Sarawak Health Journal vol 7, 2020

50i
Table of Content Page
Key Note Address
Advancing Healthcare through Quality Research
Dr Jamilah Hashim
1
Hospital Clinical Research
Incidence and Outcome of Teenage Pregnancy Compared to Low-Risk Pregnancy in Kapit
Hospital, Sarawak
Hii King Ching, Hii Ling Yien
3-4
Second Victim Experience and Support Survey in Sarawak General Hospital
Alex Kim Ren Jye, Chin Zin Hing, Sharlyn Peter, Zubalqiah Binti Zulkifli, Priscilla
Bartholomew, Josephine Senok
5
Improving Bedside Dispensing Service Delivers through Pharmacist-coordinated Medication
Discharge Planning
Oh Ai Ling, Chong Wan Choon, Irene Chieng Yee Yew, Jaime Chan Yoke May, Tan Yi Ying
6
Effectiveness of Pharmacist Managed Diabetes Mellitus Therapy Adherence Clinic in Sibu
Hospital
Tie Ga Teck, Kelly Wong Wang Ling, Ong Yee Ching
7
Knowledge and Perception of Pharmacists in Sarawak General Hospital on Influenza
Vaccination
Kho Boon Phiaw, Doreen Chow Ru Ting, Adeline Ong Chek Kim, Johnny Chew Seng Wen,
Lau Yee Wei
8
Factors Influencing Sustainability of Lean Healthcare in Sarawak General Hospital
Alex Kim Ren Jye, Chin Zin Hing, Adeline Lau Koh Mei, Wong Ai Li, Kandong Jarop
9
The Practice of Intravenous to Oral Antibiotic Switch in Chest Infection at Sarawak General
Hospital
Irene Chieng Yee Yew, Chong Wan Choon, Kho Boon Phiaw, Oh Ai Ling, Andrew Gerald
Tan Hua Kiong
10
Review of Medication Adherence and Knowledge in Type 2 Diabetes Mellitus Patients in
Kanowit Hospital
Lo Chieng Ting, Ngo Swee San, Doris Ling Yew Hui, Ting Hie Kwang, Luke Elle Ak Nyanti
11
How Much Do They Know About Their Chronic Medications? A Cross-sectional Study
among Patients at the Outpatient Pharmacy Department, Sarawak General Hospital
Kho Boon Phiaw, Audrey Wong San Ying, Choong Yuan Chyi, Emelia Yeo Tze Yin, Dorina
Yong Li Fern
12

51
Public Health Observational Research
Endodontic Practices among General Dental Practitioners in Kuching, Sarawak
Kong Lik Lin
15
Community Perception and Practice of Malaria Control and Prevention in a Plasmodium
knowlesi Endemic Area: An Intervention Study in Julau District, Sarikei
Johny Anak Kelak, Emmanuel Joseph Fong
16
Sub-clinical Hyperthyroidism as a Major Complication of Universal Salt Iodisation among
Pregnant Women in Sarawak: Finding form Sarawak Iodine Deficiency Disorder Survey
2018
Lim Kuang Kuay, Tan Beng Chin, Nur Azna Mahmud, Chan Ying Ying, Tahir Aris
17
Relationship between Urinary Iodine Level and Thyroid Hormones in the First Trimester
Pregnant Women: Finding from Sarawak Iodine Deficiency Disorder Survey 2018
Lim Kuang Kuay, Tan Beng Chin, Nur Azna Mahmud, Chua Boon Kee, Chan Ying Ying
18
Case Report and Case Series
A Rare Case: C1-C2 Septic Arthritis
Dhineshkumar Chandarasegran, Denny Clare @ Charles Embun, Ismyth Bin Abdul Rahman,
Norzatulsyima Nasirudin
21
A Rare Localisation of Tuberculosis
Dhineshkumar Chandarasegran, Denny Clare @ Charles Embun, Ismyth Bin Abdul Rahman,
Norzatulsyima Nasirudin
22
A Rare Case of Patella Sleeve Fracture
Norhana Mohamed Ali, Denny Clare @ Charles Embun, Ismyth Abd Rahman, Thiru Kumara
A/L Mootha Kumaran, Norzatulsyima Nasirudin.
23-24
Bilateral Transient Loss of Vision as Presenting Feature of Posterior Reversible
Encephalopathy Syndrome in Post-Infectious Glomerulonephritis in Children
Hii King Ching, Chin Kar Ling, Kong Sing Ling, Johnny Goh Keh Tun, Lai Shen-Ly
25
Concurrent Aortic Arch Aneurysm and Pulmonary Artery Dilation as a Rare Cause of
Ortner Syndrome
Cheong Kang Wei, Isaac Tan Yieng Ler, Intan Zariza Hussain, Heng Pek Ser
26
Kounis Syndrome: When Atopy Affects the Heart
Choo Li Yong, Mohd Saifful Nizam Ismail
27-28
A Rare Case of Bilateral Foot Squamous Cell Carcinoma
Nur Shakinah Binti Ajak, Mohamad Norazrin Bin Mohd Abas, Denny Clare @ Charles A.
Embun, Norzatulsyima Binti Nasirudin
29
ii

52
Revealing the Truth in Masquerade: Stanford A Aortic Dissection
Loi Siew Ling, Neoh Shu Chin, Chan Hiang Chuan
30
The Deceit of Plasmodium knowlesi: Report of Four Plasmodium knowlesi Death in Kapit
Divisional Hospital
Chuang Jia Yun, Hii King Ching
31-32
Unusual Presentation of Varicella Bleeding Post Total Gastrectomy
Lim Kim Ying, Chea Chan Hooi
33
Sailing in the Rage of Samudra: A Case of Neck Trauma
Suresh Shanmugam, Loi Siew Ling, Lai Joon Thian
34
What Bit Me? Mysterious Bug or Worse?
Ng Li-Wei, Mohd Saifful Nizam Ismail, Nazirah Hamzah, Chan Swee Sing
35
Acute Pancreatitis, a Rare Complication of Leptospirosis
Liew Mun Thing, Danny Wong Ling Siong
36
A Rare Encounter of Congenital Buphthalmos and Corneal Clouding in a District Hospital
in Sarawak
Wei Honn Lim, Shin Wei Pan, Teck-Hock Toh
37-38
Malaysia’s First Case of Chronic Cerebral Melioidosis
Woo Xiang Ling, Goh Chin Hwee, Low Peh Hueh, Teck-Hock Toh
39-40
Worms in the Brain: A Case Report of Neurocysticercosis
Chia Bing En
41
Case Report of an Axillary Abscess Secondary to Strongyloides stercolaris Infection
Rosdi Pon, Ling Chieng Loo, Chieng Tiong How, Teck-Hock Toh
42
Multiple Intra-Axial Lesions with Hydrocephalus in a HIV-Positive Patient
Yiek Siew Hong
43-44
A Diagnostic Conundrum of Heat Stroke: Severe Rhabdomyolysis or Myocardial Infraction?
Chia Bing En
45-46
Case Series of Rambutan Seeds Phytobezoar
Rosdi Pon, Sharon Divya, Pui Wei Cheng, Chieng Tiong How
47
iii

1
Keynote Address
Advancing Healthcare through Quality Research
Dr Jamilah Hashim (Sarawak State Health Director)
As a doctor or allied health professionals, when we started the training in medical school or
allied health colleges, most of us, if not all have a dream. We all want to provide the best care to
help our patients, to get well faster, to feel better, if not to cure all diseases. Soon we realised that it
is not possible. We all know there are many things we do today in medicine isn’t ideal. We have far
too many patients whose recovery isn’t as expected, and some did not make it at all. Therefore, we
always fight to improve ourselves to deliver a better and hopefully, more efficient care to our patients.
Some of us do this by accumulating years of experience - trial and errors. But that is at best,
the lowest level of evidence-based practice, and it takes too long and too many mistakes. A better
way is by doing research - in a controlled manner. We observe what has been done in our daily
practices systematically, we conduct clinical trials, and we write up rare cases. All these constitute
research.
The theme for the Sarawak State Health Research Day 2019 is “Advancing Healthcare through
Quality Research”. But what is good quality research? Good quality research requires sound research
design resulting in a meaningful research outcome. It is research providing evidence that is robust,
ethical, stands up to scrutiny and can be used to inform policymaker. Rolfe Leary, a research scientist
from the USA, published a paper with the title of “Some Characteristics of High-Quality Scientific
Research” in 1985. I want to share some of the things that he said:
The following characteristics may help to identify quality research…. scholarship, citation
analysis, society needs, answers or questions, degree of quantification, creativity or originality,
scientific method, productivity, closure, the maturity of science and paradigm. Characteristics are
summarised according to the source of the criterion and the time perspective in which the research
is viewed. Each combination of the summaries has an arbiter of quality. Thus, there is no single
criterion.
In the short term, methodology, closure and citation frequency may be appropriate measures
for research quality. Whereas, in the long run, support for the paradigm and contribution to the
maturing of science seem necessary standards of research quality. Regardless of the type of research
that one does, make sure they have all these good research qualities. These can translate to a better
healthcare system and eventually result in policy change one day.
Many examples have taken place in Sarawak, which has many clinical researchers that have
been active over the years. Despite their busy schedules serving in busy government hospitals, they
have been productive. Their discovery in medicine has led to advancing healthcare. Take the studies
of Japanese encephalitis and hand, foot and mouth disease. More than ten years ago, these were
scary diseases. Clinicians have managed to learn so much about these diseases and implement
effective public health programs such as a vaccine, and management protocol to tackle these
dreadful diseases. Clinicians in Sarawak General Hospital have been productive in their research.
They have many publications in the field of cardiology, oncology, and many more. Of course,
Industrial Sponsored Researches (ISRs) are also important. Furthermore, with support from Clinical
Research Malaysia, the three Clinical Research Centres (CRC) in Sarawak are leading many ISRs
in our country. The fourth CRC will be soon established in Bintulu.
Medicine is a dynamic field. It will not stop on the day one graduate from MBBS or become
a specialist. Neither does other healthcare workers should stop learning the day they graduate from
their diploma or degree. We want clinicians, and healthcare professionals not only graduate with
skills and knowledge but to continue to improve. Let’s advance healthcare together through quality
research.

3
Incidence and Outcome of Teenage Pregnancy Compared to Low-Risk
Pregnancy in Kapit Hospital, Sarawak
Hii King Ching1
, Hii Ling Yien2
1
Department of Paediatrics, Kapit Hospital, Kapit, Sarawak; 2
Department of Obstetrics & Gynaecology,
Sabah Women & Children Hospital, Kota Kinabalu, Sabah
Corresponding Author: Dr Hii King Ching (drhiikc@gmail.com)
Introduction: Sarawak recorded 4,131 teenage pregnancies in 2012 contributing 22% of the total
number in Malaysia. There are no published statistics about teenage pregnancy in Kapit.
Objective: This study aims to determine the incidence of teenage pregnancy and its outcomes
between teenage pregnancy and low-risk pregnancy in Kapit Hospital.
Methods: A cross-sectional study between 2013 and 2015 was conducted. Incidence and outcome
of teenage pregnancy less than 19 years old and pregnant women aged between 20 and 25 years old
were compared. Data were collected from the labour room registry, Sarawak Online Obstetrics
Registry [Informatik Kelahiran Sarawak (IKS)], Medical Social Worker and medical records.
Results: A total of 2,028 records of deliveries were reviewed, with 526 teenage mothers and 695
mothers between 20 and 25 years old were included. The incidence of teenage pregnancy declined
from 27.0% in 2013 to 20.8% in 2015. The mean age was 17.4 years old (SD±1.41). The youngest
was 12 years old. Eighty-eight (19.6%) teenage mothers conceived more than once prior to the
current pregnancy. Iban race, unemployment and unmarried status were identified demographic
factors associated with teenage pregnancy. Non-primigravida was 103 cases (19.5%). Eight patients
had no formal education (4.2%), with primary school 25 patients (12.6%) and secondary school 159
patients (83.2%). Postnatal-outcome associated with third- and fourth-degree tear (OR=0.3, 95% CI:
0.2, 0.4) and a higher rate of episiotomy (OR=5.2, 95% CI: 4.0, 6.9) occurred in the teenage group.
Neonatal outcome associated with preterm delivery (OR=1.6, 95% CI: 1.1, 2.3), low birth weight
(OR=1.7, 95% CI: 1.2, 2.3) but not associated with low Apgar score occurred among the teenage
group. Only one teenage mother had no antenatal check-up. No case of an abandoned baby was
reported during the study period. Two teenage mothers wished for child adoption.
Discussion: This is a hospital-based study and not generalisable to whole Sarawak. A multi-agency
approach is necessary to create awareness to reduce teenage pregnancy. We implemented birth
control with the subcutaneous contraceptive implant after the first pregnancy. We carried out
educational radio talk, sexual health talk and “No Apologies” program in secondary school and
“DREAM” project (self-designed) for primary school. Further analysis showed a steady reduction
of teenage pregnancy rate from 2016 to 2018 as in Figure 1. Study limitation includes missing data.
Conclusion: Kapit Hospital has a high incidence of teenage deliveries with a few contributing
factors. Teenage pregnancy leads to maternal and neonatal adverse outcome. The declining trend
was observed over the past six years, with all the measures and efforts.
NMMR ID: 18-2739-44004

