Queen Elizabeth II Hospital

Lead toxicity (plumbumism) is a rare but clinically significant diagnosis in developed countries. It can manifest with a wide array of systemic and haematological symptoms. Due to its non-specific presentation and overlap with common conditions such as iron deficiency anaemia, diagnosis may be delayed without a high index of suspicion. We report a case of a 30-year-old previously healthy male patient who presented with generalised abdominal pain, jaundice, constipation, and lethargy. Laboratory investigations revealed a microcytic, hypochromic anaemia with indirect hyperbilirubinaemia and Coombs-negative haemolysis. Peripheral smear demonstrated basophilic stippling, prompting a lead level assessment, which returned markedly elevated (73.3 µg/dL). Upon further history, the patient disclosed recent ingestion of Indian Ayurvedic medicine, which was identified as the likely source of lead exposure. Chelation therapy was initiated with clinical improvement. This case highlights the importance of considering lead toxicity in the differential diagnosis of haemolytic anaemia, especially in patients using complementary or imported medicines. Peripheral smear findings, particularly basophilic stippling, can provide a vital clue. Early recognition and chelation therapy are essential to prevent long-term complications. Clinicians should maintain caution for lead poisoning in atypical anaemia presentations and take thorough exposure histories, including the use of traditional medicines.

Abstract Cardiac perforation is an uncommon but potentially fatal complication of pacemaker lead placement and pericardiocentesis. We report the case of a 61-year-old woman who sustained two distinct iatrogenic right ventricular perforations, the first following temporary endocavitary pacemaker (TPM) insertion and the second during rescue echocardiography-guided pericardiocentesis performed for cardiac tamponade after initially presented with symptomatic bradycardia secondary to complete heart block. Emergency surgery via median sternotomy revealed both perforations, which were repaired with pledgeted sutures. Her postoperative recovery was uneventful, and a permanent pacemaker was implanted prior to discharge. This case highlights the rare occurrence of sequential iatrogenic cardiac perforations in a single patient and underscores the importance of vigilance, timely recognition of pacing complications, and multidisciplinary management to prevent fatal outcomes.

Melioidosis is a potentially life-threatening infectious disease caused by the Gram-negative bacterium Burkholderia pseudomallei. Its clinical manifestations are highly diverse, including pneumonia, abscesses in internal organs, non-healing ulcers, bone and joint infections, and encephalomyelitis. Mycotic aneurysms, a rare but serious complication of melioidosis, arise as sequelae of bacteremia involving the arterial wall. Despite appropriate antimicrobial therapy and surgical intervention, the mortality rate associated with this complication remains significant. In this report, we present a case of a melioidosis-related mycotic aneurysm of the distal aorta, successfully managed with a combination of targeted antimicrobial therapy and surgical intervention. This case highlights the challenges in diagnosing and treating such a rare manifestation of melioidosis.

Abstract Cases of H5 highly pathogenic avian influenzas (HPAI) are on the rise. Although mammalian spillover events are rare, H5N1 viruses have an estimated mortality rate in humans of 60%. No human cases of H5 infection have been reported in Malaysian Borneo, but HPAI has circulated in poultry and migratory avian species transiting through the region. Recent deforestation in Malaysian Borneo may increase the proximity between humans and migratory birds. We hypothesise that higher rates of human-animal contact, caused by this habitat destruction, will increase the likelihood of potential zoonotic spillover events. In 2015, an environmentally stratified cross-sectional survey was conducted collecting geolocated questionnaire data in 10,100 individuals. A serological survey of these individuals reveals evidence of H5 neutralisation that persisted following depletion of seasonal H1/H3 binding antibodies from the plasma. The presence of these antibodies suggests that some individuals living near migratory sites may have been exposed to H5. There is a spatial and environmental overlap between individuals displaying high H5 binding and the distribution of migratory birds. We have developed a novel surveillance approach including both spatial and serological data to detect potential spillover events, highlighting the urgent need to study cross-species pathogen transmission in migratory zones.

Hoarseness is a symptom of Ortner’s syndrome, a rare disorder caused by mechanical left recurrent laryngeal nerve compression by enlarged cardiovascular structures. This is a case of Ortner’s syndrome in an elderly 74-year-old male with an aortic arch aneurysm presenting with hoarseness. We believe the aneurysm causes the left recurrent laryngeal nerve compression, resulting in unilateral vocal cord paralysis. We emphasise the significance of Ortner’s syndrome as hoarseness of voice, a significant differential diagnosis in an elderly patient despite the absence of cardiac symptoms.

