Introduction: Primary adrenal insufficiency is rare and potentially lifethreatening, with an estimated prevalence of five cases per million in Southeast Asia. Local data remain limited, and diagnosis is frequently delayed due to non-specific clinical manifestations. Widespread use of traditional medication in Malaysia may further undermine recognition, particularly when steroid exposure is concealed. We report a female on prolonged use of traditional remedies presented with classic features of Addison’s disease rather than cushingoid features, confirmed by biochemical results. Case: A 65-year-old female with underlying dyslipidemia and osteoarthritis presented with 4 days of giddiness, poor intake, nausea, and diarrhea. Further history revealed prolonged use of multiple traditional Chinese medicines, discontinued months prior, raising suspicion of prior steroid exposure. She claimed her skin has become darker over the past 2 months. She denied any infectious symptoms, contact with PTB patients, or exposure to birds. There was no family history of autoimmune disease. Clinically, she was dehydrated and hypotensive. Her blood pressure improved after fluid resuscitation. There was hyperpigmentation involving the face, extremities, tongue, and buccal mucosa. Investigation results showed severe hyponatremia (119 mmol/L), hyperkalemia (4.93 mmol/L), with normal creatinine and negative infective markers. Hyponatremia persisted despite adequate hydration. Thyroid function test was normal (Free T4 12.28 pmol/L and thyroid-stimulating hormone 4.16 µIU/mL). Morning cortisol was suppressed (37 nmol/L) with markedly elevated adrenocorticotropic hormone levels (1,134 pg/mL), confirming the diagnosis of primary adrenal insufficiency. Hence, hydrocortisone was commenced, and serum sodium was normalized 2 days later. The underlying etiology remains under evaluation, although autoimmune adrenalitis is the most likely cause. Conclusion Primary adrenal insufficiency should be considered in patients presenting with unexplained hyponatremia and hypotension. In a setting where traditional medication use is prevalent, unrecognized steroid exposure may further complicate diagnosis. A thorough clinical and appropriate biochemical assessment is crucial to differentiating primary from secondary adrenal insufficiency.
Hyponatremia

Introduction: Diabetic sensorimotor polyneuropathy (DSPN) is a common complication of long-standing diabetes mellitus marked by neuropathic pain and sensory deficits. Evidence supporting combination antioxidant and vitamin-based therapy remains limited, particularly in patients with chronic disease. This study aims to determine symptom improvement after 12 weeks of oral alpha-lipoic acid, vitamin B complex, and vitamin E (Bionerv E+) in chronic diabetic patients with symptomatic DSPN. Methodology: This single-centre, randomized, double-blind, placebocontrolled trial at HCTM enrolled 31 patients with symptomatic DSPN, assigned to Bionerv E+ (n = 16) or placebo (n = 15) for 12 weeks. Symptoms were assessed at baseline and post intervention using the Neuropathy Impairment Score–Lower Limb (NIS LL), Short Form McGill Pain Questionnaire (SF MPQ), Toronto Clinical Scoring System (TCSS), and nerve conduction studies (NCS). Results: A total of 31 participants were recruited; 18 completed the study (11 intervention, 7 placebo). The cohort was predominantly elderly (median age 68 ± 12 years), male (51.6%), with long-standing diabetes (mean duration of 18.6 ± 8.2 years), and a mean hemoglobin A1c of 7.3 ± 0.6%. A statistically significant reduction in TCSS score was observed in the intervention arm (5.5 ± 3.8 vs 3.3 ± 3.4; p = 0.002), indicating improvement in neuropathic symptom severity in this chronic population. The SF MPQ scores showed a downward trend in both arms, but were not statistically significant. Among intervention participants who completed sural NCS, three patients demonstrated normalization, and five showed partial amplitude gains, indicating directional improvement in nerve function. Four patients with normal baseline studies exhibited further amplitude gains. Otherwise, limited improvements were observed in those with abnormal conduction velocity parameters. Bionerv E+ was well tolerated, with only mild and self-limiting adverse events reported. Conclusion Short-term supplementation with Bionerv E+ showed improvement in neuropathic symptoms among longstanding diabetic patients. However, longer-term studies with larger cohorts are necessary to determine its effects on patients with DSPN.
Thioctic Acid ; Vitamin B Complex ; Polyneuropathies ; Vitamin E

Prior to COVID-19, dengue was an important public health problem in Malaysia. Due to the movement control order imposed by the Malaysian government to curb the COVID-19 transmission, a study predicted that mosquito-borne diseases would increase during lockdown and partial lockdown seasons. Thus, this study aims to determine the current situation of dengue incidence during the pre-COVID-19 pandemic (2019) and during the COVID-19 pandemic (2020 and 2021). We compared the number of laboratory-confirmed cases in the pre-COVID19 year (2019) and during the COVID-19 pandemic (2020 and 2021). In addition to that, we characterized the clinical manifestation, dengue serotype and viremia levels of dengue patients that were admitted to the Hospital Cancelor Tuanku Muhriz. We found a significant decrease in the number of laboratory-confirmed cases between COVID-19 pandemic and the pre-covid period (p2020=0.064; p2021<0.001). In this study, we found DENV 4 serotype was the most common serotype in dengue patients admitted to our hospital. There was no significant correlation between DENV serotype/viremia level with clinical manifestation of dengue fever and dengue with warning signs. However, patients infected with DENV4 had the highest viral load compared to patients infected with other serotypes. We also found high viremia levels were significantly associated with the febrile phase.