Immune-mediated necrotizing myopathy (NAM) related to SARS-Cov-2 infection: a case report.

BACKGROUND: There is a growing body of evidence that severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) or COVID-19 infection is associated with the development of autoimmune diseases. A recent systematic review reported that the new-onset autoimmune disorders during or after COVID-19 infection included inflammatory myopathies such as immune-mediated necrotizing myopathies. CASE PRESENTATION: We described a 60-year-old man diagnosed with COVID-19 infection and later presented with a two-week history of myalgia, progressive limb weakness, and dysphagia. He had a Creatinine Kinase (CK) level of more than 10,000 U/L, was strongly positive for anti-signal recognition particle (SRP) and anti-Ro52 antibody, and a muscle biopsy revealed a paucity-inflammation necrotizing myopathy with randomly distributed necrotic fibers, which was consistent with necrotizing autoimmune myositis (NAM). He responded well clinically and biochemically to intravenous immunoglobulin, steroids and immunosuppressant and he was able to resume to his baseline. CONCLUSION: SARS-CoV-2 may be associated with late-onset necrotizing myositis, mimicking autoimmune inflammatory myositis.

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.

A Case Report on Cholestatic Jaundice Secondary to Adverse Effect of Phaleria macrocarpa (Mahkota Dewa).

Drug induced cholestatic liver injury can posed a great diagnostic difficulty as a result of its long non-exhaustive list of potential offending causes which can be either prescribed or over-the-counter medications, such as medicinal herbs and remedies. Phaleria macrocarpa, or more commonly known as the 'God's crown' by the local people of South East Asia, is not listed as one of the causes. This medicinal plant extract has been increasingly used for traditional treatment for various ailments. Here, we report a case of a young man who has no known medical illness presented with cholestatic pattern of liver injury which caused by chronic ingestion of Phaleria macrocarpa. The objective of this case report is to share the uncommon side effect of taking this traditional product which may have been under-reported due to the unknown effect.

The poorly understood yet potent risk of pulmonary artery thrombosis in-situ in Post-Acute COVID-19 syndrome.

Pulmonary artery thrombosis in-situ is a term used to describe a pulmonary embolism occurs in the absence of deep vein thrombosis in the lower extremities. Most cases occur in a patient who had a recent traumatic injury to the chest. Other risk factors include the presence of hypercoagulable conditions, including inflammatory state, hypoxia and vascular endothelial injury. Although it has been discussed extensively in the acute COVID-19 disease, pulmonary artery thrombosis in-situ that occur in the setting of Post-Acute COVID-19 syndrome is not commonly reported and poorly understood.

Anxiety among hospitalized COVID-19 patients: a case-control study from a tertiary teaching hospital in Malaysia.

Introduction: Anxiety has been increasingly recognized as part of the psychosocial health issues in COVID-19 patients. However, the impact of this topic may be underestimated in low- and middle-income countries. This study aimed to estimate the prevalence of and risk factors of anxiety in COVID-19 patients compared to controls in a local tertiary teaching hospital in Malaysia. Methods: In this case-control study, we analyzed data on adult patients aged 18 years and above hospitalized for COVID-19 infection with matched hospitalized controls. The demographic, clinical data and anxiety measures using the Generalized Anxiety Disorder-7 questionnaire were analyzed using univariate and multivariate analysis. Results: 86.6% in the COVID-19 group had anxiety, significantly higher than 13.4% in the control group (p = 0.001). The COVID-19 group was significantly associated with the GAD-7 severity (p = 0.001). The number of COVID-19 patients in the mild, moderate, and severe anxiety groups was 48 (84.2%), 37 (86%), and 18 (94.7%), respectively. Multiple logistic regression showed significant predictors for anxiety, including COVID-19 diagnosis and neurological symptoms. Anxiety was found 36.92 times higher in the patients with COVID-19 compared to those without COVID-19 (OR 36.92;95% CI 17.09, 79.78, p = 0.001). Patients with neurological symptoms were at risk of having anxiety (OR 2.94; 95% CI 1.03, 8.41, p = 0.044). Discussion: COVID-19 patients experience a significant disruption in psychosocial functioning due to hospitalization. The burden of anxiety is notably high, compounded by a diagnosis of COVID-19 itself and neurological symptomatology. Early psychiatric referrals are warranted for patients at risk of developing anxiety symptoms.

Improving Tuberculosis Medication Adherence: The Potential of Integrating Digital Technology and Health Belief Model.

