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Autosomal dominant chronic mucocutaneous candidiasis (CMC) without endocrinopathy (OMIM 114580) is a well-described entity. The associations recorded with this disorder to date are intercellular adhesion molecule-1 (ICAM-1) deficiency and hyper-immunoglobulin E syndrome.We report a new association in a family (mother and nonidentical twin sons) where acne rosacea is a prominent feature together with CMC. In addition, antibodies to thyroid microsomal and antiparietal cell were also isolated. The autoantibodies might be associated with a current "latent" endocrinopathy in particular autoimmune thyroiditis.The patient was treated with intermittent pulses of itraconazole for the candidiasis and doxycycline initially before being substituted with isotretinoin 6 months later for the rosacea.The patient's candidiasis responded well and has been in remission for 3 months while his rosacea continues to improve.

Mycobacterium haemophilum, a nontuberculous mycobacterium (NTM) that was first described in 1978, is a pathogen that can cause an array of symptoms in immunocompromised patients, predominantly cutaneous.We report our hospital's experience with the first 3 patients diagnosed with this infection from 1994 to 2002. All were women; one had systemic lupus erythematosus (SLE), one had mycosis fungoides and the last had Sjogren's syndrome with recurrent bacterial infections, although the specific nature of her immunocompromised state has not been defined. All were HIV negative. All 3 women presented with cutaneous lesions--the first with recurrent erythematous plaques on the limbs and back, the second with tender nodules and abscesses on the knees, and the third with papular eruptions on the cheek.All responded to a combination of antibiotics and are presently still undergoing treatment and follow-up.Infections caused by M. haemophilum occur mainly in immunocompromised patients. They can present with a variety of cutaneous manifestations, which require a high index of suspicion and coordination between the treating physician and the laboratory for diagnosis. Combination antibiotic treatment is recommended, and patients should be followed up after treatment to survey for possible relapse.

The objective was to evaluate the incidence of gastrointestinal abnormalities amongst those fetuses with antenatally diagnosed echogenic bowel (EB).A retrospective review of all cases delivered from April 2002 to March 2003 with antenatally diagnosed EB was conducted. This was defined as bowel that appeared as echogenic as (if not greater than) the iliac bone on a real-time image. The postnatal outcomes with regard to gastrointestinal abnormalities, till their discharge, were noted.Of the 13,941 patients delivered, there were 70 cases with antenatally diagnosed EB, giving an incidence of 70/13,941 or 0.50%. Of these, 6 defaulted follow-up and 1 had a mid-trimester termination of pregnancy at 21 weeks' gestation for social reasons. Of the remaining 63 cases with EB, 2 were stillbirths at 31 weeks and 35 weeks of gestation, respectively. Three fetuses (3/63 or 4.76%) were diagnosed with gastrointestinal abnormalities. Meconium plug syndrome was diagnosed postnatally in 2 cases, of which, 1 resolved with conservative management while the other required an emergency laparotomy. Intestinal atresia was diagnosed in the postmortem of one of the stillbirths. There was evidence of intrauterine growth retardation (IUGR) in both the stillbirth and the fetus that had required laparotomy. None of the 3 fetuses exhibited clinical features of aneuploidy.As the quoted background risk for gastrointestinal pathology is 0.23%, an increased incidence (4.76%) is observed in those fetuses found to have antenatal EB. It is possible that the presence of IUGR is associated with a worse prognosis. Further prospective studies are needed to verify this association.

Sotalol is a potent antiarrhythmic often used in patients with atrial fibrillation. However, it has been associated with a risk of provoking other potentially dangerous arrhythmias, especially if used in high doses and in patients with uncorrected electrolyte imbalance or impaired renal and cardiac function.We present 4 patients with atrial fibrillation treated with sotalol who developed torsade de pointes due to marked prolongation of the QT interval. While 1 patient had renal failure, all had normal left ventricular function. One patient had been treated with sotalol for more than 10 months before developing torsade de pointes precipitated by hypokalaemia, while another had tolerated sotalol for a 3-month period before the drug was discontinued, and only developed torsade de pointes when the drug was restarted 2 years later. Significantly, the doses used in all patients were relatively low, in contrast to most other reported cases where higher doses were used.As with all antiarrhythmic therapy, these cases illustrate the need for close follow-up of patients treated with sotalol, even if relatively low doses are used. In addition, patients who had previously tolerated the drug well are still susceptible to its proarrhythmic effects.

