Immune-mediated neurological syndrome in SARS-CoV-2 infection: a review of literature on autoimmune encephalitis in COVID-19.

INTRODUCTION: The novel Coronavirus Disease 2019 (COVID-19) is an infection caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) which has been spreading rapidly amongst humans and causing a global pandemic. The notorious infection has shown to cause a wide spectrum of neurological syndrome, including autoimmune encephalitis. OBJECTIVE: Here, we systematically review the literature on autoimmune encephalitis that developed in the background of SARS-CoV-2 infections and also the possible pathophysiological mechanisms of auto-immune mediated damage to the nervous system. METHODOLOGY: An exhaustive search was made in Medline/PubMed, Embase, Scopus and other medical databases, and 28 relevant published articles were selected according to the strict inclusion criteria. RESULTS: Autoimmune encephalitis can occur via three possible proposed pathophysiological mechanism and can manifest during or after the acute infection period. It is more common in adult but can also occur in the paediatric patients. There were various spectra of autoantibody panels reported including antineuronal antibody, anti-gangliosides antibody and onconeural antibody. Majority of the patients responded well to the immunomodulating therapy and achieved good recovery. CONCLUSION: In conclusion, SARSCoV-2 infection can induce various spectrum of autoimmune encephalitis. It is a major concern since there is very limited long-term study on the topic. Hence, this review aims to elucidate on the potential long-term complication of SARS-CoV-2 infection and hopefully to improve the management and prognosis of COVID-19.

Denosumab for an inoperable giant cell tumour of the ischial bone.

Giant cell tumour of bone is a benign, locally aggressive osteolytic tumour that typically affects skeletally mature young individuals. It predominantly emerges within the metaphysis, extending towards the epiphysis of long bones, while occurrences in flat bones are exceptionally rare. We present a case of a woman in her late 20s who presented with a large right ischial mass. A biopsy confirmed the mass as a giant cell tumour. The tumour extended to the acetabulum, and due to the potential risk of significant bleeding and contamination during en bloc excision, a prudent approach involved initiating denosumab therapy, a monoclonal antibody targeting receptor activator of nuclear factor-κB ligand therapy, before proceeding with radical surgery. Denosumab therapy successfully rendered a previously inoperable tumour favourable for surgical intervention. We went on to perform a type 2 and 3 internal hemipelvectomy, followed by a reconstruction with a hip endoprosthesis replacement.

Experience of diagnosing and managing a patient with spinal Rosai-Dorfman-Destombes disease in a tuberculosis hyperendemic region.

Classic Rosai-Dorfman-Destombes disease (RDD) is a rare histiocytic disorder with bilateral massive painless cervical lymphadenopathy. It is a mysterious disease and there is little knowledge of its pathogenesis, clinical features, radiological findings, laboratory investigations, effective treatments and prognosis. Some of its clinical presentations may overlap with those of Mycobacterium tuberculosis infection. Just like tuberculosis infection, RDD may involve many other organs, for example, skin, kidney, bone, brain and spine. The diagnosis can easily be overlooked, especially in communities hyperendemic to tuberculosis infection. We report our experience in diagnosing and managing a patient with spinal RDD with concurrent tuberculosis infection, who was treated empirically for cervical tuberculous lymphadenitis without a conclusive laboratory finding prior to her spinal condition. In view of her acute neurological deficit, emergency spinal decompression was performed. Her intraoperative spinal samples had shown classic histopathological features of RDD. We believe the lymphadenopathy was part of the clinical presentation of RDD. She showed favourable neurological recovery throughout the follow-up.

Poland's syndrome mimicking traumatic chest injury.

Poland's syndrome (PS) is a rare developmental anomaly that can manifest mild (pectoralis muscles involvement) to severe deformities (rib hypoplasia and hand deformities). We report a case of 69-year-old man who presented to the emergency department with a traumatic chest injury after a fall. It was initially thought to have a significant chest injury as the trauma survey revealed a palpable defect and tenderness in the right anterior chest wall. There was also a symbrachydactyly deformity in the right hand. CT of the chest showed lack of right pectoralis muscles, which were consistent with PS. This case highlights the importance of gathering detail history in adult trauma patients such as congenital disorder especially in the presence of bony deformity. With possibilities of several traumatic conditions in trauma patients eliminated, one can expand the non-traumatic differential, keeping in mind the possibility of a congenital disorder that can mimic traumatic chest injury.

Atraumatic trismus induced by duloxetine: an uncommon presentation of acute dystonia.

Atraumatic trismus can be one of the presentations of medication-induced acute dystonia, particularly by antipsychotics and less commonly antidepressants. A case of an unusual emergency presentation of atraumatic trismus on initiation of duloxetine is reported. The patient was a 40-year-old woman experiencing sudden difficulty in mouth opening and speaking due to a stiffened jaw after taking 5 days of duloxetine prescribed for her fibromyalgia-related chest pain. Assessment of vital signs is prudent to ensure there is no laryngeal involvement. Other physical examinations and her recent investigations were unremarkable. She was treated for acute dystonia and intravenous procyclidine was given together with oral diazepam. Her symptoms improved immediately and her duloxetine was suggested to be stopped. To our knowledge, this is the first case of isolated trismus induced by duloxetine. Clinicians should be aware of this risk, especially considering the limitation of important physiological functions (such as swallowing, eating, etc) associated with this condition.

Strangulated Morgagni hernia masquerading as an acute coronary syndrome.