Plasmodium knowlesi is the major cause of zoonotic malaria in Southeast Asia. Rapid and accurate diagnosis enables effective clinical management. A novel malaria diagnostic tool, Gazelle (Hemex Health, USA) detects haemozoin, a by-product of haem metabolism found in all Plasmodium infections. A pilot phase refined the Gazelle haemozoin identification algorithm, with the algorithm then tested against reference PCR in a larger cohort of patients with P. knowlesi mono-infections and febrile malaria-negative controls. Limit-of-detection analysis was conducted on a subset of P. knowlesi samples serially diluted with non-infected whole blood. The pilot phase of 40 P. knowlesi samples demonstrated 92.5% test sensitivity. P. knowlesi-infected patients (n = 203) and febrile controls (n = 44) were subsequently enrolled. Sensitivity and specificity of the Gazelle against reference PCR were 94.6% (95% CI 90.5–97.3%) and 100% (95% CI 92.0–100%) respectively. Positive and negative predictive values were 100% and 98.8%, respectively. In those tested before antimalarial treatment (n = 143), test sensitivity was 96.5% (95% CI 92.0–98.9%). Sensitivity for samples with ≤ 200 parasites/µL (n = 26) was 84.6% (95% CI 65.1–95.6%), with the lowest parasitaemia detected at 18/µL. Limit-of-detection (n = 20) was 33 parasites/µL (95% CI 16–65%). The Gazelle device has the potential for rapid, sensitive detection of P. knowlesi infections in endemic areas.

BackgroundSmall reference vessel diameters (RVDs) are a predictor of ischemic events after coronary stenting. Among patients at high bleeding risk (HBR) precluding long-term dual antiplatelet therapy (DAPT), those with small vessel disease (SVD) constitute an especially high-risk subgroup. Here, we evaluated the results of a durable-polymer, coronary zotarolimus-eluting stent (ZES) for the treatment of patients with SVD at HBR with 1-month DAPT.MethodsIn the prospective, multicenter Onyx ONE (One-Month DAPT) Clear study, 1506 patients at HBR treated with a ZES that discontinued DAPT at 30 days were included. The clinical outcomes of patients undergoing treatment of lesions with an RVD of ≤2.5 mm (SVD group, as determined by the angiographic core laboratory) were compared with patients without SVD. The primary end point was the composite of cardiac death or myocardial infarction between 1 and 12 months.ResultsSmall vessel diameter treatment was performed in 489 (32.5%) patients. Patients with SVD were more likely to be women, have undergone a previous percutaneous intervention, and have multivessel coronary artery disease than patients without SVD. There were no significant differences in lesion, device, or procedural success between the groups. The Kaplan-Meier rate estimate of the primary end point was 8.5% and 6.8% in patients with SVD and those without SVD, respectively (P = .425). No significant differences were found in any secondary end point. The Kaplan-Meier rate of stent thrombosis was 0.6% and 0.8% in patients with SVD and those without SVD, respectively (P = .50).ConclusionsAmong patients at HBR treated with a ZES and 1-month DAPT, those with SVD had favorable 12-month ischemic and bleeding outcomes, which were comparable with those of patients with larger caliber vessels.

BackgroundAlthough the burden of premature myocardial infarction (MI) is high in Malaysia, direct evidence on the determinants of MI in this multi-ethnic population remains sparse.ObjectiveThe Malaysian Acute Vascular Events Risk (MAVERIK) study is a retrospective case-control study established to investigate the genomic, lipid-related, and other determinants of acute MI in Malaysia. In this paper, we report the study protocol and early results.MethodsBy June 2019, we had enrolled approximately 2500 patients with their first MI and 2500 controls without cardiovascular disease, who were frequency-matched by age, sex, and ethnicity, from 17 hospitals in Malaysia. For each participant, serum and whole blood have been collected and stored. Clinical, demographic, and behavioral information has been obtained using a 200-item questionnaire.ResultsTobacco consumption, a history of diabetes, hypertension, markers of visceral adiposity, indicators of lower socioeconomic status, and a family history of coronary disease were more prevalent in cases than in controls. Adjusted (age and sex) logistic regression models for traditional risk factors indicated that current smoking (odds ratio [OR] 4.11, 95% CI 3.56-4.75; P<.001), previous smoking (OR 1.34, 95% CI 1.12-1.60; P=.001), a history of high blood pressure (OR 2.13, 95% CI 1.86-2.44; P<.001), a history of diabetes mellitus (OR 2.72, 95% CI 2.34-3.17; P<.001), a family history of coronary heart disease (OR 1.28, 95% CI 1.07-1.55; P=.009), and obesity (BMI >30 kg/m2; OR 1.19, 95% CI 1.05-1.34; P=.009) were associated with MI in age- and sex-adjusted models.ConclusionsThe MAVERIK study can serve as a useful platform to investigate genetic and other risk factors for MI in an understudied Southeast Asian population. It should help to hasten the discovery of disease-causing pathways and inform regionally appropriate strategies that optimize public health action.International Registered Report Identifier (IRRID)RR1-10.2196/31885