This is a review of sexual knowledge, behaviour and the extent of sexually transmitted infections (STI), including human immunodeficiency virus (HIV) infection, in Singapore adolescents.Data were retrieved from relevant studies, reports and statistics concerning STI and HIV in Singapore.For many reasons, adolescents are at a higher risk of acquiring STI and HIV infections. Adolescents in Singapore are still relatively conservative in their sexual attitudes and behaviour. Most of those who had sex never used condoms. Fortunately, the incidence of STI and HIV infections among adolescents is relatively low. However, this may be changing, and there is a proportion of individuals who exhibit higher risk behaviours.In this age of rapidly changing morals and values, accurate information and skills need to be provided to young people to ensure that they are adequately prepared to protect themselves from acquiring STI/HIV infection.

Since the introduction of BCG vaccination in 1921, there have been numerous reports of cutaneous complications. Although common local effects such as erythema, soreness and local abscesses are well known, the incidence of cutaneous granulomas and BCG-induced lupus vulgaris is rare.This is a retrospective analysis of our local experience in dealing with cases of cutaneous granulomas following BCG vaccination. Cases were seen at a local tertiary level dermatological referral centre.There were 14 cases seen over an 8-year period. Of these cases, 4 were clinically suggestive of BCG-induced lupus vulgaris, but only 1 of these cases was confirmed by culture. All but one of these cases had developed these complications after multiple BCG vaccinations. The 3 suspected but unconfirmed cases were treated with isoniazid. The 1 case of confirmed BCG-induced lupus vulgaris was treated with rifampicin and ethambutol, as sensitivity testing revealed resistance to isoniazid. All 4 cases responded well to treatment. The other 10 cases of vaccine-induced cutaneous granulomas responded to local symptomatic treatment.Although local effects such as induration and pustule formation at the injection site are not rare, the development of cutaneous granulomas is uncommon. Incidence of complications increases with multiple vaccinations. Cases usually respond to local symptomatic therapy, while more aggressive lesions responded to the use of oral isoniazid. Confirmed cases of BCG-induced lupus vulgaris should be treated based on antibiotic sensitivity profile.

Sexually transmitted diseases (STDs) in persons older than 50 years are rarely studied because STDs are more common in young people.To study the distribution and types of STDs in older persons, defined in our study as individuals aged 50 years or older.Retrospective analysis of surveillance data for diseases notified under the Infectious Disease Act, which include syphilis, gonorrhoea, non-gonococcal urethritis (NGU), vaginal discharge and chancroid. Human immunodeficiency virus (HIV) infections were not included. Data from notifications of diseases, such as genital herpes and genital warts, which are not compulsory, were also analysed. Period of study was from January 1996 to December 2000.During the study period, STD notifications for persons aged 50 years and older accounted for 7.6% of all notifications. Among these older persons, males were predominantly affected. The most common disease notified in older persons was gonorrhoea (600 cases), followed by non-infectious syphilis (578 cases) and NGU (339 cases). There were 76 cases of infectious syphilis. The age-specific disease rates for this group of older patients were as follows (number of cases per 100,000 patients per year): gonorrhoea-17.61, non-infectious syphilis-16.96, infectious syphilis-2.23, NGU-20.66, genital warts-6.92 and genital herpes-7.33.Although STDs occur mainly in the young, it affects a small but significant proportion of persons aged 50 years and older. A better understanding of the epidemiology of STDs in these population is important for reducing STD morbidity and improving STD care.