Morgagni hernia is the rarest type of congenital diaphragmatic hernia, which can present late in adulthood. Here, we report a case of Morgagni hernia in an elderly woman who presented as an acute coronary syndrome with raised troponin level. X-ray of the chest (CXR) showed air-fluid level in the right lower hemithorax with loss of right diaphragmatic outline and subsequently confirmed strangulated Morgagni hernia with CT. She was treated with emergency laparotomy to reduce the hernia content and surgical repair with mesh done. In conclusion, Troponin can be falsely positive in Morgagni hernia patients, possibly due to strain on the heart by herniated bowel contents. Basic imaging such as a (CXR) is useful in the case of chest pain to rule out the non-cardiac causes. Although 'time is the myocardium' in the setting of all cases of chest pain with raised troponin, CXR should be done before treatment that poses bleeding risk and unnecessary delay in laparotomy.

Atypical presentation of catastophric spontaneous mesenteric bleeding.

Spontaneous mesenteric bleeding is an exceptionally rare clinical condition and potentially lethal especially among elderly patients who are taking oral anticoagulant. We present a case of a 79-year-old woman who presented to the emergency department with atypical chest pain which was radiating to the back. She developed profound hypotension with a sudden drop of haemoglobin. Contrast-enhanced CT of the aorta showed active mesenteric bleeding with mesenteric haematoma. The early diagnosis relies solely on a high index of suspicion of occult bleeding in patients with unexplained hypotension with a sudden drop of haemoglobin. Troponin can be falsely positive in mesenteric bleeding. Close monitoring to detect any sign of deterioration and early imaging in diagnosing intra-abdominal bleeding can help to avoid delay in treatment which is essential to prevent mortality and morbidity.

Double-edged sword effect of anticoagulant in COVID-19 infection.

Coagulation predominant-type coagulopathy such as microthrombosis and macrothrombosis is a well-known recognised complication found in COVID-19 infected critically ill patients. In the context of high incidence of thrombotic events in patients with COVID-19, supplementation with anticoagulant therapy has been routinely recommended and shown to reduce mortality. However, the recommended type, dose, duration and timing of anticoagulant has not been determined yet. Spontaneous retroperitoneal haematoma secondary to anticoagulant therapy is one of the well-known but self-limiting conditions. We report a 51-year-old COVID-19 positive woman, who was taking intermediate-intensity heparin therapy for venous thromboembolism prophylaxis and died from complication of retroperitoneal bleeding. Further studies are needed to verify the risk-benefit ratio of anticoagulant therapy in patients with COVID-19. Although anticoagulant deems appropriate to use in patients with COVID-19, clinicians should be cautious about major bleeding complication such as retroperitoneal haemorrhage even when full therapeutic dosage is not used.

An evaluation study on gamified online learning experiences and its acceptance among medical students.

Objective: The successful application of gamification in different educational settings shows that the use of gamification in medical education may be an effective solution. Even though many studies have been conducted to investigate the efficacy of the integration of gamification to different education curriculums, few studies have examined the reactions, behaviors, and attitudes of learners toward the use of gamification in medical education. Hence, this study aimed to evaluate the medical students' learning experience and acceptance of the use of gamification for the delivery of electrocardiogram lessons. Materials and Methods: A qualitative research method was used to generate findings in this study. The data collection methods included focus group discussions and interviews. Triangulation methods were used to ensure the validity and reliability of the qualitative data analyzed in this study. The thematic analysis of the data collected in this study helped to garner insights into the perception of participants and experts about the use of GaMed@™ for the delivery of ECG lessons. Results: A total number of 32 medical students and four experts in the fields of user experience, communication, social psychology, and game design participated in this study. The findings showed that in spite of the negative reports about the user experience and application of GaMed@™, the participants and experts affirmed its positive impact on the increased motivation and engagement of users. Conclusions: The impact of this concept can be maximized by tailoring the game design to foster-positive learning attributes, behaviors, and outcomes in students. However, further research studies must be conducted to investigate the impact of gamification designs on specific learning outcomes in students.

A qualitative study on negative attitude toward electrocardiogram learning among undergraduate medical students.

OBJECTIVE: Negative affect state toward learning has a substantial impact on the learning process, academic performance, and practice of a particular subject, but such attitude toward electrocardiogram (ECG) learning has still received relatively little attention in medical education research. In spite of the significant emphasis in investigating ECG teaching method, the educators would not be able to address ECG incompetency without understanding the negative perception and attitude toward ECG learning. The purpose of this study was to assess the undergraduate students' difficulties in ECG learning and hence help educators design appropriate ECG learning curriculum to instill competent skill in ECG interpretation based on this outcome. MATERIALS AND METHODS: A total of 324 undergraduate preclinical (year 2) and clinical (year 3-5) medical students participated in this study. The research design used thematic analysis of an open-ended questionnaire to analyze the qualitative data. RESULTS: The thematic analysis detected five major emergent themes: lack of remembering (18.2%), lack of understanding (28.4%), difficulty in applying (3.6%), difficulty in analysis (15.1%), and difficulty in interpretation (17.8%), of which addressing these challenges could be taken as a foundation step upon which medical educators put an emphasis on in order to improve ECG teaching and learning. CONCLUSION: Negative attitude toward ECG learning poses a serious threat to acquire competency in ECG interpretation skill. The concept of student's memorizing ECG is not a correct approach; instead, understanding the concept and vector analysis is an elementary key for mastering ECG interpretation skill. The finding of this study sheds light into a better understanding of medical students' deficient points of ECG learning in parallel with taxonomy of cognitive domain and enables the medical teachers to come up with effective and innovative strategies for innovative ECG learning in an undergraduate medical curriculum.