Performance of the World Health Organisation suspected COVID-19 case definition in cluster-associated and sporadic SARS-CoV-2 transmission in Malaysia.

INTRODUCTION: Cluster-associated transmission has contributed to the majority of COVID-19 cases in Malaysia. Although widely used, the performance of the World Health Organization (WHO) case definition for suspected COVID19 in environments with high numbers of such cases has not been reported. MATERIALS AND METHODS: All suspected cases of COVID-19 that self-presented to hospitals or were cluster screened from 1st April to 31st May 2020 were included. Positive SARS-CoV-2 rRT-PCR was used as the diagnostic reference for COVID-19. RESULTS: 540 individuals with suspected COVID-19 were recruited. Two-third of patients were identified through contact screening, while the rest presented sporadically. Overall COVID-19 positivity rate was 59.4% (321/540) which was higher in the cluster screened group (85.6% vs. 11.6%, p<0.001). Overall, cluster-screened COVID-19 cases were significantly younger, had fewer comorbidities and were less likely to be symptomatic than those present sporadically. Mortality was significantly lower in the cluster-screened COVID-19 cases (0.3% vs. 4.5%, p<0.05). A third of all chest radiographs in confirmed COVID-19 cases were abnormal, with consolidation, ground-glass opacities or both predominating in the peripheral lower zones. The WHO suspected case definition for COVID-19 accurately classified 35.4% of all COVID-19 patients, a rate not improved by the addition of baseline radiographic data. Misclassification rate was higher among the cluster-associated cases (80.6%) compared to sporadic cases (35.3%). CONCLUSION: COVID-19 cases in Malaysia identified by active tracing of community cluster outbreaks had lower mortality rate. The WHO suspected COVID-19 performed poorly in this setting even when chest radiographic information was available, a finding that has implications for future spikes of the disease in countries with similar transmission characteristics.

Adult-onset nasopharyngeal diphtheria: an uncommon but rapidly progressive and potentially fatal infection.

Nasopharyngeal diphtheria is an acute infectious upper respiratory tract disease caused by toxigenic strains of Corynebacterium diphtheriae. We report a case of a young adult who presented to us with a short history of fever, sore throat, hoarseness of voice and neck swelling. He claimed to have received all his childhood vaccinations and had no known medical illnesses. During laryngoscopy, a white slough (or membrane) was seen at the base of his tongue. The epiglottis was also bulky and the arytenoids were swollen bilaterally. The membrane was sent to the microbiology laboratory for culture. A diagnosis of nasopharyngeal diphtheria was made clinically and the patient was treated with an antitoxin together with erythromycin, while awaiting the culture result. Nevertheless, the patient's condition deteriorated swiftly and although the laboratory eventually confirmed an infection by toxin-producing C. diphtheriae, the patient had already succumbed to the infection.

Influenza B outbreak in female psychiatric ward of Hospital Kuala Lumpur, Malaysia.

Influenza outbreaks in tropical countries are rarely reported. This article reports four cases of influenza within a psychiatric ward of a tertiary hospital in Malaysia. These were patients with severe mental illness who were involuntarily admitted and did not show the classical triad of influenza-like-illness (ILI) at the beginning. However, severe respiratory complications developed requiring intubation. Referral and cooperation with the infectious disease team was initiated to help manage the outbreak while continuing psychiatric treatment. Incidences of influenza among hospitalised psychiatric patients should be treated seriously with immediate multidisciplinary approach to prevent severe unwanted complications.

Community-acquired necrotising pneumonia caused by Panton-Valentine leucocidin-producing methicillin-resistant Staphylococcus aureus.

A 61-year-old male presented with community-onset pneumonia not responding to treatment despite given appropriate antibiotics. Computed tomography scan of the thorax showed large multiloculated pleural effusion with multiple cavitating foci within collapsed segments; lesions which were suggestive of necrotising pneumonia. Drainage of the effusion and culture revealed methicillin-resistant Staphylococcus aureus, which had the same antibiotic profile with the blood isolate and PVL gene positive.

Treating hepatitis C in HIV/HCV co-infected patients in Malaysia - the outcomes and challenges.

BACKGROUND: Co-infection by human immunodeficiency and hepatitis C viruses (HIV/HCV) is common and results in significant morbidity and mortality despite effective antiretroviral therapies (ART). METHOD: A retrospective and prospective evaluation of the efficacy and safety of pegylated interferon alfa 2a/2b plus ribavirin (PEG-IFN/RBV) in consecutive HIV/HCV co-infected patients treated in real life clinical practice in Malaysia. RESULTS: Forty-five HIV/HCV co-infected patients with a median age (interquartile range, IQR) of 41 years (37; 47) were assessed for treatment with PEG-IFN/RBV. All except one are of male gender and the most common risk behaviour was injecting drug use. At baseline 75.5% was on ART and the median (IQR) CD4 count was 492 cells/µl (376; 621). The HCV genotypes (GT) were 73 % GT3 and 27% GT1. Liver biopsies in forty patients showed 10% had liver cirrhosis and another 50% had significant liver fibrosis. The treatment completion rate was 79.5% with 15.9% dropped out of treatment due to adverse effects (AE) or default and 4.6% due to lack of early virological response. The AE causing premature discontinuations were neuropsychiatric and haematological. The overall sustained virological response (SVR) was 63.6% with a trend towards higher SVR in GT3 compared with GT1 (71.9% vs. 41.7%; p=0.064). In patients with bridging fibrosis plus occasional nodules or cirrhosis on liver biopsy, the SVR was significantly lower at 20% (p=0.030) compared to those with milder fibrosis. CONCLUSION: HIV/HCV co-infected patients can be successfully and safely treated with PEG-IFN/RBV achieving high rates of SVR except in cirrhotic patients.

