforts.

Longitudinal Analysis of Influenza A(H5) Sero-Surveillance in Myanmar Ducks, 2006-2019.

Between 2006 and 2019, serological surveys in unvaccinated domestic ducks reared outdoors in Myanmar were performed, using a haemagglutination inhibition (HI) test, to confirm H5 avian influenza virus circulation and assess temporal and spatial distribution. Positive test results occurred every year that samples were collected. The annual proportion of positive farms ranged from 7.1% to 77.2%. The results revealed silent/sub-clinical influenza A (H5) virus circulation, even in years and States/Regions with no highly pathogenic avian influenza (HPAI) outbreaks reported. Further analysis of the 2018/19 results revealed considerable differences in seroconversion rates between four targeted States/Regions and between years, and showed seroconversion before and during the sampling period. By the end of the trial, a high proportion of farms were seronegative, leaving birds vulnerable to infection when sold. Positive results likely indicate infection with Gs/GD/96-lineage H5Nx HPAI viruses rather than other H5 subtype low-pathogenicity avian influenza viruses. The findings suggested persistent, but intermittent, circulation of Gs/GD/96-lineage H5Nx HPAI viruses in domestic ducks, despite the veterinary services' outbreak detection and control efforts. The role of wild birds in transmission remains unclear but there is potential for spill-over in both directions. The findings of this study assist the national authorities in the design of appropriate, holistic avian influenza control programs.

Mental health of adolescents in Myanmar: A systematic review of prevalence, determinants and interventions.

Adolescence is a developmental phase where mental disorders typically manifest and where platforms for response (including schools and health services) change rapidly. However, data to inform public mental health responses are limited, including in countries like Myanmar which has a large adolescent population and where mental health has been identified as a priority of policy. In this paper we sought to systematically review the peer-reviewed and grey literature to determine (i) the prevalence of mental disorder among adolescents in Myanmar, (ii) determinants of mental disorder and (iii) interventions that have been implemented and evaluated. Nine publications met inclusion criteria (7 peer-reviewed and 2 grey literature) that included 7 publications reporting prevalence, 6 reporting correlates and one an intervention. The available data from the 2016 Global School-based Health Survey highlight that depression (27.2%) and suicidal ideation (9.4%) are prevalent in Myanmar, and these rates are substantially higher than regional averages. The limited available data on correlates identified violence and bullying, alcohol and substance use, and home, family and community security and cohesion as being closely related to mental health for adolescents. Only one study focussed on interventions and this found mindfulness meditation training to be an effective approach for young people whose parents were affected by HIV. These findings underscore the need to address adolescent mental health in Myanmar, but also to invest in better data collection efforts.

Comparison of Latent Tuberculosis Infections among General versus Tuberculosis Health Care Workers in Myanmar.

Health care workers (HCWs) in high tuberculosis (TB) prevalence countries have to care for many cases, thus increasing their risk of infection. The objective of the study was to compare the prevalence of latent TB infection (LTBI) between general HCWs and TB HCWs, and also to explore the associated factors. A cross-sectional study was conducted in Nay Pyi Taw, Myanmar from September 2019 to January 2020. Staff working at two general hospitals were recruited. Those allocated for TB care were classified as TB HCWs, while the remaining were classified as general HCWs. Participants were interviewed using a structured questionnaire, and screened for LTBI using a tuberculin skin test (TST). Individuals who had an induration of 10 mm or more with normal chest radiograph were regarded as having LTBI. The prevalence of LTBI among general HCWs was 2.04 times higher than that of TB HCWs (31.2% vs. 15.3%, p < 0.001). The associated factors for LTBI included low education level, duration of work experience ≥ 10 years, a low knowledge of regular TB screening, and teaching cough etiquette to TB patients. The higher prevalence of LTBI in the general HCWs in this study was due to confounding by education and experience. After adjustment for these, we have no evidence to support that either group of HCWs had higher LTBI risk.

Haemoptysis management in cystic fibrosis: A case report and treatment pathway.

WHAT IS KNOWN AND OBJECTIVE: Haemoptysis is a major complication of cystic fibrosis (CF) and is associated with pulmonary exacerbations and admission to the hospital. The US CF Pulmonary Foundation guidelines fail to reach consensus on haemoptysis treatment regarding pharmacotherapy options. CASE SUMMARY DESCRIPTION: We describe a case in which systemic tranexamic acid was utilized to treat haemoptysis in a CF adult patient who was experiencing progressively worsening haemoptysis despite numerous bronchial artery embolization procedures. WHAT IS NEW AND CONCLUSION: The use of antifibrinolytic agents may be of potential benefit in refractory haemoptysis episodes in adult CF patients.

