2009

Sulaiman S, Tan KH
Correspondence: Dr Tan Kok Hian, khtan@kkh.com.sg

ABSTRACT
A 26-year-old Chinese woman first presented to the Singapore Anti-Tuberculosis Association with fever and cough, and was diagnosed with pulmonary tuberculosis. She was then referred to KK Women’s & Children’s Hospital to exclude a gynaecological pathology when she was found to have abnormally high levels of cancer antigen CA125 in a health screening done concomitantly. Pelvic examination and pelvic ultrasonography were normal. Other tumour markers (CA199, CEA, AFP and BHCG) were normal. The level of CA125 was monitored and returned to normal levels with anti-tuberculosis treatment. A non-gynaecological diagnosis like pulmonary tuberculosis must always be considered as one of a differential diagnosis in a woman presenting with a markedly-raised CA125.

Keywords: cancer antigen 125, health screening, pulmonary tuberculosis, tuberculosis
Singapore Med J 2009; 50(1): e39-e40

Athappan G, Chengat V, Unnikrishnan A, Chandraprakasam S, Kumar S, Ganesh N
Correspondence: Dr Ganesh Athappan, ganeshathappan@gmail.com

ABSTRACT
Aortic dissection is a rare and life-threatening event. While pain is the most common symptom of aortic dissection, it may be absent in ten percent of patients and present with a myriad of symptoms suggestive of a diverse range of other conditions. A high index of clinical suspicion is mandatory for the accurate and rapid diagnosis of aortic dissection. We report a 25-year-old woman with aortic dissection presenting as a posterior circulation stroke. This combination is very rare.

Keywords: aortic disease, aortic dissection, cerebellar infarct, cerebrovascular accident, chronic aortic dissection, posterior circulation stroke, stroke
Singapore Med J 2009; 50(1): e35-e38

Abdul Ghani R, Zainudin S, Kamaruddin NA, Kong NCT
Correspondence: Dr Rohana Abdul Ghani, agrohana@gmail.com

ABSTRACT
Drug-induced acute interstitial nephritis is a well-recognised and important reversible cause of acute renal failure. Peroxisome-proliferator activated receptor-gamma agonists, such as rosiglitazone, have been proven to be safe in chronic kidney disease patients. We describe a 65 year-old-man with long-standing diabetes mellitus and hypertension, presenting with a five-day history of fluid overload and uraemic symptoms. There was no ingestion of analgesics, alternative medicine and other nephrotoxic drugs, the only new prescription being rosiglitazone, which was commenced during his last clinic follow-up two weeks prior to presentation. He required haemodialysis with minimal improvement in renal profile, despite cessation of the offending drug. Renal biopsy revealed findings consistent with acute interstitial nephritis. An episode of upper gastrointestinal bleeding with bleeding duodenal ulcer limited the use of steroids. He was treated with a course of mycophenolate mofetil which showed good gradual response and he remained stable with residual renal impairment.

Keywords: acute interstitial nephritis, acute renal failure, mycophenolate mofetil, peroxisome-proliferator activated receptor-gamma, rosiglitazone, thiazolidinediones
Singapore Med J 2009; 50(1): e32-e34

Kandpal H, Bhatia V, Garg P, Sharma R
Correspondence: Dr Raju Sharma, raju152@yahoo.com

ABSTRACT
Annular pancreas is an uncommon congenital anomaly that usually presents early in childhood. The role of endoscopic ultrasonography in the diagnosis of this condition has been only sparsely reported. We present annular pancreas in a 50-year-old man; the anomaly was initially suspected during endoscopy and endoscopic ultrasonography, and subsequently confirmed on magnetic resonance cholangiopancreatography.

Keywords: annular pancreas, endoscopic ultrasonography, magnetic resonance cholangiopancreatography, pancreatic anomaly
Singapore Med J 2009; 50(1): e29-e31

Korula A, Shah A, Philip MA, Kuruvila K, Pradhip J, Pai MC, Chacko RT
Correspondence: Dr Anu Korula, chinnukorula@rediffmail.com

ABSTRACT
Synovial sarcoma is a distinctive soft tissue neoplasm, most commonly seen in the extremities of young adults. Mediastinal synovial sarcoma is a well-documented entity; however, in many cases, the differentiation between this and other spindle cell tumours may be difficult, especially in monophasic tumours. Unlike most pleuropulmonary synovial sarcomas which are well circumscribed, mediastinal tumours are often infiltrative and resection may not be adequate, leading to a high rate of recurrence. We present a 49-year-old man with a primary pericardial synovial sarcoma, with transdiaphragmatic intra-abdominal extension, which clinically, radiologically and grossly mimicked a tuberculous pericarditis.