Tuberculosis (TB) is a significant public health concern. Globally, TB is among the top 10 and the leading cause of death due to a single infectious agent. Providing standard anti-TB therapy for at least 6 months is recommended as one of the crucial strategies to control the TB epidemic. However, the long duration of TB treatment raised the issue of non-adherence. Non-adherence to TB therapy could negatively affect clinical and public health outcomes. Thus, directly observed therapy (DOT) has been introduced as a standard strategy to improve anti-TB medication adherence. Nonetheless, the DOT approach has been criticized due to inconvenience, stigma, reduced economic productivity, and reduced quality of life, which ultimately could complicate adherence issues. Apart from that, its effectiveness in improving anti-TB adherence is debatable. Therefore, digital technology could be an essential tool to enhance the implementation of DOT. Incorporating the health belief model (HBM) into digital technology can further increase its effectiveness in changing behavior and improving medication adherence. This article aimed to review the latest evidence regarding TB medication non-adherence, its associated factors, DOT's efficacy and its alternatives, and the use of digital technology and HBM in improving medication adherence. This paper used the narrative review methodology to analyze related articles to address the study objectives. Conventional DOT has several disadvantages in TB management. Integrating HBM in digital technology development is potentially effective in improving medication adherence. Digital technology provides an opportunity to improve medication adherence to overcome various issues related to DOT implementation.

SARS-CoV-2-induced liver injury: A review article on the high-risk populations, manifestations, mechanisms, pathological changes, management, and outcomes.

The novel coronavirus disease 2019 is an infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and was declared a global pandemic with more than 500 million reported cases and more than 6 million deaths worldwide to date. Although it has transitioned into the endemic phase in many countries, the mortality rate and overall prognosis of the disease are still abysmal and need further improvement. There has been evidence that shows the significance of SARS-CoV-2-related liver injury. Here, we review the literature on the various spectrum of SARS-CoV-2 infection-induced liver injury and the possible mechanisms of damage to the hepatobiliary system. This review aimed to illustrate the latest understanding regarding SARS-CoV-2-induced liver injury including the high-risk populations, the characteristic clinical manifestations, the possible pathogenic mechanism, the pathological changes, the current suggestions for clinical treatment for various spectrum of populations, and the prognosis of the condition. In conclusion, SARS-CoV-2 patients with a liver injury warrant close monitoring as it is associated with the more severe and poorer outcome of the infection.

Atypical presentation of an atypical pneumonia: a case report.

BACKGROUND: Neurologic impediments occur in only 0.1% of Mycoplasma pneumoniae infections. Although direct intracerebral infection can occur in these patients, autoimmune-mediated reactions secondary to molecular mimicry are the most common pathophysiology of such neurological complications. These complications include immune-mediated encephalitis, peripheral neuritis such as Guillain-Barré syndrome, and many others. Miller Fisher syndrome is a one of the variants of Guillain-Barré syndrome that has been rarely linked to Mycoplasma pneumoniae infection. It is a condition classically characterized by the triad of ophthalmoplegia, areflexia, and ataxia. Most patients with Miller Fisher syndrome will have positive anti-ganglioside GQ1b antibodies found in their serum, making this autoantibody a very useful serological confirmation parameter. We report a case of a Miller Fisher syndrome in a woman with Mycoplasma pneumoniae infection. To the best of the authors' knowledge, such cases have been only rarely described in literature. CASE PRESENTATION: A 35-year-old Chinese woman presented with sudden onset of double vision and ataxia 5 days after fever and mild flu symptoms. Her Mycoplasma pneumoniae antigen was positive with 1 over 2560 titer of total mycoplasma antibody and presence of immunoglobulin M antibody, suggesting acute infection, and her nerve conduction study revealed mild sensory axonal polyneuropathy with segmental demyelination. the Miller Fischer syndrome variant of Guillain-Barré syndrome secondary to Mycoplasma pneumonia was suspected and later confirmed by presence of serum anti-GQ1b autoantibody. She was treated with intravenous immunoglobulin 0.4 g/kg once daily for 5 days. CONCLUSIONS: The objective of this report is to share a case of an uncommon neurological complication of Mycoplasma pneumoniae infection, to increase the level of suspicion among clinicians that Miller Fischer syndrome can occur as an atypical presentation of an atypical pneumonia.

An uncommon cause of myalgia: A case report on systemic lupus erythematous myopathy.

Introduction: Myositis in systemic lupus erythematous may present in a wide range of clinical spectrum. It can be part of an overlap syndrome, or mixed connective tissue disease or a musculoskeletal manifestation of systemic lupus erythematous itself. Case presentation: Here, we present a young girl with an underlying systemic lupus erythematous presented with the typical manifestation of severe proximal myopathy in the background of normal creatine kinase values. The diagnosis of systemic lupus erythematous myopathy was made after excluding other more common causes of myopathies which in itself is a very rare occurrence. Discussions: A normal creatine kinase values does not exclude systemic lupus erythematous myositis, but make the diagnosis more challenging. However, there are other parameters or diagnostic tools which can be used to exclude a myositis. Conclusion: This case elucidates the importance of history and physical examination in the face of some conflicting laboratory data.

