Spontaneous splenic rupture in Plasmodium knowlesi malaria.

BACKGROUND: Plasmodium knowlesi, a malaria parasite typically found in long-tailed and pig-tailed macaques, is the most common cause of human malaria in Malaysian Borneo. Infections in humans result in a spectrum of disease, including fatal outcomes. Spontaneous splenic rupture is a rare, but severe complication of malaria and has not been reported previously for knowlesi malaria. CASE PRESENTATION: A 46-year-old man presented with fever and acute surgical abdomen with concomitant P. knowlesi malaria infection at Kapit Hospital. He was in compensated shock upon arrival to the hospital. He had generalized abdominal tenderness, maximal at the epigastric region. Bedside focused abdominal ultrasonography revealed free fluid in the abdomen. He underwent emergency exploratory laparotomy in view of haemodynamic instability and worsening peritonism. Intraoperatively, haemoperitoneum and bleeding from the spleen was noted. Splenectomy was performed. Histopathological examination findings were suggestive of splenic rupture and presence of malarial pigment. Analysis of his blood sample by nested PCR assays confirmed P. knowlesi infection. The patient completed a course of anti-malarial treatment and recovered well post-operation. CONCLUSIONS: Spontaneous splenic rupture is a rare complication of malaria. This is the first reported case of splenic rupture in P. knowlesi malaria infection. Detection of such a complication requires high index of clinical suspicion and is extremely challenging in hospitals with limited resources.

A Randomized Controlled Trial of Novel Treatment for Hemorrhagic Radiation Proctitis.

BACKGROUND: Various methods have been used for treatment of hemorrhagic radiation proctitis (HRP) with variable results. Currently, the preferred treatment is formalin application or endoscopic therapy with argon plasma coagulation. Recently, a novel therapy with colonic water irrigation and oral antibiotics showed promising results and more effective compared to 4% formalin application for HRP. The study objective is to compare the effect of water irrigation and oral antibiotics versus 4% formalin application in improving per rectal bleeding due to HRP and related symptoms such as diarrhoea, tenesmus, stool frequency, stool urgency and endoscopic findings. METHODS: We conducted a study on 34 patients with HRP and randomly assigned the patients to two treatment arm groups (n=17). The formalin group underwent 4% formalin dab and another session 4 weeks later. The irrigation group self-administered daily rectal irrigation at home for 8 weeks and consumed oral metronidazole and ciprofloxacin during the first one week. We measured the patients' symptoms and endoscopic findings before and after total of 8 weeks of treatment in both groups. RESULTS: Our study showed that HRP patients had reduced per rectal bleeding (p = 0.003) in formalin group, whereas irrigation group showed reduced diarrhoea (p=0.018) and tenesmus (p=0.024) symptoms. The comparison between the two treatment arms showed that irrigation technique was better than formalin technique for tenesmus (p=0.043) symptom only. CONCLUSION: This novel treatment showed benefit in treating HRP. It could be a new treatment option which is safe and conveniently self-administered at home or used as a combination with other therapies to improve the treatment outcome for HRP.
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Successful resection of a giant thoracic myxoid liposarcoma.

Primary liposarcoma is an extremely rare disease. We report a case of giant thoracic myxoid liposarcoma that occupied the whole left hemithorax and was successfully resected. We discuss the surgical considerations and difficulties encountered, and how we overcome these challenges. This is the third largest thoracic myxoid liposarcoma resection reported, weighing 4 kg.

Periampullary Carcinoma with Penile Metastasis

Periampullary carcinoma metastases are usually located at regional nodes, adjacent organs, liver or lung. On the other hand, metastatic penile cancer is uncommon. Penile metastasis usually originates from pelvic region with prostate and bladder being the most frequent primary location. We present a very rare case of periampullary carcinoma with penile metastasis in a 49-year-old man. He initially presented with early ampullary type periampullary carcinoma and had pyloric preserving pancreatoduodenectomy and adjuvant chemotherapy. However, after six years of uneventful follow up, he presented with a penile lesion which was confirmed to be pancreatic metastasis. He was started on chemotherapy but passed away two months later. Ampullary carcinoma type of periampullary carcinoma usually presents early with favourable prognosis. However, tumour recurrence can present much later after definitive treatment and at a rare site such as penis with generally poor outcome.