Women with history of gestational diabetes mellitus (GDM) have up to 50% lifetime risk of developing frank diabetes mellitus (DM). They are an ideal group of patients to implement early interventional measures to halt the progression to diabetes. The success of any early intervention programme would depend largely on postpartum follow-up. We set out to study the response rate to postpartum oral glucose tolerance test (OGTT) and to profile the non-responders on 105 women who attended our Gestational Diabetes Joint Clinic (GDJC).We divided these women into 3 groups according to their response to postpartum OGTT and compared their weights, glycaemic parameters and other clinical characteristics during gestation. Group A comprised non-responders or those who did not turn up for postpartum OGTT; group B comprised responders with a normal postpartum OGTT; and group C comprised responders with an abnormal postpartum OGTT defined as 2-hour plasma glucose equal or more than 7.8 mmol/L.The non-respondent rate to postpartum diabetes screening was 37.1%. The non-responders were found to be significantly heavier, with more severe hyperglycaemia during their pregnancy (in terms of glycosylated haemoglobin and results of antepartum OGTT) and had bigger babies compared to the responders with normal postpartum OGTT. Their features instead resembled those who had failed their postpartum OGTT.The group of non-responders was probably at similar risk of developing glucose intolerance postpartum as those who were tested abnormal. A more effective call and recall system and education programme is, therefore, needed to ensure postpartum attendance of all patients with GDM.

Diabetic ketoacidosis is generally thought to be the classical presentation of individuals with Type 1 diabetes. Clinicians are beginning to see individuals with atypical diabetes presenting with severe hyperglycaemia associated with or without ketosis and after the initial period of intensive insulin therapy, becoming non-insulin dependent and remaining in remission for years. So far, these patients have only been identified amongst African Americans and have only recently been reported amongst the Japanese and the Chinese in Hong Kong. We therefore set out to identify the existence of such patients in our population.We have a database of patients admitted for diabetic ketoacidosis. From this, we recruited patients who fulfilled the criteria for atypical diabetes and proceeded to perform a retrospective analysis together with a prospective analysis of their outcome.We identified 10 individuals with atypical diabetes with characteristics similar to those previously described. Our data showed that these patients deferred from classical individuals with Type 1 diabetes in the following ways--older age of onset, relatively higher BMI, marked elevation in HBA1c suggesting a significant period and degree of hyperglycaemia and prolonged remission after reversal of hyperglycaemia.Atypical Type 2 diabetes exists in our population. Clinicians looking after individuals with diabetes should be made aware of this as there are important implications in the subsequent management of such patients.

Granuloma annulare (GA) is a benign, inflammatory skin disorder that has no proven aetiology or widely accepted theory of pathogenesis. We present the results of a local study examining the characteristics of this disorder.This is a retrospective study of 41 patients with granuloma annulare seen at a tertiary dermatological skin hospital in Singapore. The disease was classified based on whether it was localised or generalised. Remission rates and associated diseases were documented.The majority (93.9%) of lesions were localised. GA tends to occur within the first three decades of life, and 39.4% of patients were 10 years old and below. There was a slight female preponderance, and no predilection for any particular racial group. Remissions were seen in 67.6% of patients who were followed up for at least 12 months, and remissions only occurred with the localised form of GA. There were 4 cases of disseminated GA and 1 case of perforating GA. There were 6 patients with associated diabetes mellitus, 2 with pulmonary tuberculosis, and 4 patients each with hypercholesterolaemia and a history of atopy.The characteristics of GA in our local population do not differ significantly from that of overseas studies. While localised forms of GA have a high chance of resolving, the generalised forms of the disease are difficult to treat and do not tend to resolve totally.

