2009

Sathya A, Radhika R, Mahadevan S, Sriram U
Correspondence: Dr Sathya Anjali, anjalisathyab@yahoo.co.in

ABSTRACT
Hypothyroidism is a common problem in clinical practice, with diverse manifestations. Neuropsychiatric problems include affective disorders, disturbances in cognition and psychosis. Mania is commonly associated with hyperthyroidism. Only a few selected case reports mention mania as a presenting feature of hypothyroidism. We report a case of mania with psychotic symptoms in a 47-year-old woman who had no previous history of psychiatric disorder. She had signs of florid hypothyroidism. She required both antipsychotic drugs and thyroxine replacement for the amelioration of her symptoms. The report is followed by a brief review of the literature on mania as a clinical presentation of hypothyroidism and its probable pathogenesis. One has to have a high index of suspicion of underlying organic causes in patients presenting with depression, psychosis or cognitive disorders.

Keywords: hypothyroidism, mania, psychosis
Singapore Med J 2009; 50(2): e65-e67

Bruglia M, Palmonella G, Silvetti F, Rutigliano P, Criante P, Marmorale C, Boscaro M, Taccaliti A
Correspondence: Dr Augusto Taccaliti, a.taccaliti@univpm.it

ABSTRACT
A 44-year-old man with total thyroidectomy for papillary thyroid carcinoma (PTC) performed at the age of 38 years was referred for mediastinal metastases demonstrated on chest radiograph and high serum thyroglobulin (Tg 328 ng/ml). Computed tomography revealed mediastinal lymph node enlargement with left bronchial compression and reduction of bronchial diameter, as well as two metastases in the left lung. Bronchoscopic biopsy findings showed a poorly-differentiated PTC, while a whole body scan after 131-Iodine therapy demonstrated uptake in the right subclavicular region. External beam radiotherapy and chemotherapy yielded no benefit; the neoplasm was aggressive, diffuse and experienced fast growth, leading to the formation of metastases also at unusual sites, such as the skin and thigh muscle. The patient died from a brain metastasis. We report a rare case of PTC metastasis with a poorly-differentiated component in a young patient. Rapid and diffuse metastases also to unusual sites led to death eight years after the initial diagnosis and treatment.

Keywords: papillary thyroid carcinoma, skin metastasis, thigh metastasis, thyroglobulin, thyroid cancer
Singapore Med J 2009; 50(2): e61-e64

Mathew BK, Bandgar T, Menon PS, Shah NS
Correspondence: Dr Tushar Bandgar, drtusharb@gmail.com

ABSTRACT
A carotid body tumour is a rare presentation of an extra-adrenal pheochromocytoma. They commonly present with asymptomatic neck masses, and careful preoperative evaluation is required to find out the functional and vascular status of these tumours. We report three cases of carotid body paraganglioma, their evaluation, management and the final outcome.

Keywords: carotid body paraganglioma, carotid body tumour, paraganglioma, phaeochromocytoma
Singapore Med J 2009; 50(2): e58-e60

Khadgawat R, Singh Y, Kansara S, Tandon N, Bal C, Seith A, Kotwal P
Correspondence: Dr Rajesh Khadgawat, rajeshkhadgawat@hotmail.com

ABSTRACT
Oncogenic osteomalacia, or tumour-induced osteomalacia (TIO), is a rare paraneoplastic syndrome characterised by hypophosphataemia, phosphaturia, inappropriately low serum levels of 1,25-dihydroxyvitamin D for hypophosphataemia. TIO is caused by mesenchymal tumours that secrete phosphaturic substances, leading to increased renal wasting of phosphates. These tumours are very small in size and grow slowly. Localisation of these tumours has always been difficult with the available biochemical and imaging techniques. At times, despite all efforts, the tumour could not be localised. We report our experience with a 42-year-old woman with TIO where whole-body magnetic resonance imaging could not localise the tumour, a scapular haemangiopericytoma. PET/CT was helpful in the localisation of the tumour which, when surgically removed, resulted in the normalisation of biochemical parameters with clinical improvement.

