Malacca General Hospital (Malay: Hospital Besar Melaka) is a government-funded public hospital in Malacca City, Malacca, Malaysia. A secondary and specialist hospital, it serves as a referral centre for patients from primary and health centres in the state as well as the northern part of Johor and the Tampin district of Negeri Sembilan.
Acral lentiginous melanoma (ALM) with pleural metastases is rare and under-recognised. We report an 86-year-old woman with progressive dyspnoea and pleuritic chest pain. 18 months ago, she was diagnosed with stage IIC ALM of the right heel, and was treated with wide local excision, but she declined adjuvant therapy. Imaging demonstrated a large left pleural effusion with diffuse pleural thickening, pulmonary mass, and hepatic metastases. Brownish pleural fluid, along with thoracoscopic identification of multiple pigmented nodules, led to a histologically confirmed diagnosis. Talc pleurodesis was performed for symptom control, and best supportive care was pursued. This case highlights the diagnostic value of medical thoracoscopy in identifying pleural melanoma metastases and emphasises the need to consider melanoma recurrence when pigmented effusions are encountered.
INTRODUCTION:Adrenal insufficiency is a life-threatening condition that often presents with non-specific symptoms, complicating diagnosis in elderly patients. CASE REPORT:We report a case of a 77-year-old man with diabetes mellitus, hypertension and a history of cerebrovascular accident who presented with nausea, vomiting, weight loss and persistent giddiness. Laboratory tests revealed hyponatraemia and low serum osmolality. Further endocrine evaluation showed low morning cortisol, a suboptimal response to the short Synacthen test and suppressed adrenocorticotropic hormone levels confirming secondary adrenal insufficiency. The patient later disclosed recent use of a traditional Chinese medicine suggesting possible hidden glucocorticoid exposure and suppression of the hypothalamic-pituitary-adrenal axis. He improved after initiation of hydrocortisone replacement and discontinuation of the suspected products. DISCUSSION:This case emphasises the need for greater awareness of the potential adulteration of traditional Chinese medicines with glucocorticoids. It also highlights the critical role of laboratory testing in diagnosing adrenal insufficiency, detecting hidden adulterants and recognising the limitations of immunoassays in interpreting adrenal function tests.
Background: Tuberculous pleural effusion (TBE) and malignant pleural effusion (MPE) are the most common causes of exudative pleural effusion in tuberculosis-endemic regions. This study evaluates transthoracic ultrasound (TUS) features of TBE vs. MPE and incorporates clinical and pleural fluid (Pf) parameters into a machine learning-based random forest (RF) model for differentiation. Methods: This prospective observational study was conducted over 6 months across six tertiary hospitals in Malaysia, involving patients undergoing diagnostic medical thoracoscopy (MT). Diagnostic confidence for TBE and MPE was determined based on final thoracoscopic diagnosis. Logistic regression and RF models were applied to predefined clinical, imaging, and laboratory variables. Results: Among 187 recruited patients, 132 (70 TBE and 62 MPE) subjects with at least moderate diagnostic confidence were analyzed. On TUS, TBE was more likely to be non-hyperechoic, complex, and loculated, with the presence of fibrin and less pleural thickening, while MPE showed hyperechoic effusion and hemidiaphragm nodules. Independent predictors for TBE included younger age [adjusted odds ratio (aOR) =0.94], presence of fibrin (aOR =2.86), lower Pf lactate dehydrogenase (LDH) (aOR =0.996), and higher Pf adenosine deaminase (ADA) (aOR =1.10). Without Pf ADA, these parameters, along with the absence of hemidiaphragm nodules (aOR =0.33), remained significant for TBE prediction. The RF model outperformed logistic regression (92.6% vs. 87.9% accuracy), even without Pf ADA. Conclusions: TUS parameters can aid in differentiating TBE from MPE. The RF model demonstrated superior diagnostic performance, offering a potential point-of-care tool, even in the absence of Pf ADA.