Online rapid sampling microdialysis (rsMD) using enzyme-based electroanalysis for dynamic detection of ischaemia during free flap reconstructive surgery.

We describe an enzyme-based electroanalysis system for real-time analysis of a clinical microdialysis sampling stream during surgery. Free flap tissue transfer is used widely in reconstructive surgery after resection of tumours or in other situations such as following major trauma. However, there is a risk of flap failure, due to thrombosis in the flap pedicle, leading to tissue ischaemia. Conventional clinical assessment is particularly difficult in such 'buried' flaps where access to the tissue is limited. Rapid sampling microdialysis (rsMD) is an enzyme-based electrochemical detection method, which is particularly suited to monitoring metabolism. This online flow injection system analyses a dialysate flow stream from an implanted microdialysis probe every 30 s for levels of glucose and lactate. Here, we report its first use in the monitoring of free flap reconstructive surgery, from flap detachment to re-vascularisation and overnight in the intensive care unit. The on-set of ischaemia by both arterial clamping and failure of venous drainage was seen as an increase in lactate and decrease in glucose levels. Glucose levels returned to normal within 10 min of successful arterial anastomosis, whilst lactate took longer to clear. The use of the lactate/glucose ratio provides a clear predictor of ischaemia on-set and subsequent recovery, as it is insensitive to changes in blood flow such as those caused by topical vasodilators, like papaverine. The use of storage tubing to preserve the time course of dialysate, when technical difficulties arise, until offline analysis can occur, is also shown. The potential use of rsMD in free flap surgery and tissue monitoring is highly promising.

Lactic acidosis in HIV patients receiving highly active antiretroviral therapy.

Exposure to highly active antiretroviral therapy (HAART) may lead to adverse effects related to mitochondrial toxicity such as lactic acidosis. We describe two cases of severe lactic acidosis in HIV-positive patients to illustrate the clinical symptoms and abnormal laboratory results associated with this condition. There is a lack of awareness about the risk factors for developing severe lactic acidosis and recognition of its onset with dire consequences.

Laryngocoele presenting as acute airway obstruction.

A laryngocoele is an abnormal dilatation of the laryngeal saccule. Symptomatic laryngocoeles can present as rapidly developing airway obstruction. In this case report of a 37-year-old man with a laryngocoele, we discuss the management dilemma presented by his repeated flight from the hospital prior to definitive treatment. This resulted in repeated admissions with life-threatening airway symptoms, culminating in emergency tracheostomies. Surgical excision of the laryngocoele was not achieved until the third presentation. We recommend early surgical intervention in patients who are potentially non-compliant to treatment or follow-up. A brief literature review of laryngocoele, as well as management of the difficult airway, are also discussed.

Providing guidelines and education is not enough: an audit of gentamicin use at The Royal Melbourne Hospital.

BACKGROUND: Aminoglycoside antibiotics are commonly prescribed for the treatment of Gram-negative infections. Appropriate dosing and therapeutic monitoring of aminoglycosides are important because these agents have a narrow therapeutic index. AIM: To audit gentamicin use at our hospital, focusing on selection of the initial dose and therapeutic monitoring practices, and to compare the results against recommendations in the existing hospital aminoglycoside guidelines, which had recently been promoted to doctors. METHODS: This audit included all inpatients receiving gentamicin at The Royal Melbourne Hospital from 1 February to 12 March 2004. The principal researcher checked the drug charts of all inpatients to identify those receiving gentamicin and collected data from the medical records and the pathology database. Doses were considered 'concordant' if the dose given was within the recommended dosing range +/-20 mg. RESULTS: A total of 132 courses of gentamicin was included in the study. Gentamicin was prescribed for prophylaxis in 31.1% of courses. Thirty-six per cent of patients prescribed gentamicin were more than 65 years of age. Eighty-two per cent of the gentamicin used therapeutically was given as a single daily dose. Sixty-six per cent of gentamicin initial dosing was not in accordance with existing hospital guidelines. Seventy-seven per cent of gentamicin courses requiring therapeutic drug monitoring received such monitoring; however, in only 8.8% of these was the monitoring conducted according to guidelines. CONCLUSION: Aminoglycoside prescribing practices at our hospital are suboptimal, despite ready access to prescribing guidelines. Provision of a guideline and education sessions with doctors do not necessarily lead to widespread adoption of recommended practices. We suggest that changes to hospital systems related to prescribing and monitoring of aminoglycosides are required.

Spectrophotometric determination of germanium with Catechol Violet and cetyltrimethylammonium bromide.

A ternary complex between germanium, Catechol Violet (CV) and cetyltrimethylanunoniuni bromide is proposed for the determination of germanium. The stoichiometric ratio Ge:CV is 1:2. Beer's law is obeyed from 0.1 to 1.0 ppm of Ge. The method is highly selective. Interference from Sn(IV), Fe(III), Bi(III), Cr(VI), Mo(VI), V(V) and Sb(III) in mg amounts is eliminated by extracting the germanium into carbon tetrachloride from 9M HC1 and then stripping into water before the photometric determination.