4
Table1. Comparison between the teenage and low-risk group, according to pregnancy outcome
Variable
Age group
12 - 19 y/o
Frequency (%)
Age group
20 - 25 y/o
Frequency (%)
OR
(95% CI)
p value
N n=526 n=695
Period of gestation during delivery
36 weeks or less 114 61 (13.0) 53 (8.7) 1.6
(1.1, 2.3)
0.023
37 weeks or more 962 407 (87.0) 555 (91.3)
Mode of delivery
Vaginal 1136 487 (92.6) 649 (93.4) 0.9
(0.5, 1.4)
0.768
Caesarean 85 39 (7.4) 46 (6.6)
Type of vaginal delivery
Spontaneous 1127 485 (99.4) 642 (99.1) 1.5
(0.4, 6.0)
0.558
Assisted 9 3 (0.6) 6 (0.9)
Indication for caesarean delivery
Foetal distress 41 21 (75.0) 20 (60.6) 2.0
(0.6, 5.9)
0.233
Dysfunction labour 20 7 (25.0) 13 (39.4)
Degree of perineal injury
No tear 109 19 (3.9) 90 (14.2)
0.3
(0.2, 0.4)
0.0001st and 2nd degree tear 1006 461 (95.6) 545 (85.8)
3rd and 4th degree tear 2 2 (0.4) 0 (0.0)
Mechanism of perineal tear
Episiotomy 650 382 (79.3) 268 (42.2) 5.2
(4.0, 6.9)
<0.001
Spontaneous / no tear 467 100 (20.7) 367 (57.8)
Apgar of newborn
6 or less than 6 14 8 (1.5) 6 (0.9) 1.8
(0.6, 5.1)
0.287
7 or more than 7 1207 518 (98.5) 689 (99.1)
Birth weight of newborn
< 2500g 196 106 (20.2) 90 (12.9) 1.7
(1.2, 2.3)
0.001
≥ 2500g 1025 420 (79.8) 605 (87.1)
Birth weight of newborn delivered >37 weeks
< 2500g 103 56 (13.8) 47 (8.5) 1.7
(1.1, 2.6)
0.009
≥ 2500g 859 351 (86.2) 508 (91.5)
Estimated blood loss during delivery
< 500ml 1161 497 (98.4) 664 (98.5) 0.9
(0.4, 2.4)
0.889
≥ 500ml 18 8 (1.6) 10 (1.5)
Fig. 1: Number and percentage of delivery according to age between 2013 and 2018 in Kapit Hospital

5
Second Victim Experience and Support Survey in Sarawak General Hospital
Alex Kim Ren Jye1
, Chin Zin Hing2
, Sharlyn Peter1
, Zubalqiah Binti Zulkifli1
, Priscilla
Bartholomew1
, Josephine Senok1
1
Quality & Patient Safety Unit; 2
Director Office; Sarawak General Hospital, Kuching, Sarawak
Corresponding author: Alex Kim Ren Jye (alexkimsgh@gmail.com)
Introduction: Second victim experience relates to healthcare providers’ response to an
unanticipated adverse patient event, a medical error, or a patient-related injury.1
The provider
becomes a victim in the sense that the provider is traumatised by the event. However, the level of
experience in a healthcare provider is not widely considered nor discussed when a medical error
occurs.
Objectives: To study the experience of “second victim” phenomenon among doctors and nurses in
Sarawak General Hospital (SGH) and their desirability for support following medical error. We
assessed how doctors and nurses cope with being involved in medical errors; and how the doctor
and nurses desire for support from their superiors and colleagues in response to medical error.
Methods: The Second Victim Experience and Support Tool (SVEST) was used to assess the quality
of the support received and the desirability of other support options.2
The questionnaire mostly uses
the 5-point Likert scale. Random sampling was used to survey doctors and nurses in SGH. The
calculated sample size for the survey was 550, conducted from August to October 2018.
Result: A total of 508 respondents completed the questionnaire (response rate was 92.3%).
Respondents involved in Patient Safety Incidents (PSI) within the last six months was 31.9% and
throughout their career was 43.1%. There was an association between position and PSI whereby
more doctors involved in PSI compared to nurses (p=0.003). The second victim manifested a
spectrum of symptoms from mild to severe and its durations varied (Fig. 1, refer to page 6).
Flashbacks, fear and stress tended to persist longer compared to other symptoms. Following PSI,
respondents tended to seek support from family and friends. For those who have been negatively
affected by their involvement in an adverse PSI, about 44.7% desired for support from the hospital.
Discussion: This survey provided a deeper understanding of the second victim phenomenon in SGH.
Furthermore, it supplied the respondents with educational information and resources on second
victim phenomenon. These results serve to inform health managers and leaders on the second victim-
related harm and recommends programs to address it. Furthermore, by assessing the quality of
support resources, SVEST can help pinpoint areas for improvement within the organisation.
Conclusion: Second victim experience following PSI in SGH was a significant cause of distress to
healthcare professionals and supports within the hospital could be further improved.
NMRR ID: 18-1953-43147
References:
1. Bryant SL. Quality improvement initiative: Supporting the Second Victim. 2018
2. Burlison JD, Scott SD, Browne EK, et al. The Second Victim Experience and Support Tool:
Validation of an organizational resource for assessing second victim effects and the quality. J Patient
Safety. 2017 Jun; 13(2): 93-102.

6
Improving Bedside Dispensing Service Delivery through Pharmacist-
Coordinated Medication Discharge Planning
Oh Ai Ling, Chong Wan Choon, Irene Chieng Yee Yew, Jaime Chan Yoke May, Tan Ji Ying
Department of Pharmacy, Sarawak General Hospital, Kuching, Sarawak, Malaysia
Corresponding author: Oh Ai Ling (ohailing79@yahoo.com)
Introduction: Ward pharmacists can expedite discharge process through medication discharge
planning, an intervention that reduces the time for producing discharge prescriptions and improves
the delivery of bedside dispensing service (BEDISC). BEDISC activities encompass prescription
screening, medication reconciliation, bedside dispensing and counselling.
Objectives: To assess the impact of pharmacist-coordinated medication discharge planning on the
delivery of BEDISC activities, and to characterise medication errors and cost savings.
Methods: A three-phase, prospective 9-month interventional study was conducted at the general
medical wards of Sarawak General Hospital. During the intervention phase, medication discharge
planning was implemented by encouraging doctors to produce discharge prescriptions once a
discharge decision has been made and by reminding discharge nurses to hand the prescriptions to
ward pharmacists. The total numbers of discharge prescriptions, prescriptions with bedside
dispensing and medication errors were recorded at pre-intervention (usual routine without active
reminders) and post-intervention (with active reminders). Cost savings by reusing patients’ own
medicines (POMs) were also calculated. Descriptive statistics were used to analyse the data.
Results: The rate of bedside dispensing increased by 9.8% post-intervention (41.6% vs 31.8%), with
a 7.3% increase in detection of prescriptions with medication errors by ward pharmacists (12.9% vs
5.6%). Inappropriate drug (41.3%) was the most common medication error identified, followed by
inappropriate dose (13.6%). The use of POMs had resulted in an overall cost saving of RM13,884.64
during the study period, mainly contributed by reusing respiratory medications (40.2%).
Conclusion: Medication discharge planning has increased the delivery of bedside dispensing service,
which consequently enhanced patient safety and reduced medication costs.
NMRR ID: 18-3303-45025
For the following figure, please refer to the main text on page 5, entitled Second Victim Experience
and Support Survey in Sarawak General Hospital, by Alex Kim Ren Jye et al.
Fig. 1: Factors influencing the sustainability of Lean Healthcare in Sarawak General Hospital

7
Effectiveness of Pharmacist Managed Diabetes Mellitus Therapy Adherence
Clinic in Sibu Hospital
Tie Ga Teck, Kelly Wong Wang Ling, Ong Yee Ching
Out-patient Pharmacy, Hospital Sibu, Sibu, Sarawak
Corresponding author: Tie Ga Teck (wilsontie@yahoo.com)
Introduction: The increasing prevalence of diabetes mellitus (DM) in Malaysia is a major concern
to society due to its macro and microvascular complications as well as increasing premature
mortalities. In the pharmacist-led Diabetes Mellitus Therapy Adherence Clinic (DMTAC)
programme, pharmacists play a vital role in providing optimum diabetic care.
Objective: This study aimed to evaluate the effectiveness of the pharmacist-led DMTAC in
improving glycaemic control in Sibu Hospital, as reflected on the reduction of glycated haemoglobin
(HbA1c) level and lipid profile. The primary objective of the present study was the mean difference
of pre- and post-intervention level of HbA1c. The secondary objective measured the mean difference
of pre- and post-intervention lipid parameters including triglyceride (TG), low-density lipoprotein
(LDL), high density-lipoprotein (HDL) and total cholesterol (TC).
Methodology: This is a retrospective study of the effectiveness of DMTAC programme in Sibu
Hospital. We included all patients who were enrolled in DMTAC from 1st
January 2016 to 31st
December 2018 with type 2 diabetes, aged 18 and above with HbA1c more than 8% and had
completed at least four visits of DMTAC clinic. Patients with type 1 DM, end-stage renal failure,
gestational diabetes, lost to follow-up, and those with mental illness were excluded from the study.
Results: Throughout the study period, 118 patients who met inclusion criteria were selected for the
study. A mean reduction of 1.14% in HbA1c from 10.22 (SD=2.621) to 9.08 (2.323) post completion
of fourth DMTAC visit was observed with p<0.001, indicating a statistically significant difference.
HbA1c reduction of 1.0% and above was seen in 55 (46.6%) patients. In addition, mean reduction
was observed in TC and triglyceride (TG) level post completion of four DMTAC visits. The mean
level of TC was reduced by 0.22 while TG level was reduced by 0.16. A slight increase in LDL and
decrease in HDL were observed in the current study, but they were not statistically significant.
Conclusion: Pharmacist-managed DMTAC significantly improved HbA1c levels in patients with
DM. The result of this study supports the effectiveness of DMTAC programme in managing DM
patient.
NMRR ID: 18-721-41171
References:
1. Ministry of Health Malaysia. National Diabetes Registry. Putrajaya: Ministry of Health Malaysia;
2013; 5-10.
2. Lim PC, Lim K. Evaluation of a pharmacist-managed diabetes medication therapy adherence clinic.
Pharm Prac (Granada). 2010 Oct; 8(4): 250-4.
3. Ministry of Health Malaysia. Protocol Medication Therapy Adherence Clinic: Diabetes Second
Edition 2014. Putrajaya; 2014; 1-28.