Gaps in Implementing Bidirectional Screening for Tuberculosis and Diabetes Mellitus in Myanmar: An Operational Research Study.

In Myanmar from July 2018, as a pilot project in 32 townships, all tuberculosis (TB) patients aged ≥40 years were eligible for diabetes mellitus (DM) screening by random blood sugar (RBS) and all DM patients attending hospitals were eligible for TB screening. We assessed the bidirectional screening coverage of target groups through a cross sectional study involving secondary analysis of routine program data. From January to March 2019, of the 5202 TB patients enrolled, 48% were aged ≥40 years. Of those aged ≥40 years, 159 (6%) were known to have DM, and the remaining 2343 with unknown DM status were eligible for DM screening. Of these, 1280 (55%) were screened and 139 (11%) had high RBS values (≥200 mg/dL, as defined by the national program). There was no information on whether patients with high RBS values were linked to DM care. Of the total 8198 DM patients attending hospitals, 302 (3.7%) patients were tested for sputum smear and 147 (1.7%) were diagnosed with TB. In conclusion, only half of the eligible TB patients were screened for DM and the yield of TB cases among screened DM patients was high. There is an urgent need for improving and scaling up bidirectional screening in the country.

Geographical heterogeneity in prevalence of subclinical malaria infections at sentinel endemic sites of Myanmar.

BACKGROUND: The malaria burden of Myanmar still remains high within the Greater Mekong Subregion of Southeast Asia. An important indicator of progress towards malaria elimination is the prevalence of parasite infections in endemic populations. Information about malaria epidemiology is mostly derived from reports of confirmed acute malaria cases through passive case detection, whereas the prevalence of baseline subclinical malaria infections is much less known. METHODS: In this study, cross-sectional surveys were conducted during the rainy season of 2017 in four townships (Bilin, Thabeikkyin, Banmauk and Paletwa) of Myanmar with divergent annual malaria incidences. A total of 1991 volunteers were recruited from local villages and Plasmodium subclinical infections were estimated by light microscopy (LM), rapid diagnostic tests (RDTs) and nested PCR. The nested PCR analysis was performed with a modified pooling strategy that was optimized based on an initial estimate the infection prevalence. RESULTS: The overall malaria infection prevalence based on all methods was 13.9% (277/1991) and it differed drastically among the townships, with Paletwa in the western border having the highest infection rate (22.9%) and Thabeikkyin in central Myanmar having the lowest (3.9%). As expected, nested PCR was the most sensitive and identified 226 (11.4%) individuals with parasite infections. Among the parasite species, Plasmodium vivax was the most prevalent in all locations, while Plasmodium falciparum also accounted for 32% of infections in the western township Paletwa. Two RDTs based on the detection of the hrp2 antigen detected a total of 103 P. falciparum infections, and the ultrasensitive RDT detected 20% more P. falciparum infections than the conventional RDT. In contrast, LM missed the majority of the subclinical infections and only identified 14 Plasmodium infections. CONCLUSIONS: Cross-sectional surveys identified considerable levels of asymptomatic Plasmodium infections in endemic populations of Myanmar with P. vivax becoming the predominant parasite species. Geographical heterogeneity of subclinical infections calls for active surveillance of parasite infections in endemic areas. The pooling scheme designed for nested PCR analysis offers a more practical strategy for large-scale epidemiological studies of parasite prevalence. Such information is important for decision-makers to put forward a more realistic action plan for malaria elimination.

c-Jun N-terminal kinase (JNK)-mediated phosphorylation of SARM1 regulates NAD+ cleavage activity to inhibit mitochondrial respiration.

Mitochondrial dysfunction is a key pathological feature of many different types of neurodegenerative disease. Sterile alpha and Toll/interleukin receptor motif-containing protein 1 (SARM1) has been attracting much attention as an important molecule for inducing axonal degeneration and neuronal cell death by causing loss of NAD (NADH). However, it has remained unclear what exactly regulates the SARM1 activity. Here, we report that NAD+ cleavage activity of SARM1 is regulated by its own phosphorylation at serine 548. The phosphorylation of SARM1 was mediated by c-jun N-terminal kinase (JNK) under oxidative stress conditions, resulting in inhibition of mitochondrial respiration concomitant with enhanced activity of NAD+ cleavage. Nonphosphorylatable mutation of Ser-548 or treatment with a JNK inhibitor decreased SARM1 activity. Furthermore, neuronal cells derived from a familial Parkinson's disease (PD) patient showed a congenitally increased level of SARM1 phosphorylation compared with that in neuronal cells from a healthy person and were highly sensitive to oxidative stress. These results indicate that JNK-mediated phosphorylation of SARM1 at Ser-548 is a regulator of SARM1 leading to inhibition of mitochondrial respiration. These findings suggest that an abnormal regulation of SARM1 phosphorylation is involved in the pathogenesis of Parkinson's disease and possibly other neurodegenerative diseases.

