Bone health status was investigated in 178 free-living Chinese post-menopausal women in Kuala Lumpur. Body mass index (BMI), body composition (using whole body DXA), calcium intake and serum 25-OH vitamin D status were measured along with biochemical markers of bone turnover, that is, pro-collagen Type 1 N-terminal peptide (P1NP), osteocalcin (OC) and C-telopeptide ß cross link of Type 1 collagen (CTX- β). Bone mineral density (BMD) was measured using DXA (Hologic, USA) at the lumbar spine, femoral neck and total hip. Results showed that osteopenia was present in 50% of the subjects at the spine and 57.9% at the femoral neck. Osteoporosis was diagnosed in 10% of the subjects at both the femoral neck and spine. A total of 29.3% of the subjects had high levels of CTX- ß. Mean serum level of 25-OH vitamin D was 60.4+15.6 nmol/L and 50.6% of the subjects had hypovitaminosis D (defined as <50 nmol/l). Mean total calcium intake of the subjects was 497 + 233 mg, of which only 14% met the RNI for calcium with the additional intake of calcium supplements. Body fat was also significantly correlated (r=0.181, p<0.05) with BMD at the spine but not BMD at the femoral neck. Lean body mass was positively correlated with BMD at the spine (r=0.289, p<0.001) and femoral neck (r=0.295, p<0.001). CTX-β was negatively correlated with BMD at the spine (r= -0.235, p<0.001), whereas P1NP (r=-0.215, p<0.001) and osteocalcin (r=-0.265, p<0.001) were both negatively correlated with BMD at the femoral neck. Generally, the study found that women with osteopenia had higher levels of bone turnover markers, less lean body mass and lower calcium intake than women with normal BMD. In conclusion, this study demonstrated that the majority of free living Chinese post-menopausal women in Kuala Lumpur have low calcium intake, low 25-OH vitamin D status and low bone mass and elevated biochemical markers of bone turnover.

Antihistamine is standard chronic spontaneous urticaria (CSU) therapy. Weight gain is a side effect of concern as prolonged high dose therapy is common. We investigated the effects of 12-weeks loratadine therapy on weight, appetite and parameters of metabolic syndrome (MetS). A cohort study was performed involving CSU patients aged ≥18 years. Patients with diseases or on drugs affecting weight or appetite were excluded. CSU was treated according to standard management. Weight, height, waist circumference (WC), body mass index (BMI) and blood pressure (BP), Urticaria Activity Score 7 (UAS7), Dermatology Life Quality Index (DLQI), hunger and satiety questionnaire, fasting blood sugar (FBS) and fasting lipid profile (FLP) were obtained at baseline, week 6 and week 12. Loratadine cumulative dose were determined. Thirteen (33.33 %) males and 26 (66.67 %) females aged 33.00 (12.00) years participated. Median weight was 62.55 (18.30) kg, BMI 24.60 (6.80) kg/m2, 13(33.33%) patients had normal weight, 12 (30.77%) overweight, 11 (28.21%) obese and 3 (7.69%) underweight. Significant weight gain was observed at week 6, 67.56 ± 16.14 kg vs 68.16 ± 16.95 kg, p < 0.05 and 67.56 ± 16.14 kg vs 64.73 ± 14.60 kg, p = 0.04 at week 12. Changes in BMI, WC, BP, FBS and FLP were insignificant. Three patients developed MetS. Hunger and satiety scores were unaffected. Loratadine induced weight gain despite no effects on appetite. Weight should be monitored in patients on long term loratadine therapy.

Diabetes in pregnancy is associated with risks to the woman and her developing fetus. Management of the condition at the primary care level includes pre-conception care, screening, diagnosis, as well as antenatal and postpartum care. A multidisciplinary approach is essential in ensuring its holistic management.

