Background Autoimmune pemphigus is a potentially life threatening bullous disease. The cornerstone of treatment is systemic corticosteroids. However, adjuvant therapy with immunosuppressant drugs is commonly used to improve disease control and alleviate the high morbidity and mortality associated with the use of corticosteroids. Adjunctive treatment with pulse intravenous cyclophosphamide may be more efficacious and less toxic than other immunosuppressants. Objective To retrospectively review the clinical outcome of 18 patients with recalcitrant pemphigus who were treated with cyclophosphamide over the past 10 years. Methodology A retrospective study was conducted between 1985 and 2009 in thirteen Malaysian dermatology centres. Data collected were analysed for comparison of relapse rates, compliance rates and adverse drug effects between the 2 regimes. Results Eighteen patients were included in this audit of which 12 patients had pemphigus vulgaris and 6 patients had pemphigus foliaceous. Prior to treatment with cyclophosphamide, fourteen patients were on azathioprine, three were given intravenous immunoglobulin, and two were prescribed dapsone; however all these patients were either unresponsive, intolerant or suffered serious side-effects with these drugs. Subsequently, 7 patients (median age: 31 years) received a combination of pulse intravenous cyclophosphamide and either intravenous dexamethasone or methylprednisolone. These seven patients received between 2 to 21 pulses of intravenous cyclophosphamide and steroids at monthly intervals with oral prednisolone and cyclophosphamide (50-100mg) in between pulses. The remaining 11 patients (median age: 46 years) received oral cyclophosphamide and corticosteroids. Of the 18 patients in our cohort, 15 achieved control and consolidation of disease activity at an average of 4 weeks and 10 weeks respectively. The remaining three patients are yet to achieve disease control. The total duration of treatment with cyclophosphamide ranged from 2 to 62 months with a cumulative dose ranging from 2.95g to 93.55g. Four patients achieved partial remission on minimal therapy and 3 achieved complete remission. None of patients experienced serious side effects. Conclusion Cyclophosphamide may be an alternative treatment option in patients in patients with pemphigus who fail to respond to standard therapy. Controlled trials are needed to further evaluate the efficacy and safety of this therapy.

Objective: To explore the biotechnological potential of Ophiorrhiza mungos for micropropagation and camptothecin (CPT) production from in vitro grown plants.Methods: Surface sterilized explants of O. mungos were transferred aseptically in MS media containing various combinations of phytohormones for callus initiation and multiple shoot proliferation. The content of CPT was quantified in the methanolic extract of O. mungos plants and in in vitro grown plants by using high performance liquid chromatography (HPLC). Results: Maximum fresh weight and dry weight biomass of O. mungos callus was obtained from MS medium supplemented with IAA (2 ppm)+ BAP (2 ppm) + GA (1 ppm). The maximum shoot proliferation (25) and elongation (6.5 cm) was found in MS medium supplemented with Picloram + Thidiazuron + Gibberellic Acid in 1:2:1 ratio after four weeks of incubation. The maximum content of CPT (0.0768 % w/w) was found in wholein vitro plants whereas the minimum CPT was observed in adventitious buds (0.0026 % w/w) as compared to the naturally grown O. mungos plants (0.0030% w/w).Conclusions: Present findings indicate that O. mungos plants respond favourably for in vitro propagation and also produce higher amount of CPT as compared to naturally grown plants.

Introduction: Stevens Johnson syndrome (SJS), Stevens Johnson Syndrome - toxic epidermal necrolysis overlap syndrome (SJS-TEN overlap), toxic epidermal necrolysis (TEN) and drug-induced hypersensitivity syndrome (DHS) are well known severe adverse cutaneous drug reactions (SACDRs). All clinicians are responsible for the diagnosis and management of SACDR. Objective: To retrospectively review the clinical patterns, management strategies and outcome of 134 patients with severe adverse cutaneous drug reactions managed at the Department of Dermatology, Kuala Lumpur Hospital between 2006 and 2010. Results: The mean age of presentation was 44.8 years (13-83). The male: female ratio was 1:1. There were 68 cases (50.7%) of SJS, 10 cases (7.5%) SJS-TEN overlap, 32 cases (23.9%) TEN and 24 cases (17.9%) DHS. The five commonest drugs associated with SACDRs were allopurinol (26.9%), carbamazepine (13.4%), phenytoin (9.7%), non-steroidal anti-inflammatory drugs (11.2%) and co-trimoxazole (7.5%). The mean duration of drug exposure before the onset of reaction was 2.8 weeks. A hundred and thirty patients (97%) were managed as in-patient. The mean duration of in-patient stay was 12.4 days. All identified culprit drugs were withheld. Systemic corticosteroids was given to 96% cases of DHS with mean duration of 9.7 weeks; 52.9% of SJS with mean duration of 2.8 weeks; 60% of SJS-TEN overlap with mean duration of 2.3 weeks; and 62.5% of TEN with mean duration of 3.3 weeks. Thirteen patients (42%) with TEN were treated with intravenous immunoglobulin. Eight patients (6%) died, of which 7 were TEN and one DHS. Conclusion: SACDRs are life-threatening emergencies which not only results in significant morbidity and mortality; but also potentially increases the health care cost and burden. Clinicians should recognize high risk medications and prescribe them with great caution.

Cryptococcosis is a life-threatening mycosis typically seen in immunocompromised patients. Pulmonary cryptococcosis generally presents as multiple or solitary nodular opacities. Cryptococcal infection presenting as a destructing cavernoma (cryptococcoma) without diffuse infiltration of the lung is an extremely rare presentation, even in immunocompromised patients. This report presents a healthy, HIV negative, immunocompetent patient who presented with a large solitary lung mass provisionally diagnosed as a lung malignancy on radiological imaging that proved to be a large cryptococcoma after biopsy. The patient was treated with liposomal Amphotericin B and fluconazole, and the lesion showed regression on serial imaging. This case report thus highlights an unconventional presentation of pulmonary cryptococcosis in an immunocompetent individual.

Corona virus is a crucial respiratory disease, which impacted the health in both aspects, physically and mentally. High expectations, lack of time, skills, and social support may lead to occupational stress among nurses, which spontaneously causes anxiety, post traumatic stress disorder, distress, and other psychological problems. Nurses may also accompany with somatic symptoms, such as palpitations, nausea, dyspnea, and dizziness. The study aims to assess the level of stress among the nurses at SMCH and association between the level of stress and selected demographic variables of staff nurse in quantitative non experimental approach by descriptive research design. A samples was 50 staff nurse selected using recruited by non-probability purposive sampling technique. A selfstructured questionnaire and Likert 5 point scale was used to assess the demographic data and level of stress among the staff nurses. The results shows that, about 38 (76%) of the staff nurse had severe stress, 5 (10%) of the staff nurse had moderate stress and remaining 7 (14%) of the were of mild stress. The chi-square test also shows statistically significant association between education and level of stress among staff nurses at p<0.05 level. This study concluded that, the corona virus has caused severe stress among the nurses at SMCH.