Emerging Zoonotic Influenza A Virus Detection in Myanmar: Surveillance Practices and Findings.

We describe 2-season, risk-based, virological surveillance for zoonotic avian influenza in Myanmar and report the first detection of influenza A subtypes H5N6 and H9N2 in Myanmar. The study focused mainly on the live bird markets in border townships, where illegal poultry importation from China usually takes place. The objective was to enhance early warning for low pathogenic avian influenza A(H7N9) incursion. The study followed the guidelines of the Food and Agriculture Organization (FAO) of the United Nations for influenza A(H7N9) surveillance in uninfected countries. The sampling strategy was risk-based at all sampling levels. Sample collection and laboratory analysis were carried out with the government of the Union of the Republic of Myanmar. Laboratory testing was according to a previously published FAO laboratory protocol and algorithm designed to detect a range of influenza A subtypes. Challenges to implementation are outlined. The study provided evidence that the H7N9 subtype had not entered Myanmar but detected other subtypes, including H5N6 and H9N2. Although there were logistical difficulties associated with nation-related issues, the results highlight the importance and feasibility of this risk-based active surveillance, which should be urgently established in other countries, especially those located at the east-southeast influenza epicenter.

Clinical and molecular surveillance of artemisinin resistant falciparum malaria in Myanmar (2009-2013).

BACKGROUND: Emergence of artemisinin-resistant malaria in Southeast Asian countries threatens the global control of malaria. Although K13 kelch propeller has been assessed for artemisinin resistance molecular marker, most of the mutations need to be validated. In this study, artemisinin resistance was assessed by clinical and molecular analysis, including k13 and recently reported markers, pfarps10, pffd and pfmdr2. METHODS: A prospective cohort study in 1160 uncomplicated falciparum patients was conducted after treatment with artemisinin-based combination therapy (ACT), in 6 sentinel sites in Myanmar from 2009 to 2013. Therapeutic efficacy of ACT was assessed by longitudinal follow ups. Molecular markers analysis was done on all available day 0 samples. RESULTS: True recrudescence treatment failures cases and day 3 parasite positivity were detected at only the southern Myanmar sites. Day 3 positive and k13 mutants with higher prevalence of underlying genetic foci predisposing to become k13 mutant were detected only in southern Myanmar since 2009 and comparatively fewer mutations of pfarps10, pffd, and pfmdr2 were observed in western Myanmar. K13 mutations, V127M of pfarps10, D193Y of pffd, and T448I of pfmdr2 were significantly associated with day 3 positivity (OR: 6.48, 3.88, 2.88, and 2.52, respectively). CONCLUSIONS: Apart from k13, pfarps10, pffd and pfmdr2 are also useful for molecular surveillance of artemisinin resistance especially where k13 mutation has not been reported. Appropriate action to eliminate the resistant parasites and surveillance on artemisinin resistance should be strengthened in Myanmar. Trial registration This study was registered with ClinicalTrials.gov, identifier NCT02792816.

Detection of Schistosoma Antibodies and exploration of associated factors among local residents around Inlay Lake, Southern Shan State, Myanmar.