8
Knowledge and Perception of Pharmacists in Sarawak General Hospital on
Influenza Vaccination
Kho Boon Phiaw, Doreen Chow Ru Ying, Adeline Ong Chek Kim, Johnny Chew Seng Wen, Lau
Yee Wei
Pharmacy Department, Hospital Umum Sarawak, Kuching, Sarawak
Corresponding author: Kho Boon Phiaw (khoboonphiaw@gmail.com)
Introduction: Healthcare settings are an ideal environment for the rapid spread of influenza, and
vaccination is recommended for healthcare workers not just to protect themselves but also to reduce
transmission to patients and family members.
Objective: To evaluate the rate of influenza vaccination among pharmacists working in Sarawak
General Hospital (SGH), as well as their knowledge and perceptions toward the vaccination.
Methods: A self-administered questionnaire was distributed to all pharmacists working in SGH
early October 2018. Data collected include their demographic profile, influenza vaccination status,
knowledge and rationale for vaccinating or not vaccinating. Responses were collected back by hand
and analysed using SPSS.
Results and Discussion: Seventy-eight responses were received (response rate: 53.4%). There was
no significant differences in the sociodemographic characteristics between responders and non-
responders. Only five respondents (6.4%) had updated vaccination; and a further 19.2% were
previously vaccinated. Respondents’ knowledge of certain aspects of influenza vaccination was not
optimal. The majority were unaware or unsure about the incubation period of influenza infection
(91.0%), whether having a fever is an absolute contraindication for vaccination (87.2%) and whether
vaccination will be effective for everyone (57.7%). Main reasons for not vaccinating included
vaccination is expensive (54.8%), not compulsory (45.2%) and may not be effective (41.1%).
Findings suggested that the most effective approach to improving influenza vaccination rate among
pharmacists was to provide free vaccination, or at least make it compulsory; 93.1% and 47.9% of
unvaccinated respondents agree to vaccinate under these provisions respectively. Pharmacists’
demographic background has no significant influence on any variables.
Conclusion: Influenza vaccination rate among pharmacists in SGH was low. Providing free
vaccination will be the most effective policy to improve the vaccination rate.
NMRR ID: 18-1551-42190
With Complement
from
Syarikat Perniagaan Miscell Sdn. Bhd.
1st Floor, Lot 3250, Sublot 37, Block 12, MTLD,
TT3 Commercial Centre, Jalan Canna,
93350 Kuching, Sarawak
Email: sales@miscell.com

9
Factors Influencing Sustainability of Lean Healthcare in Sarawak General
Hospital
Alex Kim Ren Jye1
, Chin Zin Hing2
, Adeline Lau Koh Mei3
, Wong Ai Li4
, Kandong Jarop4
1
Quality & Patient Safety Unit; 2
Director Office; 3
Radiotherapy & Oncology Department; 4
Medical
Department; Sarawak General Hospital, Kuching, Sarawak
Corresponding Author: Alex Kim Ren Jye (alexkimsgh@gmail.com)
Introduction: Lean Healthcare initiative was first implemented in Sarawak General Hospital (SGH)
in April 2015 at the Emergency & Trauma Department (ETD) and Medical Department. The aim
was to reduce waste and streamline work processes. Several Kaizen was successfully implemented
to reduce waiting time for doctor consultation in ETD and reduce waiting time for discharge in the
Medical Department. This initiative was then expanded to Radiotherapy & Oncology Department
in April 2017, to reduce waiting time for doctor consultation at the outpatient clinic.
Objective: To identify the factors influencing the sustainability of Lean Healthcare initiative in SGH.
Methods: This is a cross-sectional study conducted from January to March of 2019. The Long Term
Success Tool (LTST) Questionnaire was used to measure the 12 sustainability factors for projects
implemented by the organisation.1
This study used universal sampling and involved 174 subjects
who were in the Lean Healthcare initiative for at least six months, within their respective
departments.
Result: Two main factors influencing the sustainability of Lean Healthcare in SGH were leadership
and commitment to the improvement. Generally, Radiotherapy & Oncology Department has
achieved more favourable rating followed by ETD and Medical Department. Respondents perceived
the resources were inadequate to support the sustainability of the initiatives, aligned with the
challenging political and financial environment. Involvement of stakeholders, including patients and
members of the public, could be improved to obtain regular feedback into this initiative. The
majority of the respondents understood what Lean Healthcare was trying to achieve and believe their
work would lead to improvement.
Discussion: This study found the involvement of strong leaders as an important factor in advocating
for the improvement, communicating the vision and effectively managing the process. This
sustainability research was crucial for the hospital administrator to suggest ways to promote and
facilitate long-term sustainability and ensure investments leading to longer-term beneficial
outcomes.2
Conclusion: Strong leadership and commitment to improvement are important factors influencing
the sustainability of Lean Healthcare in SGH.
NMRR ID: 18-2878-44414
References:
1. Lennox L, Doyle C, Reed JE, et al. What makes a sustainability tool valuable, practical and useful in
real-world healthcare practice? A mixed-methods study on the development of the Long-Term
Success Tool in Northwest London. BMJ Open. 2017; 7: e014417.
2. Scheirer MA, Dearing JW. An agenda for research on the sustainability of public health programs.
Am J Public Health. 2011 November; 101(11): 2059-67.

10
The Practice of Intravenous to Oral Antibiotic Switch for Chest Infection at
Sarawak General Hospital
Irene Chieng Yee Yew, Chong Wan Choon, Kho Boon Phiaw, Oh Ai Ling, Andrew Gerald Tan Hua
Kiong (Pharmacy Department, Sarawak General Hospital, Kuching, Sarawak)
Corresponding author: Irene Chieng Yee Yew (irenechieng86@gmail.com)
Introduction: Early intravenous to oral antibiotic switch (IVOS) is advocated as it results in better
patient outcomes and reduced treatment cost.
Objectives: To assess the practice of IVOS in medical wards of Sarawak General Hospital (SGH)
for patients diagnosed with chest infection, by evaluating its clinical outcome, economic impact and
reasons for delayed IVOS.
Methods: Patients diagnosed with chest infection started on intravenous antibiotics for over 24
hours were recruited over four months. Patients were grouped into timely or delayed switched based
on the COMS (Clinical, Oral route, Markers, Specific indication) criteria. Length of hospital stay,
hospital readmission or restarting intravenous antibiotics within 30 days, the extra cost incurred and
reasons for the delayed switch were outcomes analysed.
Results: Of the 80 patients recruited, 58 (72.5%) had their intravenous (IV) antibiotics timely
switched upon fulfilment of COMS criteria. Mean duration of IV antibiotics in a timely and delayed
switched group was 3.6 days (SD=1.45) and 5.7 days (SD=1.73) respectively (p<0.001). The median
length of stay was longer but not significantly different in delayed switch group (8 days, IQR=7.5
versus 7.0 days, IQR=3; p=0.056). No difference in hospital readmission or restarting intravenous
antibiotics rate was identified. The additional cost of RM529.46 was incurred by the delayed
switched group. Nine (40.9%) of the delayed switch was due to unavailability of culture and
sensitivity results. Timely availability of these culture results is likely to improve IVOS.
Conclusion: The current practice of IVOS in SGH is encouraging. Nonetheless, it can be further
improved to reduce IV antibiotic duration and treatment cost without jeopardising patient outcomes.
NMRR ID: 17-1851-36873
For the following figure, please refer to the main text on page 9, entitled Second Victim Experience
and Support Survey in Sarawak General Hospital, by Alex Kim Ren Jye et al.
Fig. 1: Symptoms and duration after patient’s safety incidence

11
Review of Medication Adherence and Knowledge in Type 2 Diabetes Mellitus
Patients in Kanowit Hospital
Lo Chieng Ting, Ngo Swee San, Doris Ling Yew Hui, Ting Hie Kwang, Luke Elle Anak Nyanti
1
Pharmacy Department, Kanowit Hospital, Kanowit, Sarawak, Malaysia
Corresponding author: Lo Chieng Ting (jennloct@gmail.com)
Introduction: Diabetes mellitus is a major public health concern in Malaysia and is a major
contributing factor towards increased mortality and morbidity of patients. Studies were done on
knowledge and medication adherence among diabetes patients in West Malaysia, but there is yet
any similar study among patients with diabetes in Kanowit Hospital.
Objectives: This study aims to assess adherence to medication, medication knowledge, and factors
affecting glycaemic control and non-adherence among type 2 diabetes patients in Kanowit Hospital.
Methods: A cross-sectional study was conducted in outpatient pharmacy at Kanowit Hospital using
a validated questionnaire with three main components: demographic variables, medication
knowledge (DIFT score) and medication adherence assessment (Malaysian Medication Adherence
Scale (MALMAS). Chi-square test was used to test the correlation between the studied variables.
Results: A total of 145 patients participated in the study. The mean age was 59.0 (SD=10.50) years
old. They were mainly female (64.1%), Iban (84.8%), overweight (35.9%), had primary education
(39.3%), and comorbidity of hypertension (93.8%). Approximately half (53.8%) of the participants
had normal fasting blood glucose during the interview, and 96.5% of patients had a recent mean
HbA1c level of 7.8% (SD=0.16). A total of 99 (68.3%) participants demonstrated adherent to
medications, while 76.5% of them had a medication knowledge score ranging 91 to 100%. Areas of
knowledge that gave wrong response were mainly the time of administration (37.2%), followed by
its indication (17.9%), dose (15.3%) and frequency (13.1%). This study found patients with higher
knowledge score were associated with better glycaemic control (p=0.026). However, there was no
significant association between medication adherence and glycaemic control (p=0.093), knowledge
of medication (p=0.176) and fasting blood glucose level (p=0.292).
Conclusion: Despite good knowledge of patients in Kanowit Hospital, their adherence to
medications was low. Further study is needed to understand factors affecting medication non-
adherence.
NMMR ID: 17-841-35518
References:
1. Chua SS, Lai PSM, Tan CH, et al. The development and validation of the Malaysia Medication
Adherence Scale (MALMAS) on patients with type 2 diabetes in Malaysia. Int J of Pharm Pharm
Sci. 2013; 5(3): 790-4.
2. Protocol Medication Therapy Adherence Clinic: Diabetes. 2nd
edition 2014. Pharmaceutical Services
Division. Ministry of Health, Malaysia.
3. Ahmad NS, Ramli A, Islahudin F, et al. Medication adherence in patients with type 2 diabetes mellitus
treated at primary health clinics in Malaysia. Patient Prefer Adherence. 2013 Jun 17; 7: 525-30.

