Eventration of the diaphragm is caused by weakened musculature of the diaphragm. This can occur in one or both hemidiaphragms. Symptoms may be minimal and it is usually detected incidentally on chest radiograph which would show an elevation of the diaphragm. We report and discuss a case of eventration of right diaphragm in a patient presented with a lobulated lung mass on chest radiograph.

Background: Pneumococcal pneumonia is the commonest type of bacterial pneumonia worldwide. In Malaysia, the reported incidence of pneumococcal pneumonia is low. This may be due to poor sensitivity of conventional methods. The use of BinaxNOW, a urinary antigen test for Streptococcus pneumoniae can aid in the diagnosis of pneumococcal pneumonia. Objective: To determine the detection rate of pneumococcal pneumonia using BinaxNOW kit and to compare this with the conventional culture method for blood and sputum. Methods: This was a prospective cohort study involving patients 18 year-old and above admitted for community-acquired pneumonia (CAP) or health-care associated pneumonia (HCAP) to UKMMC between December 2011 and June 2012. BinaxNOW test, serology for Mycoplasma, Legionella and Chlamydia and cultures from blood/sputum/other respiratory tract samples and other routine investigations were performed. Results: A total of 102 patients were recruited; 89 (87.3%) with CAP, 13 (12.7%) with HCAP. 57 (55.9%) had pneumonia of unknown aetiology, 11 patients (10.8%) had positive blood cultures, 8 patients (7.8%) had a positive urine BinaxNOW test and 6 patients (5.9%) had positive sputum cultures. Streptococcus pneumoniae was the commonest isolate accounting for 9 cases (8.8%) followed by Klebsiella pneumoniae in 7 cases (6.9%). 8 out of 9 patients with positive urine BinaxNOW test had negative cultures for Streptococcus pneumoniae. One patient grew Streptococcus pneumoniae from the tracheal aspirate however the urine BinaxNOW test was negative. Conclusion: The use of urine BinaxNOW kit in UKMMC increased the detection rate of pneumococcal pneumonia in hospitalized patients.

Theincidence of envenoming from king cobra, Ophiophagus hannah in human is relatively rare. Its venom acts on the postsynaptic region of the neuromuscular junction causing descending flaccid paralysis. Locked-in syndrome is a clinical state of inability to provide motor response in a conscious patient. Many reported cases of locked-in syndrome following neurotoxic snake-bite mimics brain death. We report a case of a middle aged man who presented with progressive neurological deficit following a king cobra bite over his right arm. He had local and systemic neurotoxic envenoming. His condition deteriorated, and was intubated and ventilated in the emergency department. He received a total of 33 vials of the Ophiophagus hannah monospecific antivenom and subsequently recovered well with no neurological deficit. Retrospectively, he was able to recall the events and while he was lying paralysed and intubated under minimal sedation in the intensive care unit. He described it as a terrifying and painful experience. This case highlights the rare presentation of locked-in syndrome following a systemic envenoming from a king cobra bite. It is important to differentiate neurotoxic snake envenoming lock-in syndrome from brain dead. Patients are unable to respond to physical pain and require adequate analgesia. A patient suffering this highly distressing experience may require psychological support.