Sensory Predominant Guillain-Barré Syndrome Concomitant with Dengue Infection: A Case Report.

Guillain-Barre syndrome is an acute demyelinating polyneuropathy disease which is autoimmune in nature and usually follows gastrointestinal or respiratory infections. Dengue fever is however not a common trigger to the condition. Here, we report a patient who developed sensory predominant demyelinating polyradiculopathy during febrile phase of dengue fever. It was later confirmed with serology test and nerve conduction study. He was successfully treated with intravenous immunoglobulin and discharged home well. The purpose of this case report is to highlight that Guillain-Barré syndrome can occur as an uncommon neurological complication of dengue fever which can occur during any phase of the illness.

'Crescendo transient ischemic attack'-an uncommon presentation of a very common disease: a case report on capsular warning syndrome.

Capsular warning syndrome is a rare presentation of transient ischaemic attack, which described as recurrent episodes of motor and/or sensory deficits which typically sparring the cortical function. It has a significant risk to progress into a massive stroke with permanent disability, thus important to be recognise early. Here, we report a middle-age gentleman with no known medical illness presented with eight episodes of transient ischaemic attack within the span of 24 h. He was treated with double anti-platelet for 21 days and was not subjected to thrombolysis at time of presentation because it was outside the window period of 4.5 h, and has fully recovered after each episode. The purpose of this case report is to share the uncommon clinical presentation of transient ischaemic attack, which is still not fully understood and warrant more studies especially on the treatment that can affect the progression of the disease.

Neuroleptic malignant syndrome secondary to olanzapine, a presentation with severe acute kidney injury requiring hemodialysis: a case report.

BACKGROUND: We present this case to draw attention to the importance of early diagnosis in terms of life-saving, noting that greater awareness is important among healthcare professionals. Our patient developed neuroleptic malignant syndrome (NMS) after his neuroleptic drug dosage was increased. His condition was complicated by acute kidney injury (AKI) which required hemodialysis. The uniqueness of this case is that the causative agent of NMS is an atypical antipsychotic, and atypical antipsychotics are generally considered to be safer than typical antipsychotics. CASE PRESENTATION: A 31-year-old Chinese man with underlying schizophrenia presented to our hospital with aggressive behavior. He was admitted to the psychiatric hospital and started on his regular medications, with an increase in the dose of olanzapine tablet from 5 to 10 mg daily. After 5 days in the ward, the patient was noted to have high fever, restlessness, confusion, increased muscle rigidity, tachycardia and tachypnoea. Antipsychotic therapy was stopped in view of suspected NMS. The first laboratory test for serum creatine kinase (CK) showed a markedly high level of this molecule. His renal profile showed raised serum creatinine in comparison to 2 months prior when the baseline serum creatinine was within the normal range. A diagnosis of NMS with AKI was made. Although the patient was given adequate intravenous fluid hydration with close monitoring of urine output, his renal function did not show improvement but continued to show a worsening trend. In view of this, he was started on urgent hemodialysis. The patient was dependent on intermittent hemodialysis before his AKI showed complete recovery. After 2 weeks, his blood test results returned to normal. He was discharged well. CONCLUSION: Neuroleptic malignant syndrome is a life-threatening iatrogenic medical emergency in which high index of clinical suspicion is required for diagnosis and prompt treatment.

Children's eating behaviour: A comparison between normal, overweight and obese children.

Background: Childhood obesity has become a major global health concern and has been increasing dramatically over the years. Previous study has shown that specific eating behaviours may have been associated with obesity especially under-responsiveness to internal satiety cues and over-responsiveness to external food cues such as the taste, smell, availability and emotions. However, there is still inadequate number of studies present to describe the association between the children's body mass index (BMI) and their eating behaviours, especially in Sabah, Malaysia. Therefore, the objective of this study is to established the association between the children's eating behaviours with their nutritional status based on their body mass index. Materials and methods: A cross-sectional study involving 484 children aged 6-12 years old was conducted in Kota Kinabalu, which is a developing urban area in Sabah. The children were recruited from five primary schools that were selected based on multistage stratified and convenience sampling method. Sociodemographic details and anthropometric measures both parents and children, and eating behaviours of children were assessed using Children Eating Behaviour Questionnaires (CEBQ). Age-adjusted BMI z-scores were then calculated according to the World Health Organization recommendations to assess nutritional status. Results: The prevalence of childhood obesity among children aged 6-12 years old is 13.2%. The mean scores of 'Food Approach' subscales from the CEBQ showed higher mean score in overweight and obese groups as compared to the mean score in normal weight group. The mean scores of 'Food Avoidance' subscales showed lower mean score in overweight and obese groups as compared to mean score in normal weight group. Conclusion: This study provides evidence that childhood obesity is yet to be a prevalent health problem in a developing urban area considering the "Food approach" subscales were positively associated with the excess weight in children.