12
How Much Do They Know About Their Chronic Medications? A Cross-sectional
Study Among Patients at the Outpatient Pharmacy Department, Sarawak
General Hospital
Kho Boon Phiaw, Audrey Wong San Ying, Choon Yuan Chyi, Emelia Yeo Tze Yin, Dorina
Yong Li Fern
Pharmacy Department, Hospital Umum Sarawak, Kuching, Sarawak
Corresponding author: Kho Boon Phiaw (khoboonphiaw@gmail.com)
Introduction: Studies have shown that many patients with chronic diseases have poor knowledge
about their medications, which can be influenced by their socio-demographic background and
quality of interaction with healthcare professionals.
Objective(s): To assess whether patients having their medications for chronic diseases dispensed in
the Outpatient Department (OPD), Sarawak General Hospital (SGH) have sufficient knowledge
about their medications, and determine the variables affecting their knowledge level.
Methods: This is a cross-sectional survey carried out at the OPD, SGH, using convenience sampling
to recruit patients on two or more chronic medications. Respondents filled a self-administered
questionnaire on their demographic background and quality of interaction with pharmacists before
investigators assessed their medication knowledge. Collected data were analysed using SPSS.
Results and Discussion: A total of 199 patients were surveyed. The majority were females (60.8%),
Chinese (42.7%), completed tertiary education (48.2%) and on a median of three medications. Most
(78.4%) knew the intake instructions of their medications, but only 28.1% knew the generic names;
higher educated patients have a better knowledge of both (p<0.01). Patients who self-declared higher
confidence in their knowledge recalled generic names better (p=0.04). Patients perceiving a good
quality of interaction with pharmacists recalled intake instructions of their medications better
(p=0.03). Study findings can be used to identify better patients requiring attention and prioritise
information to be delivered while dispensing, especially during periods of high patient load.
Conclusion: Certain demographic variables and quality of interaction with pharmacists affect
patient’s knowledge of their medications. More efforts are needed to educate patients on generic
names of their medications.
NMRR ID: NMRR-18-1692-42449

14
Public Health and
Community Research

15
Endodontic Practices among General Dental Practitioners in Kuching, Sarawak
Kong Lik Lin
Unit Pakar Pergigian Restoratif, Klinik Pergigian Petra Jaya, Kuching, Sarawak
Corresponding author: Dr Kong Lik Lin (lik_lin@yahoo.com)
Introduction: Endodontic therapy allows retention of natural teeth with irreversibly-damaged pulp;
wherein the alternative would be extraction and replacement with artificial prostheses. The majority
of endodontic procedures in Malaysia are performed by general dental practitioners (GDP). Baseline
surveys on endodontic practices of GDP abound all over the world; however, similar studies on the
Malaysian GDP population are scarce to non-existent. The latter is growing in number drastically
and is increasingly heterogeneous in training background. Professional bodies such as the European
Society of Endodontology and the American Association of Endodontists have clinical guidelines
that represent current good practice in endodontics. Still, little is known as to the compliance by the
local GDP. The rate of uptake of new technology in endodontics also remains to be investigated. In
a bid towards a better standard of patient care, it is essential to examine the current practice ofGDP
and to promulgate evidence-based approach to endodontic treatment that best addresses the patients’
interest.
Objectives: This study aims to gather qualitative and quantitative information on the nature of non-
surgical endodontic treatment carried out by GDP in Kuching, Sarawak.
Methods: A cross-sectional postal survey (self-administered questionnaire) was conducted on all
registered government and private GDP in Kuching.
Results: The overall response rate was 78.6% (95% government; 50% private). Among those who
responded, 20.7% of respondents did not take pre-operative radiographs routinely, and only 5.7%
routinely used rubber dam. Only 64% of respondents reported using sodium hypochlorite irrigant,
which is recommended for its disinfectant and organic debris-dissolving properties. Nearly half
(47%) of those who indicated not using rubber dam routinely used sodium hypochlorite as irrigant
(potential hazard). Routine use of lubricating / chelating agents also low (28%), although its use is
necessary to remove smear layer deposited by mechanical instrumentation. Open drainage was
practised by a quarter of the respondents. Some GDP reportedly used formaldehyde-releasing
dressing and sealer, e.g. formocresol (6%) and AH Plus (21%). The most popular obturation method
was cold lateral condensation (64.4%), with a trend towards a warm method. There was a significant
association between private practice and the use of digital radiography, rotary instrumentation and
adjunctive irrigation devices (p<0.05). Private practitioners were more likely to carry out molar
endodontics and retreatment procedures. They also appeared to be largely satisfied with current
endodontic techniques compared to the government practitioners (p<0.05).
Conclusion: The findings suggested that most GDP did not adhere to established quality guidelines
on endodontics. The level of uptake of modern endodontic technology was higher amongst private
practitioners; which were also more confident with their endodontic techniques comparatively.
NMRR ID: 13-1793-18254
References:
1. Chan AWK, Low DC, Cheung GSP, et al. A questionnaire survey of endodontic practice profile among
dentists in Hong Kong. Hong Kong Dent J. 2006; 3: 80-7.
2. Savani GM, Sabbah W, Sedgley CM, et al. Current trends in endodontic treatment by general dental
practitioners: report of a United States national survey. J Endod. 2014 May 1; 40(5): 618-24.

16
Community Perception and Practice of Malaria Control and Prevention in a
Plasmodium knowlesi Endemic Area: An Intervention Study in Julau District,
Sarikei
Johny Anak Kelak, Emmanuel Joseph Fong
Sarikei Divisional Health Office, Sarawak State Health Department, Sarikei, Sarawak
Corresponding Author: Dr Johny Anak Kelak (johnykelak@gmail.com)
Introduction: Plasmodium knowlesi malaria is a concern in Sarawak and enhancing the awareness
and knowledge on malaria via social mobilisation by communities is imperative.
Objective: This study aims to assess the effectiveness of malaria education intervention on the
knowledge, attitude and practice of malaria control and prevention among the community in Julau
District, Sarikei.
Methodology: This was a controlled intervention study in which two villages with 38 households
each were randomly assigned to either an educational or control group after collecting baseline data
using a structured questionnaire. The educational group received malaria educational activities
based on an adopted module, while the control group received only routine malaria control activities
for a similar duration. Follow-up data were collected at six weeks post-intervention using the same
questionnaire. Data were entered and analysed using SPSS version 20. A generalised linear mixed
model analysis was used to determine the between-group and within-group effects of the
intervention.
Results: The intervention was significant (p<0.001) in achieving a 10.03%, 8.74% and 6.29%
higher total knowledge, attitude and practice scores respectively for the educational group over the
control group.
Conclusion: The malaria educational intervention was effective in improving the knowledge,
attitude and practice on malaria prevention and control. Hence, we recommend this study module
be adopted and incorporated into routine malaria control activities. In view of relatively short
duration for absolute effects of the intervention, an impact evaluation and assessment after at least
one year is needed.
NMRR ID: 19-1354-48317

17
Sub-Clinical Hyperthyroidism as a Major Complication of Universal Salt
Iodisation among Pregnant Women in Sarawak: Finding from Sarawak Iodine
Deficiency Disorder Survey 2018
Lim Kuang Kuay1
, Tan Beng Chin2
, Nur Azna Mahmud1
, Chan Ying Ying1
, Tahir Aris1
1
Institute for Public Health, Ministry of Health, Setia Alam, Selangor, Malaysia; 2
Sarawak State Health
Department, Ministry of Health, Kuching, Sarawak, Malaysia.
Corresponding Author: Lim Kuang Kuay (limkk@moh.gov.my)
Introduction: Iodine is an essential element in the synthesis of thyroid hormones. The lack of iodine
in human may lead to a broad spectrum of adverse health effects collectively term as iodine
deficiency disorder (IDD).
Objective: The study aimed to assess the current status of IDD among pregnant women in Sarawak
after the introduction of the universal salt iodisation (USI) programme for ten years.
Methods: This is a cross-sectional study involving a total of 750 first trimester pregnant women
attending 30 governments Maternal and Child Health Care (MCHC) Clinics in all 12 divisions in
Sarawak from 1st
July to 30th
September 2018 were invited to participate. Urine iodine excretions
(UIE), serum thyroid-stimulating hormone (TSH), free thyroxine (fT4) and free triiodothyronine
(fT3) were analysed. Iodine status of the PW was adequate if the median UIE was within the range
of 150-249 µg/L. The normal reference ranges for assessing thyroid dysfunction were: TSH (0.35-
4.94 mIU/L), fT3 (2.63-5.71 pmol/L) and fT4 (9.0-19.1 pmol/L).
Results and Discussion: A total of 677 pregnant women responded to the study corresponding to a
response rate of 90.2%. The median UIE was 123.9 µg/L. Thyroid function tests revealed that the
median TSH level among pregnant women was 0.76 mIU/L. While, the medians of fT3 and fT4
levels were 4.40 pmol/l and 13.6 pmol/l, respectively. The distribution of thyroid hormones showed
that majority of the pregnant women had normal fT3 (97.0%) and fT4 (95.8%). However, 25.6%
(n=172) of them showed low levels of TSH (<0.35 mIU/L).
Conclusions: The study results of UIE indicated that IDD is still a public health problem among
pregnant women in Sarawak despite mandatory USI. However, low levels of TSH in the pregnant
women with normal fT4 and fT3 is suggestive of sub-clinical hyperthyroidism. Therefore, a
comprehensive monitoring program for early diagnosis and treatment of hyperthyroidism is
warranted.
NMRR ID: 17-2932-39316

18
Relationship between Urinary Iodine Level and Thyroid Hormones in the First
Trimester Pregnant Women: Findings from Sarawak Iodine Deficiency Disorder
Survey 2018
Lim Kuang Kuay1
, Tan Beng Chin2
, Nur Azna Mahmud1
, Chua Boon Kee2
, Chan Ying Ying1
1
Institute for Public Health, Ministry of Health, Setia Alam, Selangor, Malaysia; 2
Sarawak State Health
Department, Ministry of Health, Kuching, Sarawak, Malaysia.
Corresponding Author: Lim Kuang Kuay (limkk@moh.gov.my)
Introduction: Inadequate iodine in pregnancy leads to insufficient production of the thyroid
hormones, which may affect the neurological development of the foetus and newborn.
Objective: This study aims to assess the relationship between urinary iodine level and thyroid
hormones in the first trimester of pregnant women in Sarawak.
Methods: This cross-sectional study was conducted in 30 government maternal and child healthcare
clinics in Sarawak. A total of 750 first trimester pregnant women visiting the clinics between 1st
July
and 30th
September 2018 were invited to enrol in the study. Urinary iodine concentrations (UIC),
thyroid-stimulating hormone (TSH), free thyroxine (fT4) and free triiodothyronine (fT3) were
measured and analysed. Spearman’s correlation coefficient was used to analyse the direction and
magnitude of the association between UIC and thyroid hormones in capillary blood.
Results and Discussion: The median level of UIC was borderline low (123.9 µg/L, IQR: 56.5,
192.1), whereas TSH, fT4 and fT3 were normal: 0.76 mIU/L (IQR: 0.34, 1.31), 13.6 pmol/l (IQR:
12.5, 14.9) and 4.40 pmol/l (IQR: 4.00, 4.77), respectively. There was no significant correlation
between UIC and TSH (r=-0.44, p=0.26), fT4 (r=0.20, p=0.62), or fT3 (r=-0.02, p=0.63). The
spearman’s correlation analysis also showed no significant difference in correlation between the
individual UIC group (UIC<150 µg/L, UIC=150-249 µg/L and UIC≥250 µg/L) and TSH, fT4 and
fT3.
Conclusion: Pregnant women in Sarawak have adequate iodine intake, although median UIC level
was borderline low. There was no significant correlation between UIC and TSH, fT4 or fT3. The
lack of correlation could be attributed to pregnancy changes and theamount of iodine storage in the
thyroid gland in pregnant women who did not have a persistent iodine deficiency.
NMRR ID: 17-2932-39316