Keywords: mediastinal synovial sarcoma, pericardial effusion, pericardial synovial sarcoma, pericarditis, synovial sarcoma
Singapore Med J 2009; 50(1): e26-e28

Ahsan H, Ajmal F, Saleem MF, Sonawala AB
Correspondence: Dr Humera Ahsan, humera.ahsan@aku.edu

ABSTRACT
A 28-year-old Pakistani man was admitted with unresolved severe headaches for the past four weeks. Magnetic resonance (MR) imaging and MR angiography showed an enhancing mass in the sphenoid sinus, bilateral cerebellar infarcts and aneurysmal dilatation of the basilar artery. The differential diagnosis included fungal infection versus neoplastic lesion. The scrappings taken through the endoscope from the sphenoid sinus were initially negative for fungal infection. However, the second biopsy, done after putting him on antifungal, itraconazole 200 mg twice daily, revealed the presence of a fungal infection (aspergillosis). MR imaging revealed extension of the fungal infection from the sphenoid sinus into the clivus, and then intracranially. Imaging also revealed aneurysmal dilatation of the basilar artery and infarctions in the cerebellum and subarachnoid haemorrhage. Despite aggressive antifungal treatment, the patient died after 29 days. This case report describes the probable mechanism of fungal mycotic aneurysmal vascular dilatation and growth. It also points to the need for a rapid diagnosis of potential cases and an aggressive treatment approach of confirmed cases of fungal infections of the central nervous system.

Keywords: aspergillosis, aspergillus sinusitis, cerebral fungal infection, mycotic aneurysm, sinonasal infections, subarachnoid haemorrhage
Singapore Med J 2009; 50(1): e22-e25

Santhosh K, Kesavadas C, Thomas B, Gupta AK, Kapilamoorthy TR, Radhakrishnan VV
Correspondence: Dr C Kesavadas, chandkesav@yahoo.com

ABSTRACT
Magnetic resonance imaging features of three benign cystic lumbosacral schwannomas, which showed multiple fluid-fluid levels, are described. One of the tumours showed bone destruction with fluid-fluid levels that closely mimicked an aneurysmal bone cyst. Pathological examination confirmed haemorrhage as the cause of fluid-fluid levels in the tumours. Though a rare finding, fluid-fluid levels with bone destruction can also be caused by nerve sheath tumours and hence must be included in the list of differential diagnoses of spinal tumours.
 

Keywords: cystic schwannoma, fluid-fluid levels, haemorrhagic tumour, lumbosacral schwannoma, schwannoma
Singapore Med J 2009; 50(1): e16-e21

Lau KY, Lo SWS, Sy NLA
Correspondence: Dr Sherwin SW Lo, sherwinlo@gmail.com

ABSTRACT
Arterioportal fistulas are rare. Superior mesenteric arteriovenous fistula is uncommon and usually observed in patients who have abdominal trauma or have undergone abdominal surgery. If untreated, mesenteric arteriovenous fistula is potentially fatal due to portal hypertension with potential complications such as massive variceal bleeding or progressive liver failure. We report a 50-year-old Chinese man who had a history of abdominal surgery and presented with recurrent haematemesis. He was diagnosed by multidetector computed tomography to have a superior mesenteric arteriovenous fistula. Subsequently, he presented with acute bleeding oesophageal varices. Emergency transarterial embolisation was successfully performed to arrest the bleeding.

Keywords: angiography, bleeding oesophageal varices, emergency transarterial embolisation, haematemesis, mesenteric arteriovenous fistula, multidetector computed tomography
Singapore Med J 2009; 50(1): e12-e15

Khin YT, Peh WCG, Lee VKM, Teo HEL, Ng SB, Nathan SS
Correspondence: Dr Khin Yadanar Thein, kythein@yahoo.com

ABSTRACT
A nine-year-old boy presented with increasingly worsening right shoulder pain of 18 months’ duration. On physical examination, there was a tender firm swelling over the right upper arm. Radiographs showed a large osteolytic lesion in the proximal humeral diaphysis, with prominent mixed acute-on-chronic periosteal reaction in a lamellar fashion. There was a pathological fracture. The lesion appeared to be radiographically aggressive in nature. Bone scintiscan showed solitary marked uptake. On-table frozen section histopathological examination of the lesion showed an osteoblastic lesion with aggressive features. Completion curettage and high speed burring of the cavity was performed. In view of the patient’s young age, which required a biological solution, and potential for local recurrence, that necessitated a radiopaque filler, the lesion was packed with a calcium phosphate cement paste. The final diagnosis was osteoblastoma with aggressive features. The patient remained well on follow-up to date. The filler continues to be remodelled to native tissue and there is no evidence of local recurrence. Osteoblastoma is a relatively rare benign tumour that typically occurs in the posterior elements of the vertebral column. The humerus is a very rare site of disease in the appendicular skeleton, and poses a diagnostic dilemma which implicates the possibility of osteogenic sarcoma.

Keywords: bone tumours, osteoblastoma, osteogenic sarcoma, paediatric tumour
Singapore Med J 2009; 50(1): e1-e4