Keywords: mesenchymal tumours, oncogenic osteomalacia, paraneoplastic syndrome, scapular haemangiopericytoma, tumour-induced osteomalacia
Singapore Med J 2009; 50(2): e55-e57

Rathore PK, Raj A, Sayal A, Meher R, Gupta B, Girhotra M
Correspondence: Dr Ankush Sayal, ankushsayal@yahoo.com

ABSTRACT
It is not unusual for a foreign body to be swallowed and become lodged in the oesophagus. It is, however, very unusual for such a foreign body to remain lodged for a period of six months. This particular case, a 37-year-old man, is interesting because of the length of time the foreign body, a denture, remained in the oesophagus without complications, its successful removal and the nature of the foreign body, which is prone to cause complications on prolonged stay or during removal.

Keywords: denture, foreign body, impacted foreign body, oesophagus
Singapore Med J 2009; 50(2): e53-e54

Ooi CK, Goh HK, Chong KT, Lim GH
Correspondence: Dr Ooi Chee Kheong, chee_kheong_ooi@ttsh.com.sg

ABSTRACT
We report two cases of penile strangulation that presented to our emergency department. In the first case, a 60-year-old man, the object of strangulation was a metallic ring that was extricated using an orthopaedic cutter in the operating theatre. The patient recovered uneventfully. In the second case, a 77-year-old man, the object of strangulation was a plastic bottle, which was extricated using surgical instruments in the emergency department, but the patient subsequently developed postobstructive diuresis. The first case illustrates the difficulty that may be encountered in this delicate yet urgent situation, while the second case reports a rare complication.

Keywords: obstructive uropathy, penis, penile strangulation, postobstructive diuresis, urethrocutaneous fistula
Singapore Med J 2009; 50(2): e50-e52

Wong DCM, Wansaicheong GKL, Tsou IYY
Correspondence: Dr Daniel Wong Chun Ming, mskimaging@hotmail.com

ABSTRACT
Musculoskeletal ultrasonography (US) of the hands and wrist has recently been increasing in popularity. Recent rapid technical advances in the US, such as new ultra-high frequency probes and smaller probe sizes, have led to improved image quality. This, in turn, has accelerated the growth of musculoskeletal US. Known advantages of US are its lack of ionising radiation, noninvasiveness, portability and low cost. Dynamic and real-time assessment and Doppler imaging are additional benefits of this modality, especially in the imaging of the hands and wrist. Superficial structures of the hands and wrist, including the tendons, ligaments, nerves and vessels, are amenable to imaging with high frequency US. In this article, we demonstrate a spectrum of hand and wrist pathology using US, including entrapment neuropathy, inflammatory conditions, traumatic injury and masses. Ultrasound-guided procedures applicable to the hand and wrist are also briefly discussed.

Keywords: hands and wrist, musculoskeletal imaging, nerves, tendons, ultrasonography
Singapore Med J 2009; 50(2): 219-226

Smith SI, Opere B, Goodluck HT, Akindolire OT, Folaranmi A, Odekeye OM, Omonigbehin EA
Correspondence: Dr Stella Ifeanyi Smith, stellaismith@yahoo.com

ABSTRACT
Introduction Microorganisms are transferred to everyday objects from the environment and infected individuals. Pathogenic microbes are transmissible from the air, skin, hands and other interpersonal contacts and cause diseases most of the time. This study centres on the microbial assessment of telephone receivers, their ability to transfer bacterial infections and the isolation of these microorganisms from receivers, with an emphasis on Staphylococcus aureus and its antibiotic susceptibility pattern.
Methods 1,591 isolates were obtained from roadside telephone booths in 16 different locations in the Lagos metropolis. They were all characterised using the Cowan and Steel’s manual, after which the antimicrobial susceptibility pattern of the most frequently-occurring isolate was determined.
Results Of all the locations, Oshodi was found to have the largest number of microorganisms, with Akoka having the least. The organisms were Providencia, Klebsiella, Citrobacter, Enterobacter, Proteus, Escherichia, Staphylococcus, Bacillus, Streptococcus, Micrococcus and yeast. Staphylococcus spp. was the most frequently occurring, making up 20.2 percent of the total number of isolated organisms, followed by Bacillus (18 percent), while Enterobacter and Citrobacter were the least common. 44 percent of the total Staphylococcus screened for an antimicrobial susceptibility pattern showed high resistance to most of the antibiotics used.
Conclusion This result could be related to the emergence of Staphylococcus-resistant strains, especially in a highly-populated area where there are health and hygiene problems and where drugs are abused. Precautions should be taken to prevent the spread of infectious diseases through the use of public telephones.

Keywords: antibiotic resistance, antimicrobial susceptibility pattern, Staphylococcus aureus, telephone receivers
Singapore Med J 2009; 50(2): 208-211