19
HP:011-51337795
Tel: 082-505683, Fax: 082-505983

20
Case Report
and
Case Series

23
A Rare Case of Patella Sleeve Fracture
Norhana Mohamed Ali, Denny Clare @ Charles Embun, Ismyth Abd Rahman, Thiru Kumaran A/L
Mootha Kumaran, Norzatulsyima Nasirudin
Orthopaedic Department, Miri General Hospital, Miri, Sarawak
Corresponding author: Dr Norhana Mohamed Ali (nhana.mohamedali1101@gmail.com)
Introduction: More than half of paediatric patella fractures are patella sleeve fracture, but they are
relatively rare accounting for less than 1% of paediatric fractures. They commonly occur in children
between 8 and 12 years of age when patellar ossification is nearly complete.1
Most of these are
displaced fractures requiring open reduction and internal fixation.
Case Presentation: A 12-year-old boy presented to the Emergency Department with left knee pain
after a high jump during a sports event at school. He landed on his flexed knee with an audible
‘crack’ sound. Physical examination showed a knee effusion, a high riding patella and a palpable
gap at the inferior pole of the patella with disruption of the extensor mechanism. The remaining
lower limb examination was otherwise unremarkable. The x-rays showed patella alta with 1 cm
inferior fragment representing an avulsion with patella sleeve rupture.
Treatment & Follow Up: An open reduction, pull through suture and tension relieving wire of the
left patella was performed within 24 hours. A midline approach was used and fracture site identified
after paratenon was dissected off the proximal part of the patella tendon. Copious lavage of the knee
was performed. Three trans-osseous tunnels were drilled with a 2.0 mm drill in the coronal plane.
Number 5 Ethibond suture was used to oppose the ends of the sleeve via Krackow technique
anatomically. The construct was reinforced with a tension relieving wire twisted at the superolateral
pole of the patella for ease of removal later. Postoperatively the patient was immobilised in a cylinder
slab for six weeks with non-weight bearing then he was started on physiotherapy. The tension-
relieving wire was subsequently removed at three months. Upon follow up at six months, the patient
regained full range of motion and was able to return to normal function.
Discussion: In skeletally immature children, the patella has a layer of protective cartilage during
secondary ossification.1
Forced load on contracted quadriceps with knee flexion results in an
avulsion fracture.1
Sleeve fractures may be difficult to detect on radiographs since much of the
fragment is unossified peripheral cartilage.2
X-rays may look normal, especially if there is no bony
fragment. Magnetic resonance imaging may aid in diagnosis.2
Early diagnosis is vital as the prompt
surgical correction is required for recovery of function.3
Delay in management may cause
complications such as limited knee flexion, enlargement or duplication of the patella, and avascular
necrosis.2,3
Conclusion: Prompt diagnosis and treatment are vital for good prognosis in patella sleeve fracture.
Undisplaced fractures may be managed conservatively. For severely displaced fractures, early
intervention can achieve good results and pull through suture supplemented with tension relieving
wire is a reliable option for its treatment.
References:
1. Sullivan S, Maskell K, Knutson T. Patellar sleeve fracture. West J Emerg Med. 2014; 15(7): 883-4.
2. Sessions WC, Herring M, Truong WH. Extensor mechanism injury in the pediatric population - A
clinical review. J Knee Surg. 2018; 31(6): 490-7.
3. Guy SP, Marciniak JL, Tulwa N, et al. Bilateral sleeve fracture of the inferior poles of the patella in
a healthy child: case report and review of the literature. Adv Orthop. 2011; 428614.

25
Bilateral Transient Loss of Vision as Presenting Feature of Posterior Reversible
Encephalopathy Syndrome in Post-Infectious Glomerulonephritis in Children
Hii King Ching1
, Chin Kar Ling2
, Kong Sing Ling1
, Johnny Goh Keh Tun1
, Lai Shen-Ly1
1
Department of Paediatrics, Kapit Hospital, Kapit, Sarawak; 2
Department of Emergency and Trauma,
Kapit Hospital, Kapit, Sarawak
Corresponding author: Dr Hii King Ching (drhiikc@gmail.com)
Introduction: Bilateral transient loss of vision as the primary presenting symptom in post-infectious
glomerulonephritis is rare in children. We report two cases of children with posterior reversible
encephalopathy (PRES) who presented with bilateral transient visual loss secondary to post-
infectious glomerulonephritis.
Case Presentation: The first case was a 7-year-old boy who had two visits over one week. History
of exudative tonsillitis, tea-coloured urine and hypertension was not noticed during the initial
presentation. The focus was on the sudden total visual loss and the four episodes of recurring
seizures. The diagnosis of possible post-infectious glomerulonephritis was missed despite its
chronologically typical history, puffy eyes and pedal oedema. Another 12-year-old boy was
misdiagnosed as partially treated meningitis due to ten days of prolonged fever, blurring of vision
with recurring seizures and previous history of antibiotics. He was intubated for airway protection
with the intention of transferring to Sibu Hospital for computerised tomography (CT) brain.
Diagnosis of possible post-infectious glomerulonephritis was overlooked despite the hypertensive
crisis, a tinge of haematuria, frothy sputum secondary to fluid overload, healed impetigo lesions at
lower limbs, puffy eyes and pedal oedema. Both children had kidney impairment with macroscopic
haematuria. They were treated with diuretics and fluid restriction, low salt diet, oral anti-
hypertensive, and penicillin. Both cases had full vision recovery within six to nine hours with no
residual seizures, or neurological deficit as well as normalised blood pressure.
Discussion: It requires a high index of suspicion to diagnose PRES as vision loss is a red herring.
PRES is characterised by abrupt onset of headache, altered mental status, seizures and cortical
blindness or visual impairment. Visual loss is often rapidly reversible with prompt treatment directed
at causative factors. Most patients present with elevated blood pressure leading to hypertensive
emergencies. The pathophysiology of PRES is unclear but commonly known as an endotheliopathy
of the posterior cerebral vasculature. PRES was reported in children with renal disease, systemic
lupus erythematosus and Henoch-Schönlein purpura. We found only one report by Ayumi Endo on
post-streptococcal glomerulonephritis with PRES. As streptococcal infection is common in this
region, we should be more vigilant. We diagnosed post-infectious glomerulonephritis in these
children based on clinical features without a confirmatory diagnostic test of streptococcal infection.
Conclusion: Hypertension, a common presentation in children with post-infectious
glomerulonephritis, was not noticed in both cases during the initial presentation to the Emergency
and Trauma Department. We urge that blood pressure should routinely be reviewed in children
presenting with neurological signs to recognise posterior reversible encephalopathy syndrome.
Sudden loss of vision in a hypertensive crisis is a sign of PRES, which is highly reversible with
timely recognition and treatment to prevent permanent, irreversible damage.
NMRR ID: 19-1970-49733

26
Concurrent Aortic Arch Aneurysm and Pulmonary Artery Dilatation as a Rare
Cause of Ortner Syndrome
Cheong Kang Wei1
, Isaac Tan Yieng Ler2
, Intan Zariza Hussain1
, Heng Pek Ser2
1
Department of Radiology, Hospital Sibu, Sibu, Sarawak; 2
Department of Otorhinolaryngology,
Hospital Sibu, Sibu, Sarawak, Malaysia
Corresponding author: Dr Cheong Kang Wei (cheongkangwei@gmail.com)
Introduction: Ortner syndrome is defined as hoarseness resulting from compression of the left
recurrent laryngeal nerve by a cardiovascular aetiology.1
It was initially described as secondary to
left atrial enlargement and mitral valve disease.1
Other mediastinal vascular causes have now been
recently described.
Case presentation: We present a rare case of Ortner syndrome caused by disease progression in a
70-year-old male who had a concurrent aortic arch aneurysm and pulmonary artery dilatation. This
patient initially presented with central chest pain radiating to the back in August 2017. Computed-
tomography angiography (CTA) showed aortic arch aneurysm with a maximum diameter of 5.0 cm
and dilated pulmonary artery, measuring 4.1 cm. The patient subsequently developed hoarseness of
voice in early 2018. Flexiscope by otorhinolaryngology team showed left vocal cord palsy. In view
of no neck swelling or palpable cervical lymph nodes, worsening of the aortic arch aneurysm was
suspected as a cause of his left recurrent laryngeal nerve palsy. Hence, CTA was repeated in
February 2018, which revealed worsening of both the aortic arch aneurysm with a maximum
diameter of 6.7 cm and dilated pulmonary artery, measuring 4.5 cm. This patient eventually passed
away in October 2018 due to his leaking aortic aneurysm.
Discussion/Conclusion: Although neoplastic or inflammatory lesions are more common causes of
recurrent laryngeal nerve palsy, clinicians should consider the aorta and vascular structures of the
mediastinum as rare but potential life-threatening causes of laryngeal nerve compression in patients
presenting with hoarseness.2
Early contrasted computerised tomography of the thorax in these
patients allows detection of Ortner syndrome, which could be potentially lifesaving with early
intervention.3
NMRR ID: 19-1917-48435
References:
1. Mulpuru S, Vasavada BC, Punukollu GK, et al. Cardiovocal Syndrome: A systematic review. Heart
Lung Cir. 2008; 17: 1-4.
2. Mickus TJ, Mueller J, Williams R. An uncommon cause of Ortner syndrome. J Thorac Imaging. 2010
Aug; 25(3): W82-4.
3. Sobrino-Guijarro B, Virk JS, Singh A, et al. Uncommon and rare causes of vocal fold paralysis
detected via imaging. Laryngol Otol. 2013; 127, 691-8.

27
Kounis Syndrome: When Atopy Affects the Heart
Choo Li Yong, Mohd Saifful Nizam Ismail
Department of Emergency and Trauma, Sibu Hospital, Sibu, Sarawak
Corresponding author: Dr Choo Li Yong (chooliyong@outlook.com)
Introduction: Kounis syndrome (KS) represents acute coronary syndrome (ACS) triggered by
anaphylaxis with mast cell-mediated vasospasm. The release of inflammatory mediators during
allergic reactions is thought to be the culprits. It can be classified into three variants, namely Type
1 - coronary spasm, Type 2 - coronary thrombosis, and Type 3 - drug-eluting stent thrombosis.1
Case Presentation: A 31-year-old woman with no known allergy or cardiovascular risk visited the
Emergency Department (ED) twice on the same day. Initially, she complained of sudden onset of
generalised skin erythema with bilateral upper limb swelling, without any source of allergy. She was
treated as an allergic reaction with intravenous (IV) hydrocortisone and IV diphenhydramine and
was allowed discharge after her symptoms resolved. However, the patient re-visited ED four hours
after discharge due to recurrence of skin rashes with newly onset left-sided chest pain and shortness
of breath. Upon the second presentation, she was normotensive but tachycardic and mildly
tachypnoeic with urticarial rash involving her trunk and bilateral upper limbs. The first
electrocardiogram (ECG) showed sinus tachycardia with T inversion from V1 to V5 compared to
the previous record of normal ECG in 2011 (Fig. 1A). Cardiac enzymes taken less than two hours
from the onset of her chest pain were within the normal range. The patient was initially given
supplementary oxygen, H2 receptor blocker and IV Tramadol as analgesia. However, her pain did
not improve at all, the diagnosis was then revised to anaphylaxis induced ACS, and she was given
0.3 mg of intramuscular (IM) adrenaline, aspirin 300 mg and clopidogrel 300mg. Her chest pain
completely resolved after five minutes. The patient was then admitted to the medical ward for
observation, her ECG normalised with the resolution of anaphylaxis in the following days (Fig. 1B).
She was discharged with another three days of oral prednisolone and diphenhydramine. However,
there is no scheduled follow up and further cardiac assessment.
Discussion: The pathophysiology of KS in which allergic insult component with vasospasm related
myocardial injury complicates its management, as treating of either component might, in turn,
worsens the other one. Although more case studies are needed to establish appropriate use of
adrenaline in KS, there are several promising outcomes for its use in similar cases.3
Within
consideration of its potential cardiac-related side effect, adrenaline should be used in titrated dose,
preferably to be administered via IM route with close monitoring of clinical response and vital
signs.1,2
Antiplatelet and anticoagulant therapy is generally indicated in patients with the pre-existing
atheromatous disease (type II KS variant), as inflammatory mediators in hypersensitivity reaction
might trigger plaque rupture and thrombosis of the coronary artery. All KS patients should be
scheduled for follow up post-hospital discharge and arranged for cardiac assessment including 12-
lead ECG, echocardiogram and coronary angiogram if pre-existing coronary artery disease is
suspected.1
Conclusion: A high index of suspicion of KS is needed when attending atopic patients with ACS
symptoms, to avoid misdiagnosis. The benefit of adrenaline used for life-threatening anaphylaxis
outweighs its low potential risk of causing coronary vasospasm and arrhythmia in KS, especially
when administered via IM route.