We present the rare case of a 47-year-old woman with protracted primary hyperparathyroidism complicated by communicating hydrocephalus and cerebellar tonsillar herniation secondary to calvarial thickening. The parathyroidglands remained elusive, despite the use of advanced preoperative imaging modalities and three neck explorations.The serum calcium was optimally controlled with cinacalcet and alfacalcidol. Awareness of this rare complication is essential for early diagnosis and prompt intervention to prevent fatal posterior brain herniation
Cinacalcet ; Hydrocephalus ; Hypercalcemia ; Hyperparathyroidis

Hypophosphatemic osteomalacia is a rare form of metabolic bone disorder in neurofibromatosis type 1 (NF1). The exact disease mechanism of this disorder in NF1 is yet to be established. We present a 44-year-old female known to have NF1, who presents with debilitating bone pain, weakness and multiple fractures. Laboratory investigations showed persistent hypophosphatemia with renal phosphate wasting suggestive of hypophosphatemic osteomalacia. She also had concomitant vitamin D deficiency which contributed to the disease severity. Medical therapy with oral phosphate and vitamin D improved her symptoms without significant changes in fracture healing or phosphate levels.
Hypophosphatemia ; Osteomalacia ; FGF23 ; Vitamin D Deficiency

Antiphospholipid syndrome is a hypercoagulable autoimmune condition that predominantly affect the female and commonly manifest as arterio-venous thrombosis and recurrent miscarriage. Here, we present a unique case of a healthy young man who developed sudden onset of right leg swelling after exercise which was then found to be due to deep vein thrombosis via Doppler ultrasound. His blood investigations showed thrombocytopenia and prolonged coagulation profile. Therefore, antiphospholipid syndrome was suspected and later confirmed by positive autoimmune antibodies. He was treated with long term moderate intensity oral warfarin. The objective of this case report is to share the uncommon occurrence of an unprovoked deep vein thrombosis secondary to antiphospholipid syndrome in a healthy young man so that the possibility of deep vein thrombosis should be suspected in selected cases of non-resolving leg swelling after exercise as it can lead to fatal pulmonary embolism.

A 58-year-old male presented with persistent severe headache, lethargy, decline libido and no neurological deficits. Besides quadruple anterior pituitary hormonal deficiencies, magnetic resonance imaging (MRI) demonstrated an enlarged ring-enhanced non-homogenous pituitary. Following hormonal replacement, these symptoms improved but empty sella evolved. The challenges of diagnosis and management were discussed. Awareness of the unclear etiologyand uncertain clinical course of autoimmune hypophysitis in a man in this age group is essential for prompt and appropriate management.

Autoimmunity associated with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has been well-described as the mechanism of development of thyroid dysfunction following Coronavirus Disease 19 (COVID-19) infection and SARS-CoV-2 vaccination. However, the occurrence of thyroid eye disease (TED) after SARS-CoV-2 vaccination is scarcely described. The postulated mechanisms include immune reactivation, molecular mimicry and the autoimmune/inflammatory syndrome induced by adjuvants (ASIA). We report a case of new-onset TED after receiving the SARSCoV- 2 vaccine.
Thyroid eye disease ; SARS-CoV-2 vaccine ; Molecular Mimicry

Background and objective: Coronavirus Disease 2019 (COVID19) was first reported in Malaysia in March 2020. We describe here the clinical characteristics and computed tomography (CT) patterns in asymptomatic young patients who had laboratory-confirmed COVID-19. Methods: This is a retrospective observational study where 25 male in-patients with laboratory-confirmed COVID-19 in Hospital Canselor Tuanku Muhriz. Demographics, clinical data and CT images of these patients were reviewed by 2 senior radiologists. Results: In total there were 25 patients (all males; mean age [±SD], 21.64±2.40 years; range, 18-27 years). Patients with abnormal chest CT showed a relatively low normal absolute lymphocytes count (median: 2.2 x 109/L) and absolute monocyte count (median: 0.5 x 109/L). Lactate dehydrogenase was elevated in 5 (20%) of the patients. The procalcitonin level was normal while elevated levels of alanine aminotransferase, total bilirubin, platelet and C-reactive protein were common. Baseline chest CT showed abnormalities in 6 patients. The distribution of the lesions were; upper lobe 3 (12%) lower lobe 3 (12%) with peripheral distribution 4 (16%). Of the 25 patients included, 4 (16%) had ground glass opacification (GGO), 1 (4%) had a small peripheral subpleural nodule, and 1 (4%) had a dense solitary granuloma. Four patients had typical CT features of COVID-19. Conclusion: We found that the CT imaging showed peripheral GGO in our patients. They remained clinically stable with no deterioration of their respiratory symptoms suggesting stability in lung involvement. We postulate that rapid changes in CT imaging may not be present in young, asymptomatic, non-smoking COVID-19 patients. Thus the use of CT thorax for early diagnosis may be reserved for patients in the older age groups, and not in younger patients.