Coronavirus disease 2019 (COVID-19), a multisystemic disorder caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been associated with both venous and arterial thromboses. The hypercoagulable state of the disease poses a challenge to the patient’s management. We herein report a case of acute ischaemic stroke in a COVID-19 patient who had been treated with three days of Baricitinib, an immunotherapy that can potentially augment the thrombotic risks. The case highlights the dilemma faced when initiating immunotherapy in a COVID-19 patient and emphasises the importance of evaluating the patient’s thrombotic risks, balanced against the benefit of immunotherapy, to facilitate the selection of ideal candidates for the immunotherapy.

Orthostatic tremor (OT) is one of the rare abnormal movement conditions characterized by leg tremors of 13-18 Hz upon standing and is often diminished upon walking or sitting. The exact pathophysiology of OT is still not fully understood, and it is uncertain whether the tremor causes unsteadiness on standing or vice versa. Treatment is a tremendous challenge. Medication toxicity with ineffective medications may likely cause distress to the patients and the physicians. Gabapentin, clonazepam, levodopa, and pregabalin are among the medications that have been used. We herein report on an elderly patient with OT, distressed, and anxious who improved significantly with physiotherapy as an adjunct therapy to the conventional medications.

Multiple Sclerosis is an inflammatory demyelinating disease that affects the central nervous system, and is uncommon among the Asian population. It can present with a variety of symptoms, depending on the location of the demyelinating plaques, which could also potentially mimic a range of neurological and non-neurological disorders. We report a 24-year-old woman who presented with recurrent non-specific lower limb numbness, without any other neurological symptoms or signs. The symptoms were presumed to be nonspecific, but they re-occurred eight months later, leading to a more extensive investigation, including whole spine and brain MRI. The MRI showed multiple white matter lesions that are hyperintense on T2W/FLAIR, seen at the right corona radiata, bilateral parietal lobes, right periventricular region and spinal cord, with a simultaneous presence of gadolinium-enhancing and nonenhancing lesions, fulfilling 2017 Mc Donald’s diagnostic criteria for multiple sclerosis. After the careful exclusion of differential diagnoses, she was given pulsed IV methylprednisolone for 5 days, followed by oral teriflunomide. She improved partially, and at 2 months following discharge, she was tolerating the medication well with no further relapses.

During the pandemic, diagnosis of COVID-19 infection must be excluded in patients presenting with respiratory features, especially in the area where the incidence was high. This case report highlights a man who came with respiratory infection symptoms and the chest radiograph suspicious of COVID-19 pneumonia; however, his swab test for RT-PCR was negative for COVID-19. Later he was found to have a positive anti-HIV antibody and developed advanced HIV infection by multiple opportunistic infections. A 45-year-old man presented with chronic cough and dyspnea for three months which worsened five days before the presentation. It was associated with diarrhoea, dysphagia, weight loss, left lower limb weakness, with bowel and urinary incontinence. Chest auscultation revealed generalized crepitations. The first chest radiograph showed bilateral reticular opacities extending to the lung peripheries when the suspected diagnosis of COVID-19 pneumonia was made. The nasopharynx swab for RT-PCR for COVID-19 was negative, and the sputum was positive for Pneumocystis jirovecii. The contrast-enhanced CT (CECT) brain revealed changes consistent with brain abscess. The cerebrospinal fluid (CSF) examination was consistent with cryptococcal infection. He was initially treated in the Severe Acute Respiratory Infection (SARI) ward because of the initial impression of COVID-19. He was tested positive for Human Immunodeficiency Virus (HIV) rapid test and PCR, RPR and TPHA for syphilis. He was diagnosed with Pneumocystis jirovecii pneumonia, cryptococcal meningitis, brain abscess, oral and oesophageal candidiasis and syphilis. He was treated with co-trimoxazole, Amphotericin B, flucytosine, fluconazole, penicillin G and Nystatin. He initially improved upon treatment but later succumbed to his illnesses. Given the current situation of COVID-19, any patient with acute respiratory symptoms must be tested to rule out COVID-19 pneumonia. However, in a newly diagnosed advanced HIV patient presented with respiratory infection symptoms and extrapulmonary symptoms, opportunistic infections should be excluded along with COVID-19.

Pregnancy-associated spontaneous coronary artery dissection (P-SCAD) is one of the fatal conditions that most commonly causes pregnancy-associated myocardial infarction. We herein report a case of P-SCAD in a 26-year-old multigravida woman, who complained of angina postpartum with raised cardiac biomarkers and transient ST-segment elevation on electrocardiograms. We emphasize the importance of a high degree of suspicion in the diagnosis of P-SCAD, together with the common presentation, the management approach, and its psychological impacts on the patients.

Pure red cell aplasia is a rare and complex disorder due to defects in the erythroid precursors characterized by normochromic normocytic anaemia, reticulocytopenia with normal platelets and white cell count. Acquired pure red cell aplasia can be associated with other autoimmune disorders like systemic lupus erythematosus, lymphoproliferative disorder like lymphoma, and solid tumours like thymoma. The pure red cell aplasia may precede lymphoma, appear simultaneously, or occur during its remission. We aim to highlight the diagnostic dilemma when facing a case of PRCA with lymphoma due to the rarity of this association and the pathologic apprehension behind this. This is a case of a 40-year-old gentleman who was diagnosed with pure red cell aplasia in 2019. His initial bone marrow aspirate showed no obvious cluster of blasts or abnormal lymphoid cells. He has been on tapering dose of steroids since then but defaulted follow-up since 2020. His last haemoglobin level during follow-up was 15 g/dL (normal). He presented to us in late 2022 with severe sepsis and was provisionally treated for Melioidosis given a CT Abdomen suspicious of splenomegaly with multiple microabscesses. Blood investigations showed neutropenia with dropping haemoglobin and platelets in the ward. Bone marrow trephine biopsy later confirmed the diagnosis of T-cell lymphoma. The co-existence of pure red cell aplasia and lymphoma is extremely rare. While there is no direct causal relationship, their association is found to be autoimmune-mediated. A high index of suspicion is crucial when encountering such cases for a timely diagnosis and comprehensive management.

Dengue is endemic in over 100 countries worldwide, predominantly in the subtropical and tropical regions and the incidence has been increasing globally. Patients with severe dengue may develop massive bleeding, disseminated intravascular coagulopathy and multi-organ failure. Bleeding may occur in various body cavities and muscles; however, bleeding in the retroperitoneal space is uncommon. We report a case of a 37-year-old gentleman who presented with a 4-day history of fever associated with chills and rigours. On Day 6 of illness, he complained of left lumbar and left iliac fossa pain which was aggravated by movement. A computed tomography angiography scan of the abdomen showed the presence of a retroperitoneal haematoma, left iliopsoas and quadratus lumbarum intramuscular haematoma with active bleeding and left abdominal wall muscles haematoma. His condition gradually improved after multiple blood transfusions and he gained full recovery. Spontaneous retroperitoneal haematoma is an uncommon complication of severe dengue infection. Early diagnosis based on high index of clinical suspicion using appropriate imaging will aid in prompt management of these cases and may prevent deaths.