30
Revealing the Truth in Masquerade: Stanford A Aortic Dissection
Loi Siew Ling1
, Neoh Shu Chin2
, Chan Hiang Chuan2
1
Emergency & Trauma Department, Hospital Bintulu, Bintulu, Sarawak; 2
Emergency & Trauma
Department, Hospital Umum Sarawak, Kuching, Sarawak
Corresponding author: Dr Loi Siew Ling (silynloi@yahoo.com)
Introduction: As the saying “time is brain”, the main goal of acute ischaemic stroke management
is early reperfusion therapy with thrombolysis if not contraindicated. Acute limb ischaemia on the
other hand, is also a real medical emergency that requires timely intervention to avoid limb loss. In
both cases, minute makes a difference. Aortic dissection remains as one of the contraindications for
pharmacological reperfusion therapy in acute ischaemic stroke as well as anticoagulant therapy in
acute limb ischaemia. We report a case of acute aortic dissection complicated with massive cerebral
infarct and acute limb ischaemia.
Case Presentation: A 44-year-old male smoker with hypertension, dyslipidaemia and chronic
kidney disease was brought to the emergency department of a district hospital for less responsiveness.
He was confused with right facial nerve palsy and left-sided hemiplegia. He was treated as an acute
stroke with a hypertensive emergency before embarking on a 5-hour road ride to our centre for
neurology service. Computed tomography (CT) brain showed infarction in territories of the right
middle cerebral and left posterior cerebral arteries. His right upper limb was cyanosed. Bedside
ultrasound revealed global cardiac hypokinesia with thrombus in the right common carotid artery.
There was no widened mediastinum on the chest x-ray taken after intubation for airway protection.
However, CT aortogram demonstrated extensive dissection from arch to left common carotid artery
with concomitant thrombosis of the distal brachiocephalic trunk. Hence, anticoagulation or
pharmacological thrombolysis could not be initiated. No other definitive intervention could be
instituted as well in the absence of interventional radiologist and cardiothoracic surgeon. The patient
died the next day.
Discussion: Acute aortic dissection classically presents with sudden severe tearing or ripping chest
or back pain. Pain-free aortic dissection poses diagnostic difficulty when it is disguised behind
stroke-like features. If the presentation is within 4.5 hours of onset, reperfusion therapy would have
been initiated in the absence of high clinical suspicion of aortic dissection, and the outcome would
be destructive. Pulse deficit is not eminent due to the presence of ischaemic limb. Acute limb
ischaemia, on the other hand, is mostly salvageable with the immediate repair of acute Stanford A
dissection and surgical revascularization. Thrombolysis is not superior to surgical intervention.
None of the drug affecting coagulation cascade should be given until aortic dissection is repaired.
Conclusion: Acute aortic dissection is a catastrophe in disguise due to protean manifestation.
Missed or delayed recognition may lead to a fatal outcome. High suspicion is needed in cases with
acute ischaemic stroke and non-traumatic limb ischaemia despite the absence of classical tearing
chest pain.
References:
1. Gaul C, Dietrich W, Friedrich I, et al. Neurological symptoms in type A aortic dissections. Stroke.
2006; 38: 292-7.
2. Charlton-Ouw KM, Sritharan K, Leake SS, et al. Management of limb ischemia in acute proximal
aortic dissection. J Vasc Surg. 2013 Apr; 57(4): 1023-9.
3. Jana M, Martin T. Misdiagnosed acute aortic dissection type A. Signa Vitae. 2010; 5(2): 35-7.

31
The Deceit of Plasmodium knowlesi: Report of Four Plasmodium knowlesi Death
in Kapit Divisional Hospital
Chuang Jia Yun1
, Hii King Ching2
1
Emergency & Trauma Department, Kapit Hospital, Kapit, Sarawak; 2
Department of Paediatrics, Kapit
Hospital, Kapit, Sarawak
Corresponding author: Dr Chuang Jia Yun (jiayunchuang@gmail.com)
Background: Plasmodium knowlesi can cause severe and fatal malaria. In endemic Kapit, the
number of cases each year has been increasing. From the year 2015 to 2019, Kapit Hospital has
encountered four severe cases with atypical presentations which lead to death.
Case Presentations: The four cases were a 23-year-old man, a 77-year-old man, an 81-year-old
woman and an 83-year-old woman in the year 2015, 2017, 2018 and 2019, respectively. All cases
presented with septic shock and respiratory distress, and they required inotropic support and
intubation. Their conditions were complicated with acute kidney injury, metabolic acidosis and
thrombocytopaenia. However, the presenting pictures were misleading. Case 1 presented with a
history of prolonged cough and fever that was suggestive of pulmonary tuberculosis initially.
However, the presence of guarded abdomen with right iliac fossa tenderness, supported by bedside
ultrasonographic evidence of free fluid in hepatorenal pouch suggestive of acute abdomen likely
intra-abdominal bleeding. Case 2 was found to be in respiratory distress with his lungs full of
generalised rhonchi, suggestive of acute exacerbation of the chronic obstructive pulmonary disease.
His chest x-ray showed right lower zone consolidation, suggestive of pneumonia. Case 3 had chest
x-ray evidence of air below right hemidiaphragm, suspicious of acute abdomen likely perforated
gastric ulcer initially; however, it was later reported as Chilaiditi’s sign after computerised
tomography of the abdomen reported as no free air in the peritoneal cavity. Case 4 presented in an
altered mental state with one-sided body weakness, suspected of possible cerebrovascular accident.
There was neither history of a fever nor documented temperature spike. In all four cases, incidental
detection of Plasmodium knowlesi happened when screening blood film microscopy parasites
(BFMP) were sent.
Discussions: Diagnosis of severe Plasmodium knowlesi with atypical presentations requires a high
index of suspicion, particularly in the elderlies. Due to increasing endemicity of Plasmodium
knowlesi, early presentation and detection of cases are essential to prevent transformation into severe
form. In these cases, there were factors such as old age, comorbidities, delayed in presentation,
diagnosis or administration of antimalarial treatment which led to death. We have learnt from these
cases that obligatory screening of BFMP in patients with platelet count less than 100,000/uL or
patients in the critically ill state to Emergency and Trauma Department will help in earlier detection
of Plasmodium knowlesi, hence improve patient’s outcome by earlier administration of antimalarial
therapy.
Conclusion: Plasmodium knowlesi remains a major challenging health problem in this region of the
world. The accessibility of health care services is not as convenient as other places due to a large
area of jungle coverage and underdevelopment. Hence, awareness about the disease should be
highlighted among the people. Plasmodium knowlesi death is preventable if case detection and
treatment initiation are both done early.
NMRR: 19-2211-49660

32
Result Case 1 Case 2 Case 3 Case 4
Years of occurrence 2015 2017 2018 2019
Total malaria cases
in Kapit Hospital
187 371 388 136 (Jan-Jun)
Age (year) / Gender 23 / Male 77 / Male 81 / Female 83 / Female
Comorbidities No known illness COPD, HPT, BPH COPD, HPT, IHD HPT, Gastritis
Symptoms Prolonged cough,
fever, haematuria,
right iliac fossa
pain, vomiting &
diarrhoea
Fever, cough,
shortness of breath
Fever, upper
abdominal pain
Body weakness
Signs
Circulatory collapse In ETD In ICU In ICU In ETD
Respiratory distress In ETD In ETD In ETD In ETD
Impaired
consciousness
In ETD In ICU In ETD At home
Lungs Clear Generalised
rhonchi
Bibasal crepitations Generalised
transmitted sounds
Abdomen Guarding, right iliac
fossa tenderness
Normal Guarding, upper
abdomen tenderness
Normal
Radiology Findings
Chest x-ray No air under the
diaphragm or focal
consolidation
Right lower zone
consolidation
No focal changes,
or air under the
diaphragm
No focal
consolidation
Abdominal
ultrasound
Free fluid at Pouch
of Douglas
Not done No free fluid No free fluid
Lab Investigations
Metabolic acidosis Yes Yes Yes Compensated
respiratory alkalosis
pH 7.576 / HCO3
23.7 / BE 1.8
Anaemia Yes No No No
Thrombocytopaenia Yes Yes Yes Yes
Acute kidney injury
(urea & creatinine)
Normal High urea &
creatinine
High urea, normal
creatinine
High urea &
creatinine
Transaminitis /
hyperbilirubinemia
Normal AST &
ALT with high TB
High AST and TB,
but normal ALT
High ASTand TB,
but normal ALT
Normal AST / ALT,
but slightly high TB
Creatine kinase High High Normal Normal
BFMP P. knowlesi
trophozoites: 5,800
schizonts: 80
Malarial parasite
detected in
peripheral blood
film
P. knowlesi
trophozoites: 58,105
schizonts: 15,000
P. knowlesi
trophozoites: 11,710
schizonts: 11,480
Treatments
Antimalarial Artesunate None Artesunate,
doxycycline
Artesunate,
doxycycline
Antibiotics None Augmentin,
azithromycin,
ceftriaxone
Tazocin, cefepime,
metronidazole
Augmentin
Inotropes 3 3 3 3
Intubation Yes Yes Yes Yes
Renal replacement
therapy
No Peritoneal dialysis CVVH No
Table 1: Summary of patients’ clinical features and management (CVVH: continous veno-venous haemo-
filtration, COPD: chronic obstructive airway disease; HPT: hypertension; BPH: benign prostatic hyperplasia;
IHD: ischaemic heart disease)

34
Sailing in the Rage of Samudra; A Case of Neck Trauma
Suresh Shanmugam1
, Loi Siew Ling1
, Lai Joon Thian2
1
Emergency & Trauma Department, Hospital Bintulu, Bintulu, Sarawak; 2
Emergency & Trauma
Department, Hospital Umum Sarawak, Kuching, Sarawak, Malaysia
Corresponding author: Dr Suresh Shanmugam (surez2827@gmail.com)
Introduction: Neck trauma possesses various challenges with regard to its definitive management.
Penetrating neck trauma contributed to at least 5% to 10% of total trauma cases seen at the
Emergency and Trauma Department and attributed to 10% mortality rate. Lately, a more non-zonal
approach has been widely advocated to avoid unnecessary exploration. We report a case of
penetrating neck trauma managed with the traditional zonal approach and complicated with an
adverse event.
Case Presentation: A 62-year-old man presented to a district hospital with zone I neck injury after
being pierced by a wood piece at the workplace. The small laceration wound was stitched
uneventfully before referring to our centre. His vital signs were stable. However, he experienced
excruciating pain over the neck with crepitus up to the suprasternal region. Bedside sonography and
x-ray excluded pneumothorax but demonstrated extensive subcutaneous emphysema over the neck.
Oroscope examination was unremarkable. Computerised tomography (CT) neck reported numerous
deep air pockets on the right side of the neck extending from skull base to superior mediastinum.
No enhancing collection was evident adjacent to trachea and oesophagus. Vascular bundle remained
intact. The patient eventually underwent operative exploration for possible oesophageal injury,
which revealed minimal blood clots over penetrating tract but then complicated with right internal
jugular vein injury. Fortunately, the bleeding was able to be secured. He had hoarseness of voice
post-recovery.
Discussion: The complexity within the small neck space should be handled delicately. Available
published reviews focus more on the traditional zonal algorithm. As illustrated in this case,
haemodynamically stable patient with soft signs (haematemesis, haemoptysis, subcutaneous air leak,
chest tube air leak, nonexpanding haematoma, focal neurological deficit, dyspnoea, dysphonia, and
dysphagia) may benefit from lesser invasive strategy to minimise significant morbidity. CT neck
has proven to be the gold standard imaging in penetrating neck trauma. The latest non-zonal
approach incorporated with angiography is used to avoid mandatory neck exploration regardless of
neck zones. The mysterious numerous air pockets with extensive subcutaneous emphysema
surrounding the neck may arise from the laceration wound acting as a one-way valve. The crepitus
usually resolves if there is no ongoing leak; thus, a period of wait and observe may benefit in such
cases. As a result, this patient developed unnecessary neurovascular complications though able to
intervene and avoidable.1,2
Conclusion: Current trend is moving away from antiquated invasive algorithm to a more
conservative strategy. ‘No zonal’ approach may avoid unnecessary exploration in patients with
penetrating neck trauma. More uniformed guidelines should be explored and published in managing
neck trauma cases.
References:
1. Shiroff AM, Gale SC, Martin ND, et al. Penetrating neck trauma: a review of management strategies
and discussion of the 'No Zone' approach. Am Surg. 2013 Jan; 79(1): 23-9.
2. Ibraheem K, Khan M, Rhee P, et al. "No zone" approach in penetrating neck trauma reduces
unnecessary computed tomography angiography and negative explorations. J Surg Res. 2018 Jan;
221: 113-20.