Delayed presentation of a huge abdominopelvic mass during the COVID-19 pandemic.

Background: Giant ovarian cysts are rare in developed countries due to advanced achievements in medical diagnostics. However, in the midst of the coronavirus disease 2019 (COVID-19) pandemic, patients with non-COVID-19-related illnesses tend to delay their health-seeking attention; thus, they had presented late. Case presentation: A 25-year-old single lady complained of a 3-month worsening abdominal pain and distention. She was initially well but neglected the symptoms due to the COVID-19 situation, yet came to our attention after she developed obstructive symptoms. A computed tomography (CT) scan of the abdomen revealed a huge cystic lesion from the pelvic area, which later was found to be from the right ovary upon urgent laparotomy exploration. The histopathological examination was consistent with mucinous cystadenoma of the ovary. Discussion: Acute non-COVID-19-related emergencies have decreased, as evidenced by reduced visits to the Emergency Department, and the number of abdominal CT scans. An emergency case like a huge abdominopelvic mass deserves an extensive radiologic examination as clinical assessment alone may not be adequate. Preoperative CT is superior to ultrasonography in getting the extent of the lesion, local infiltration, staging purpose, and surgical intervention. Pathology with a variety of spectrums such as mucinous neoplasm deserves to be investigated, evaluated, and resected even during the COVID-19 pandemic. Conclusion: A giant abdominopelvic cystic mass can present emergency havoc during the COVID-19 pandemic. Urgent surgical intervention is mandatory by using full protection and exercising extreme precaution, regardless of the preoperative screening to avoid unnecessary viral transmissions.

An uncommon side effect of a very commonly used medication: A case report on hydrocortisone-induced bradycardia.

Sinus bradycardia is a rare but important side effect of high-dose hydrocortisone. It is a self-limiting condition that recovered spontaneously upon stopping the medication and did not recur with other types of corticosteroids.

Hypokalaemic periodic paralysis secondary to subclinical hyperthyroidism: an uncommon cause of acute muscle paralysis.

Hypokalaemic periodic paralysis secondary to subclinical hyperthyroidism is an uncommon clinical phenomenon characterised by lower limb paralysis secondary to hypokalaemia in the background of subclinical hyperthyroidism. In this article, we report a patient who presented with progressive lower limb muscle weakness secondary to hypokalaemia that was refractory to potassium replacement therapy. He has no diarrhoea, no reduced appetite and was not taking any medication that can cause potassium wasting. Although he was clinically euthyroid, his thyroid function test revealed subclinical hyperthyroidism. His 24-hour urine potassium level was normal, which makes a rapid transcellular shift of potassium secondary to subclinical hyperthyroidism as the possible cause. He was successfully treated with potassium supplements, non-selective beta-blockers and anti-thyroid medication. This case report aimed to share an uncommon case of hypokalaemic periodic paralysis secondary to subclinical hyperthyroidism, which to our knowledge, only a few has been reported in the literature.

Colo-appendico-duodenal fistula: Rare presentation of extrapulmonary tuberculosis.

A colo-appendico-duodenal fistula is a rare occurrence that results from extrapulmonary tuberculosis (TB) complications, especially in the endemic region.

Unusual Presentation of Cerebral Lupus: A Case Report of Parkinsonism in Cerebral Lupus.

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with multisystem involvement that follows a relapsing and remitting course. It is characterized by an immune-mediated response to own body defense mechanism and mistakenly attacked healthy cells of the skin, joints, kidneys, blood cells, and nervous system. Cerebral lupus refers to a constellation of neurological and/or behavioral clinical syndromes in patients with SLE. The spectrum of presentation can vary widely ranging from mild symptoms such as headaches, slight cognitive dysfunction, and mood disorders to more serious conditions like seizures, stroke, or coma. This case report is about a case of cerebral lupus manifested with symptoms of Parkinsonism. The purpose of this case report is to share an uncommon occurrence of cerebral lupus which manifested as Parkinsonism and to highlight the importance of early diagnosis of the condition which is potentially reversibility with prompt treatment [4].