To study the minimum inhibitory concentrations (MICs) of Propionibacterium acnes (P. acnes) isolates to selected antibiotics from patients with acne vulgaris in Singapore and determine if resistance increases with prolonged use of antibiotics.A single-centre prospective study.Tertiary dermatological referral centre in Singapore.One hundred and fifty patients with acne vulgaris seen at the National Skin Centre.In patients who had never been on antibiotics, there were no resistant isolates of P. acnes. In patients who had been on short-term antibiotics (between 6 to 18 weeks), there were 2 resistant strains among the 34 isolates (6.25%); in patients who had been on antibiotics for longer periods, there were 11 resistant strains among the 51 isolates (21.6%). The differences in the rates of isolation of resistant strains between patients who had not been on antibiotics to those that had been on long-term antibiotics were statistically significant (P = 0.015). There was also a significant difference in isolation of resistant strains from those on short-term antibiotics compared to those who had been on long-term antibiotics (P = 0.036). Resistance to erythromycin was most commonly encountered. Most of the erythromycin-resistant strains also showed cross-resistance to clindamycin. The average MICs to antibiotics such as minocycline, erythromycin and clindamycin in those on long-term antibiotics were significantly higher when compared to patients who had not been on antibiotics.Antibiotic resistance in P. acnes isolates in Singapore follows similar patterns to studies conducted in Europe. Resistance to erythromycin was most commonly seen, and this is associated with cross-resistance to clindamycin. Among the tetracycline group of drugs, the average MICs to tetracycline was higher than that for doxycycline, which in turn was higher than that for minocycline. Antibiotic resistance can occur with short-term antibiotic courses, and the rate of resistance increases as the duration of antibiotic consumption increases.

The role of polymerase chain reaction (PCR) in the diagnosis of cutaneous tuberculosis in clinical practice has not been defined as no PCR assay has been tested in a large-scale clinical study. The objective of this study was to test the clinical utility of a PCR assay in the diagnosis of different types of cutaneous tuberculosis and tuberculids.Analysis of archival biopsy specimens by a nested PCR assay targeting IS6110 of Mycobacterium tuberculosis (M. tb) DNA was performed in a tertiary-care skin hospital in Singapore. PCR results were compared with cultures and concordance with final diagnosis. PATIENTS AND SPECIMENS: One hundred and nineteen skin biopsies from 105 patients comprising 58 cases of confirmed or highly probable cutaneous tuberculosis, ranging from multibacillary infections to paucibacillary forms and 47 cases of possible tuberculids were analysed. Twenty-four subjects with non-tuberculous granulomas and normal skin controls were included.In 14 immunocompromised patients with multibacillary mycobacterial infections (AFB+ on biopsy), PCR was positive in 9 patients. Correlating PCR results with the final diagnosis, the PCR technique was 100% sensitive and specific in this group. In paucibacillary tuberculosis, PCR positivity rates were 55% for tuberculosis verrucosa cutis (38 cases) and 60% for lupus vulgaris (5 cases). When confirmed cases of tuberculosis were considered, the overall sensitivity was 73%. In 26 cases of erythema induratum, PCR was positive in 54% and correlated with a documented response to anti-tuberculous treatment in 80%.The use of PCR in the routine diagnostic panel for cutaneous tuberculosis should take into consideration the differential sensitivities for different clinical types. In the setting of an immunocompromised patient with AFB+ lesions, PCR has a definite role in rapid diagnosis and in differentiating atypical mycobacterial infection from tuberculosis. Where paucibacillary tuberculosis is suspected, clinical decision should not be based on PCR results alone. In erythema induratum, we found some correlation between PCR results and response to anti-tuberculous therapy.

Vegetative lead infection is an uncommon complication of permanent pacemaker implantation. The diagnosis is difficult using conventional imaging methods.An elderly Indian woman with a history of diabetes mellitus developed Staphylococcus aureus infection after implementation of a permanent pacemaker. Following a non-diagnostic transthoracic echocardiogram, transoesophageal echocardiography was performed and showed a large vegetative mass attached to the pacemaker lead within the right atrium.The pacemaker was removed and intravenous vancomycin administered for six weeks.She was discharged well but demised two months later from a second episode of septicaemia.Pacemaker lead infection remains a challenging management problem. Transoesophageal echocardiography can facilitate its diagnosis.

A case of Mycobacterium marinum infection presenting with a sporotrichoid spread in a HIV positive Chinese male is presented. The patient responded to oral cotrimoxazole treatment. A brief review of the literature concerning atypical mycobacterial infection presenting in such a fashion is discussed.