36
Acute Pancreatitis, a Rare Complication of Leptospirosis
Liew Mun Thing, Danny Wong Ling Siong
Department of Anaesthesiology and Intensive Care Unit, Hospital Sarikei, Sarikei, Sarawak
Corresponding author: Dr Danny Wong Ling Siong (lingsiong91@hotmail.com)
Introduction: Leptospirosis is one of the most common zoonotic diseases worldwide, especially in
the tropical region. Malaysia has been ranked among the top 20 countries with the highest incidence
of leptospirosis.1
Leptospirosis has emerged as a public health concern as it imposes significant
health impact and burden to the nation. A community-based study has shown that more than a third
of respondents residing in Rejang Basin Sarawak were seropositive towards leptospira.2
We report
a case of a leptospirosis complicated by acute pancreatitis.
Case Presentation: A 38-year-old Iban man from Sarikei, with a few risk factors of leptospirosis,
i.e. swimming in the river, rat infestation at home, drinking pipe water at home, presented with fever,
abdominal pain and loss of appetite for three days. Upon assessment, he appeared to be alert and
tachypnoeic, with poor hydration. He required inotropic support. Physical examinations revealed
lungs with bibasal crepitation and a liver of 4 cm. Other systemic examinations were unremarkable.
Blood investigations revealed raised white cell count of 15.8 x 103
/ L, thrombocytopenia
(50x103
/ L), acute kidney injury (urea: 13.4 mmol/L and creatinine: 193 mol/L), slightly raised
creatinine kinase (177 U/L), hyperbilirubinemia (total: 25.6 mol/L, direct: 10.2 mol/L) and
compensated metabolic acidosis (pH 7.328, HCO3 11.6 mmol/L, BE -12.1 mmol/L). Serum amylase
was 959 U/L, and urine amylase was 2023 U/L. IMRIE scoring was 2 (raised white cell count and
glucose). Ultrasound of the hepatobiliary system revealed no sonographic features of cholelithiasis
or sequelae of acute pancreatitis. Both leptospirosis serology was positive: IgM and microscopic
agglutination test was 1:400. The patient recovered fully with hydrations, oxygen supports,
antibiotics and discharged home after six days of admission.
Discussion: This deadly disease causes high mortality rate of 2 to 10%, and the infected patients are
usually productive age group male (25 to 60 years) in the country. Appropriate interventions have
to be done to reduce morbidity and mortality. Among these would include a higher index of
suspicious of the rare complication like acute pancreatitis with mortality of 25%.
Conclusion: Patient with leptospirosis who developed abdominal pain should raise suspicious of
pancreatic involvement and prompt investigation and management done to improve survival.
References:
1. Tan WL, Soelar SA, Suan MAM, et al. Leptospirosis incidence and mortality in Malaysia. Southeast
Asian J Trop Med Public Health. 2016 May; 47(3): 434-40.
2. Suut L, Mazlan MNA, Arif MT, et al. Serological prevalence of leptospirosis among rural
communities in the Rejang Basin, Sarawak, Malaysia. Asia Pac J Public Health. 2016 Jul; 28(5):
450-7.
References:
(for paper by Ng Li Wei et al on What Bit Me? Mysterious Bug or Worse? on page 35)
1. Virmani S, Bhat R, Rao R, et al. Paroxysmal atrial fibrillation due to venomous snake bite. J Clin
Diagn Res. 2017 Jun; 11(6): OD01-2.
2. Ismail, Ahmad Khaldun. (2015). Snakebite and Envenomation Management in Malaysia.
10.1007/978-94-007-6288-6_54-1.

37
A Rare Encounter of Congenital Buphthalmos and Corneal Clouding in a
District Hospital in Sarawak
Wei Honn Lim¹, Shin Wei Pan², Teck-Hock Toh1,3
¹ Clinical Research Centre, Sibu Hospital, Sibu, Sarawak; ² Department of Ophthalmology, Sibu
Hospital, Sibu, Sarawak; ³ Department of Paediatrics, Sibu Hospital, Sibu, Sarawak
Corresponding author: Dr Wei Honn Lim (weihonn88@hotmail.com)
Introduction: Primary congenital glaucoma is a rare eye condition in neonatal period characterised
by raised intraocular pressure (IOP) with a classical clinical triad of photophobia, blepharospasm
(eyelid spasm), and epiphora (tearing). This condition is rare (incidence: 1:10,000) with 75% cases
affect bilaterally. Male is predominant. This condition contributes to 0.01 to 0.04% of total blindness
worldwide.1
Case Scenario: A 22-year-old primigravida woman with low maternal BMI (16.2 kg/m2
) delivered
a healthy term baby girl in a district hospital following an uneventful pregnancy with no risk factor
of infection. She had a low-grade fever with foetal tachycardia. Soon after birth, the baby had
hypoglycaemia (1.8 mmol/L). Otherwise, the baby was haemodynamically stable. Full blood count
and blood culture were normal. The baby was given intravenous antibiotics and dextrose bolus. This
was a non-consanguineous marriage, and there was no family history of glaucoma or other eye
problem. During the newborn examination, the baby had large eyes with a grey colour appearance
on the corneas (Picture 1). There was no irritability, tearing or blepharospasm. Examinations over
the peri-orbital region, face and neck were unremarkable. The baby had no facial dysmorphism, and
the rest of systemic examination was unremarkable. TORCHES screening was normal. The baby
was referred to the specialist hospital and eye assessment was done by ophthalmologist at 15 hours
of life (Table 1). The baby was started on carbonic anhydrase inhibitors (CAI) to control the IOP;
and she was well on follow up without surgical intervention.
Discussion: There are a few conditions that could present with buphthalmos and corneal clouding
in a newborn, namely congenital glaucoma, megalocornea, corneal dystrophy, corneal anomalies
such as Sclerocornea and Peter’s anomaly, keratitis from congenital infections and obstetric birth
trauma.1
Primary congenital glaucoma is caused by developmental arrest of anterior chamber tissues
derived from neural crest cells during embryological period (improper development of the eye’s
aqueous outflow system), leading to raised IOP with consequent damage to the ocular structures,
resulting in loss of vision.2,3,4
This isolated developmental defect of the trabecular meshwork is not
associated with any other ocular anomalies. Surgical intervention is the mainstay of treatment for
primary congenital glaucoma, while medical therapy plays a supportive role in temporarily reducing
IOP and facilitating further surgical intervention.2,4
The preferred initial treatment for congenital
glaucoma is angle surgery which includes goniotomy and trabeculotomy.2,4,5,6
Among the
medications available, CAI such as topical dorzolamide is the best choice in view of its efficacy and
lesser side effects. Other medications such as oral acetazolamide, beta-blockers (eg. timolol eye
drops 0.25% or 0.5%), prostaglandin analogues (eg. latanoprost) and alpha-2 agonists (eg.
brimonidine) are less popular because of varied efficacies and side effects.2,4
Optimum visual
rehabilitation should not be forgotten even after surgical intervention as myopia and astigmatism are
common.4,6
Conclusion: Early detection of congenital glaucoma in a district hospital is important for early
referral to avoid irreversible complications and blindness. A thorough history taking, physical
examination and investigations need to be performed to look for infective and possible genetically-
inherited diseases. Medical treatment acts as an initial treatment to reduce IOP while waiting for
further surgical intervention is important. Goniotomy and trabeculotomy are the main treatments for
primary congenital glaucoma and early intervention minimise the impact of vision.

39
Malaysia’s First Case of Chronic Cerebral Melioidosis
Woo Xiang Ling1
, Goh Chin Hwee2
, Low Peh Hueh2
, Toh Teck Hock3
1
Department of Neurosurgery, Sibu Hospital, Sibu, Sarawak; 2
Department of Neurosurgery, Sarawak
General Hospital, Kuching, Sarawak; 3
Clinical Research Centre, Sibu Hospital, Sibu, Sarawak
Corresponding author: Dr Woo Xiang Ling (xiangling_day@hotmail.com)
Introduction: Central nervous system (CNS) melioidosis is rare and potentially fatal. It is found in
<5% of all melioidosis cases with a 20% mortality.1
The majority (91%) of CNS melioidosis present
acutely.1
Only four chronic melioidosis have been reported in Malaysia: two pneumonia, one liver
abscess, and one lymphadenopathy.2
This is Malaysia’s first chronic CNS melioidosis.
Case Presentation: A 30-year-old woman with no known medical illness came from rural
agriculture coastal Sarawak district longhouse that collected rainwater for drinking and cooking. She
complained of an intermittent, right-sided headache for one year, which worsened two weeks before
admission with associated fever and progressive left hemiparesis. Systematic examinations were
normal. C-reactive protein and erythrocytes sedimentation rate were raised. There was no
leucocytosis and blood culture were negative. Workout for tuberculosis, toxoplasmosis, dengue,
malaria, leptospirosis and biohazards were negative. Chest x-ray, abdominal ultrasound and
echocardiography were normal. Brain imaging showed multiple lesions suggestive of CNS infection
or tumour. She did not respond to ceftriaxone. Open brain biopsy revealed grey friable mass, with
poor brain lesion interface. There was no pus or abscess wall. Histopathology revealed nonspecific
cerebral oedema and inflamed meninges. Dexamethasone was commenced and antibiotics withheld
as the intraoperative finding was more suggestive of primary CNS lymphoma (PCNSL). However,
she did not respond to dexamethasone. Serial imaging showed a progression of her lesion with
extensive oedema requiring craniectomy with lobectomy. Green pus was noted this time.
Histopathology revealed suppurative granuloma with abscess. Her melioidosis serology returned
positive subsequently. Ceftazidime was initiated. But she continued to deteriorate and succumbed
to her illness eventually.
Discussion: Melioidosis should be suspected for patients with community-acquired sepsis
(including chronic infections), travel history to melioidosis-endemic areas, and those not responding
to empiric therapy. Even with negative cultures, melioidosis can still arise from deep occult sites.
Cerebral melioidosis can be fatal if not treated early. Initiate treatment immediately, and not wait
until the diagnostic test is positive, as that may take days to weeks. Malaysia needs a low-cost
diagnostic kit that is accurate and rapid for melioidosis.
Conclusion: Diagnostic difficulties for CNS melioidosis include nonspecific CNS symptoms and
imaging findings and the absence of traditional risk factors or rapid diagnostic test. A high clinical
index of suspicion, even in chronic presentations, is essential, as timely diagnosis ensure effective
initiation of antimicrobial therapy.