BACKGROUND: Schistosomiasis is a chronic parasitic disease caused by blood flukes (trematode worms) of the genus Schistosoma. Its transmission has been reported in 78 countries affecting at least 258 million people world-wide. It was documented that S. japonicum species was prevalent in Shan State, Myanmar, but the serological study was not conducted yet. General objective of the present study was to detect schistosoma antibodies and explore associated factors among local residents living around Inlay Lake, Nyaung Shwe Township, and Southern Shan State, Myanmar. METHODS: An exploratory and cross-sectional analytic study was conducted among local residents (n = 315) in selected rural health center (RHC) areas from December 2012 through June 2013. The participants were interviewed with pretested semi-structured questionnaires and their blood samples (serum) were tested using Schistosomiasis Serology Microwell ELISA test kits (sensitivity 100% and specificity 85%) which detected IgG antibodies but could not distinguish between a new and past infection. Data collected were analysed by SPSS software 16.0 and associations of variables were determined by Chi-squared test with a significant level set at 0.05. RESULTS: Schistosoma seroprevalence (IgG) in study area was found to be 23.8% (95% CI: 18.8-28.8%). The present study is the first and foremost study producing serological evidence of schistosoma infection-one of the neglected tropical diseases-in local people of Myanmar. The factors significantly associated with seropositivity were being male [OR = 2.6 (95% CI: 1.5-4.49), P < 0.001], residence [OR = 3.41 (95% CI: 1.6-7.3), P < 0.05 for Khaung Daing vs. Min Chaung] and education levels [OR = 4.5 (95% CI: 1.18-17.16), P < 0.05 for illiterate/3Rs level vs. high/graduate and OR = 3.16 (95% CI: 1.26-7.93), P < 0.05 for primary/middle level vs. high/graduate] all factors classically associated with risk of schistosoma infection. None of the behavioural factors tested were significantly associated with seropositivity. CONCLUSION: Schistosoma infection serologically detected was most probably present at some time in this location of Myanmar, and this should be further confirmed parasitologically and kept under surveillance. Proper trainings on diagnosis, treatment, prevention and control of schistosomiasis should be provided to the healthcare providers. TRIAL REGISTRATION: ISRCTN ISRCTN73824458 . Registered 28 September 2014, retrospectively registered.

Bioremediation of wastewater from edible oil refinery factory using oleaginous microalga Desmodesmus sp. S1.

Edible oil industry produced massive wastewater, which requires extensive treatment to remove pungent smell, high phosphate, carbon oxygen demand (COD), and metal ions prior to discharge. Traditional anaerobic and aerobic digestion could mainly reduce COD of the wastewater from oil refinery factories (WEORF). In this study, a robust oleaginous microalga Desmodesmus sp. S1 was adapted to grow in WEORF. The biomass and lipid content of Desmodesmus sp. S1 cultivated in the WEORF supplemented with sodium nitrate were 5.62 g·L(-1) and 14.49%, whereas those in the WEORF without adding nitrate were 2.98 g·L(-1) and 21.95%. More than 82% of the COD and 53% of total phosphorous were removed by Desmodesmus sp. S1. In addition, metal ions, including ferric, aluminum, manganese and zinc were also diminished significantly in the WEORF after microalgal growth, and pungent smell vanished as well. In comparison with the cells grown in BG-11 medium, the cilia-like bulges and wrinkles on the cell surface of Desmodesmus sp. S1 grown in WEORF became out of order, and more polyunsaturated fatty acids were detected due to stress derived from the wastewater. The study suggests that growing microalgae in WEORF can be applied for the dual roles of nutrient removal and biofuel feedstock production.

Spontaneous pneumomediastinum (Hamman's syndrome): a rare cause of postpartum chest pain.

We present a case of a 28-year-old primiparous woman with facial swelling followed by acute chest pain immediately after delivery. Chest radiograph revealed pneumomediastinum and surgical emphysema. She recovered well within 24 h of observation and conservative management. Postpartum spontaneous pneumomediastinum should be considered in the differential diagnosis of sudden-onset postpartum chest pain immediately or a few hours after delivery. It is a rare benign condition and usually resolves spontaneously without serious consequences. Chest X-ray is the single most important diagnostic test. It is important to rule out other serious and life-threatening conditions. Prolonged pushing, difficult labour and use of inhalational drugs place young primiparous women at higher risk. Recurrence is uncommon in subsequent pregnancy and management is unclear, although expectant management with epidural analgaesia to prevent recurrence in subsequent pregnancy is suggested.

Isolated non-hereditary angioneurotic oedema of uvula (Quincke's disease) in an adolescent.

A 19-year-old primipara woman was admitted in labour with positive vaginal swab for group B Streptococcus and given benzylpenicillin and ranitidine. She used Entonox for pain relief. She received bupivacaine in the epidural catheter and shortly after developed sensation of foreign body in her throat with muffled voice and isolated angioneurotic oedema of the uvula. She responded well to H1 and H2 histamine blockers and steroids and epinephrine were kept as standby. She recovered well soon after delivery. Penicillin, Entonox or bupivacaine seemed possible cause of the Quincke's disease. Hereditary form was ruled out by normal creatine kinase and reaction to bupivacaine by C1 esterase inhibitor assay. It can be associated with spectrum of anaphylactic reactions and the resuscitation team should be alerted. Airway maintenance should be the primary management strategy. Most cases respond to observation, oxygen therapy and antihistamines with or without steroids. Epinephrine may be required occasionally.