Resistance to activated protein C (APC-R) is the commonest inherited cause of thrombosis among Caucasians. Few studies have been carried out on its prevalence in Asians. We conducted a prospective study on 60 patients with thromboembolism to determine its prevalence in our local population. The Factor V Leiden (VaQ506) mutation associated with this condition was detected by amplification of the Factor V gene by polymerase chain reaction (PCR) and digestion of the fragment with Mnl I. Three patients were found to be heterozygous for this mutation. None of the 3 patients had other concomitant hypercoagulable states. In addition, we studied the prevalence of this condition in Malays which was found to be 0.5%. Our study suggests that the incidence of APC-R is much lower here compared to the West.

This study was done to assess the specificity and sensitivity of the DNA amplification assays of ligase chain reaction (LCR) and polymerase chain reaction (PCR) on urine specimens to detect Chlamydia trachomatis infections in both male and female patients seen at a sexually transmitted diseases (STD) clinic in Singapore, compared with other diagnostic methods currently in use. A total of 100 patients were selected; 50 male patients diagnosed with non-gonococcal urethritis based on symptoms and a positive Gram-stained urethral smear and 50 female asymptomatic sex workers were assessed. Automated assays using LCR and PCR were used, and compared to enzyme immunoassays, chlamydial cell cultures and PCR of urethral and endocervical swab specimens. In male patients, LCR and PCR of urine specimens had sensitivities of 100%, compared to 87.0% for PCR of urethral swab specimen, 82.6% for enzyme immunoassay (EIA) and 91.3% for cell cultures. In female patients, LCR and PCR of urine samples achieved sensitivities of 77.8% and 88.9% respectively, compared with 55.6% for PCR of endocervical swab specimens, 22.2% for EIA and 66.7% for cell cultures. LCR and PCR of urine samples provided higher sensitivity compared to cell cultures, EIA and PCR of urethral and endocervical swab specimens. The use of LCR and PCR on urine as a non-invasive means of detecting chlamydial infections is viable, and may have a role to play in population-based screening programmes.

We report three cases of aplasia cutis congenita of the scalp affecting two siblings and their mother, suggesting group 1, or autosomal dominant aplasia cutis congenita not associated with multiple abnormalities. A review of the clinical features and literature concerning this heterogenous and rare condition is presented.

Prostate specific antigen (PSA) and transrectal ultrasound (TRUS) are two new modalities added to improve our ability to diagnose prostate cancer at an early stage. We reviewed our own experience of 100 cancers among 579 men from August 1991 to October1994. The detection rate was 17.3%. Digital rectal examination (DRE) alone had a positive predictive value (PPV) of 39.9%. The PPV for PSA was 23%. The combination of PSA and DRE gave a PPV of 47.2%. TRUS had a PPV of 30.6%. Features of cancer on TRUS may be both hypoechoic or hyperechoic nodules which appeared to have almost equal proportions associated with cancer. The addition of age-specific ranges did not affect the PPV of PSA. The PPV of the combination of TRUS and DRE was 53%. With all 3 modalities combined, the PPV was 58.8%. An interesting finding from the study was the higher average PSA for benign and malignant disease in the local population and cases of acute retention of urine. There was a higher incidence of prostatitis and lower incidence of cancer in cases with retention of urine.

In the evaluation of the subfertile man who has severe oligospermia or azoospermia associated with a low volume ejaculate, the high resolution transrectal ultrasound (TRUS) has, in recent years, been a very important non-invasive imaging technique to detect abnormalities in the seminal vesicles, ejaculatory duct and the status of the prostate. We performed TRUS in 30 of these patients from January to December 1994 followed by scrotal exploration with vasogram using methylene blue, inspection of the epdidymis for dilatation and fibrosis together with testicular biopsy to evaluate testicular spermatogenesis and obstruction. Of the 30 patients, 11 were found to have dilated vesicles or ejaculatory duct obstruction. Three had features of prostatitis with calcification or thickened wall of the vesicles and one had an absent vesicle and vas. The remaining 15 patients had normal seminal vesicles and ejaculatory ducts on TRUS and their testicular biopsies showed atrophy, fibrosis or maturation arrest. Transurethral resection of the ejaculatory duct (TRU-ED) under TRUS guidance was done for 10 patients with dilated seminal vesicles and 6 of them had normal semen analysis 3 months after operation. Two successful pregnancies were achieved.