42
Case Report of an Axillary Abscess Secondary to Strongyloides stercolaris
Infection
Rosdi Pon1
, Ling Chieng Loo1
, Chieng Tiong How1
, Teck-Hock Toh2
1
Department of Surgery, Sibu Hospital, Sibu, Sarawak; 2
Department of Paediatrics, Sibu Hospital, Sibu,
Sarawak
Corresponding author: Dr Rosdi Pon (rosdipon@ymail.com)
Introduction: Strongyloides stercoralis is a soil-transmitted nematode and its infestation may
present with cutaneous or gastrointestinal symptoms. It is asymptomatic in over 60% of cases and
only indicated by a raised eosinophil count.1
If diagnosed early; it is easily treatable with an oral
anti-helminthic drug.
Case report: A 2-year-old boy who lived in the rural area of Sarawak had a right axillary swelling
for two weeks. He had a history of river swimming and barefoot walking on soil. Despite ten days
of intravenous ampicillin and cloxacillin, the swelling did not subside. Tuberculosis workup was
negative, and primary immunodeficiency screening result was normal. Incision and drainage were
done, and cultures grew Strongyloides stercolaris larvae (Fig 1, refer page 44). Acid-fast bacilli test
was negative. He was subsequently treated with syrup albendazole (400 mg OD) for two weeks and
discharged home well. On follow up, he was well with healed axilla wound.
Discussion: Strongyloides stercoralis infection is mostly asymptomatic and can remain undetected
for several decades.2
Infections are mostly acquired in patients who travel to endemic areas;
involving gastrointestinal, pulmonary, and cutaneous. History of soil exposure is essential in
clinching diagnosis and alternative diagnosis must be considered if patient does not respond to first
line antibiotics for Gram positive organisms. The diagnosis relies on the identification of the parasite
in stool samples or, rarely, in sputum and biopsies. The Baermann-Moraes method and faecal culture
in agar are the most sensitive and specific methods.3
The recommended treatment for uncomplicated
case is ivermectin as two single doses administered on two consecutive days.4
Albendazole for three
to seven days, is an alternative but has an efficacy of 78% compared to ivermectin with 100%.4
Conclusion: Cutaneous infestation of Strongyloides stercolaris is rare and the diagnosis is made via
examination of the lesion. The treatment is anti-helminthic medication and has good recovery.
References:
1. Agrawal V, Agrawal T, Ghoshal UC. Intestinal strongyloidiasis: a diagnosis frequently missed in the
tropic. Trans R Soc Trop Med Hyg. 2009; 103: 242-6.
2. Fardet L, Genereau T, Cabana J, et al. Severe Strongyloidiasis in corticosteroids treated patients. Clin
Microbiol Infec. 2006; 12: 945-7.
3. Lima JP, Delgado PG. Diagnosis of strongyloidiasis: importance of Baermann's method. Am J Dig
Dis. 1961; 6: 899-904.
4. Muennig P, Pallin D, Challah C, et al. The cost-effectiveness of ivermectin vs. albendazole in the
presumptive treatment of strongyloidiasis in immigrants to the United States. Epidemiol Infect. 2004;
132(6): 1055-63.

43
43
Multiple Intra-Axial Lesions with Hydrocephalus in a HIV-Positive Patient
Yiek Siew Hong
Department of Neurosurgery, Sarawak General Hospital, Kuching, Sarawak
Corresponding author: Dr Yiek Siew Hong (ysh1989@hotmail.com)
Introduction: Toxoplasma gondii is an obligate intracellular protozoan parasite that causes zoonotic
infection. It also causes severe opportunistic infections such as encephalitis and pneumonitis in
patients with human immunodeficiency virus (HIV) and disseminated infection in
immunocompromised hosts. Both toxoplasmosis and tuberculosis are prevalent in Malaysia,
especially in HIV-positive individuals.1
Diagnosing and differentiating them is often tricky because
of non-specific clinical features in immunocompromised patients. Diagnostic clues mainly depend
on radiological imaging and serology.
Case Report: A previously well 58-year-old lady presented with three months history of left third
cranial nerve palsy, chronic cough and constitutional symptoms. Initial computerised tomography
(CT) brain showed multiple ill-enhancing intra-axial mass (Fig. 1a and 1b); thought to be cerebral
metastasis. She developed meningism, and Glasgow coma scale (GCS) deteriorated one week after
admission. A lumbar puncture showed a total cell count of 84/mm3
, glucose 2.8 mmol/L, and protein
1.9 g/L. Gram stain, India ink, cryptococcal antigen, and cultures for bacteria, Mycobacterium, and
fungus for the cerebral spinal fluid (CSF) were negative. She tested positive for HIV (CD-4 count:
35 cells/mm3
). She was treated with empirical anti-tuberculosis and anti-toxoplasmosis drugs before
magnetic resonance imaging (MRI) and serology tests were available. Unfortunately, she continued
to deteriorate. Serial CT noted an increasing size of intra-axial mass with communicating
hydrocephalus (Fig 1c and 1d). External ventricular drain (EVD) was placed, and CSF pressure was
high intraoperatively. Cerebral toxoplasmosis was finally confirmed by MRI (Fig. 2), and high titre
IgG anti-toxoplasma antibodies. EVD was taken off on day 4 of insertion because of poor GCS
recovery.
Discussion: On radiography, cerebral toxoplasmosis appears as a single or multiple ring-enhancing
lesions; generally, localised at the cortico-medullary junction, deep white matter, basal ganglia, or
diffuse cerebritis.2
Hydrocephalus due to cerebral toxoplasmosis is rare3
, and; it is due to
compression of the CSF pathway by surrounding parenchymatous space-occupying lesions or a
necrotising ependymitis and plexitis obstructing CSF flow.4
In our case, the initial CT brain
suggested metastatic features; with the unknown immuno-compromised status, the diagnosis was
difficult to make.
Conclusion: The diagnosis of cerebral toxoplasmosis is difficult based on clinical and CT imaging
alone because toxoplasmosis and tuberculosis are prevalent in Malaysia. Prompt diagnosticworkup
such as MRI and serology may not be readily available in district hospitals, making timely initiation
of treatment for opportunistic infections difficult.
References:
1. Nissapatorn V, Kuppusamy I, Sim BLH, et al. Tuberculosis in HIV/AIDS patients: a Malaysian
experience. Southeast Asian J Trop Med Public Health. 2005 Jul; 36(4): 946-53.
2. Ramsey RG, Gean AD. Neuroimaging of AIDS. I. Central nervous system toxoplasmosis. Neuroimag
Clin N Am. 1997; 7(2): 171-86.
3. Basavaprabhu A, Soundarya M, Deepak M, et al. CNS toxoplasmosis presenting with obstructive
hydrocephalus in patients of retroviral disease: a case series. Med J Malaysia. 2012 Apr; 67(2): 214-
6.
4. Raut T, Garg RK, Jain A, et al. Hydrocephalus in tuberculous meningitis: Incidence, its predictive
factors and impact on the prognosis. J Infect. 2013 Apr; 66(4): 330-7.

45
A Diagnostic Conundrum of Heat Stroke: Severe Rhabdomyolysis or
Myocardial Infraction?
Chia Bing En
Emergency and Trauma Department, Hospital Sibu, Sibu, Sarawak, Malaysia
Corresponding author: Dr Chia Bing En (chiabingen@hotmail.com)
Background: Heatstroke is the most severe form of heat-related illness, leading to complications
like acute respiratory distress syndrome (ARDS), disseminated intravascular coagulation (DIVC),
acute kidney injury (AKI), hepatic injury and rhabdomyolysis.
Case Report: A healthy young man presented to the Emergency Department (ED) in severe
respiratory distress. He was working under the hot sun, and he had diaphoresis, muscle cramping,
weakness, vomiting and complained of intense thirst before having a syncopal attack. The patient
was normothermic but tachypnoeic, hypotensive, restless and confused. Tracheal intubation was
performed. He also developed gastrointestinal bleeding due to DIVC. Blood parameters showed
relative polycythaemia secondary to dehydration (haemoglobin: 16 g/dL; haematocrit: 49%),
decompensated metabolic acidosis, hyperkalaemia, hypocalcaemia, deranged liver function with a
significantly raised creatine kinase (CK, 9,950 U/L). Electrocardiography (ECG) showed ST
elevation over aVL, V1-V3 with ST depression over inferior leads and V5-V6. Bedside
echocardiography showed left ventricle apical hypokinesia, while chest x-ray showing borderline
cardiomegaly. The impression was exertional heat stroke, complicated with severe rhabdomyolysis,
ARDS, AKI, cardiomyopathy and DIVC. He was hydrated with fluids, supported with inotropes and
planned for urgent haemodialysis. During admission, his CK continued to peak until 18,500 U/L
then slowly decreased. He was extubated at day 7, clinically improving with normalising ECG and
blood parameters.
Discussion: Myocardial injury may occur during heat stroke, resulting in increased cardiac enzyme
and ST-segment changes on the ECG; causing a diagnostic confusion by mimicking the presentation
of coronary artery occlusive myocardial infarction. Heat stroke causes increase of serum
catecholamine levels, in which over secretion and abnormal responses to catecholamines are a
possible cause of stress-induced cardiomyopathy. Takotsubo cardiomyopathy manifests as anginal
symptoms, often with acute congestive heart failure, during periods of stress. The ECG demonstrates
ST-segment and/or T-wave abnormalities similar to those findings seen in acute coronary events.
These two cardiovascular maladies present in very similar fashion in the ED; bedside
echocardiography was done for this patient to help to exclude acute coronary syndrome. ECG
changes due to electrolyte abnormalities are thought to be related to their effects on the cardiac
myocyte action potential. The electrolytes imbalance in this patient could explain why there were
ECG changes which was not caused by coronary arteries occlusion. Thrombolysis is not the primary
management.
Conclusion: Raised cardiac enzyme and ST-segment changes on ECG during an event of heat stroke
cause a diagnostic dilemma by mimicking coronary artery occlusive myocardial infarction. Prompt
diagnosis, treating the underlying cause, intravenous fluid repletion and renal replacement therapy
needs to be done urgently for better prognosis of this patient.

49
This issue of Sarawak Health Journal is
published in conjunction with the 11th
Sarawak
State Health Research Day, held at Kingwood
Hotel, Sibu on the 14th
-15th
of August 2019.
The event was jointly organised by the
Sarawak State Health Department, Clinical
Research Centres of Sibu Hospital, Sarawak
General Hospital and Miri Hospital. There are
also some case reports submitted by the
authors who presented their works in other
conferences (pages 35 to 47). The papers and
authors’ names are published in accordance
with those received following the reviewers’
comments as well as editorial modifications.
All authors gave their permission for the
publication of their respective papers. Authors
that included previously published materials in
their papers assume the responsibility to obtain
permission from the copyright holder.
Disclaimer
The opinions expressed in the Sarawak Health Journal are those of the authors and contributors.
They do not necessarily reflect those of the editors, editorial committee, reviewers, advisors or the
Ministry of Health Malaysia. Any trade names, commercial products or organisations mentioned in
this journal does not imply endorsement by the editors, editorial committee, reviewers, advisors, or
Ministry of Health Malaysia.
Acknowledgement
We would like to thank the Director General of Health Malaysia for his permission to publish the
papers in this journal.
Official Publication of the Clinical Research & Post-graduate Society of Sibu Hospital
Publisher:
Clinical Research & Post-graduate Society
of Sibu Hospital
Batu 51/2, Jalan Oya Lama
96000 Sibu, Sarawak, Malaysia
Phone/Fax: 084-314569
Email: crps_sh@yahoo.com
Printer:
Borneo Printing Company Sdn. Bhd.
No. 7, Island Road, 96000 Sibu, Sarawak,
Malaysia
ISSN No: 2289-8344
Copyright Reserved. November 2020
Editors
Toh Teck Hock, MBBS, FRCPCH
Ngian Hie Ung, Bsc, MBBS, MPH
Wong Toh Mee, MBBS, MRCP
Advisors
Dr Chin Zin Hing, MBBS, M.MED (PH)
Prof. Datu Dr. Andrew Kiyu, MBBS, MPH, DrPH
External Reviewers
Teh Jo Hun, MD, MPH/DRPH
Wong Ling Siew, DDS, MSc (OMF Surg)
Emmanuel Joseph Fong Tsung, MD, MPH, DrPH
Technical Editors
Chuo Sing Hong, B.Pharm (Hons)
Kamilah Dahian, B.Biochem
Cover Design
Anthony Kiu Kiew Chiong
Administrative Assistant
Jipri Jimi
Wendy Lee Xiao Pin
2019/2020 Committee:
President: Dr Ngian Hie Ung (2019/2020)
Dr Mohamad Ng Siah Huat (2020)
Dr Justina Lau Sie Wei (2020)
Vice President: Dr. Toh Teck Hock
Secretary: Mdm Chuo Sing Hong
Assistant Secretary Dr. Wong Toh Mee
Treasurer: Dr. Yung Chun Hieng
Assistant Treasurer: Dr. Wong Siong Teck
Committee Members: Dr. Wong Voon Fei
Ms. Kamilah Dahian
Ms. Kueh Siau Chin
Matron Patimah Duat
Dr Anita Alias (2019)
Dr Chieng Chae Hee (2020)
Auditors: Dr Wong See Chang
Dr Nolan Teo (2019)
Dr Justina Lau Sie Wei (2020)

Sarawak Health Journal vol 7, 2020

Sarawak Health Journal vol 7, 2020

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