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Urinary tract infection (UTI) is one of the most common presentations in general practice and, in most instances, occurs in a single episode and is easily treated with a course of anti-microbial therapy. In the case of recurrent urinary tract infections, it is important to consider evaluation for any underlying causes. We report the case of a 32 year old female who had recurrent UTIs; this was a case of recurrent UTI secondary to xanthogranulomatous pyelonephritis from renal stones with resultant reno-colic fistula formation.

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Deaths resulting from carbon-monoxide poisoning have been reported in the medical literature under diverse circumstances. Here, we report four deaths due to carbon-monoxide poisoning as a result of a traditional practice involving the application of heat to the abdomen to facilitate uterine involution during the immediate post-partum period. Four people died due to carbon-monoxide poisoning in two separate incidents, including two women in the post-partum period. In both instances, the women slept beside a stove with burning charcoal, which was supposed to provide warmth to the lower abdomen.

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A retrospective study of suicides in Brunei Darussalam (Brunei) over a 20 year period from 1991-2010 was conducted by analysing the post-mortem examination and external examination reports and other relevant records. The suicide rate in Brunei is very low (1.9 deaths per 100,000 per year). The majority of the victims were expatriates 82(66%) and hanging was the commonest mode of suicide both in expatriate and local population. The study showed that the suicide rate among the Bruneian Malays was the lowest (0.5 deaths per 100,000 per year) among the different nationalities. The study highlights the demographics and socio-economic background of the victims, methods used in committing suicide, suicide rates in different ethnic groups and predisposing factors. The results of this study would be of use for taking preventive measures to minimize the incidence of suicide.

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Cytomegalovirus (CMV) infection can present with severe manifestations that are associated with significant morbidity and mortality, especially in immunocompromised patients. CMV infections in immunocompetent patients are usually transient and do not exhibit many symptoms. However, in some patients, the manifestations can be severe. We report CMV colitis in two immunocompetent patients; one in a young man who was critically ill with septicaemia and significant non-bloody diarrhoea that responded to specific CMV treatment, and another in an elderly woman who presented with nonspecific abdominal pain and fever that resolved without specific CMV treatment.

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INTRODUCTION: The accuracy of the Alvarado score in diagnosing acute appendicitis in an Asian population has been disappointingly low. We prospectively compared the RIPASA score with the Alvarado score for the diagnosis of acute appendicitis. METHODS: 200 consecutive patients who presented to the Accident and Emergency Department with right iliac fossa pain were recruited in the study. Both the RIPASA and Alvarado scores were derived, but decisions for appendicectomy were based on clinical judgement. Receiver operating curve (ROC), sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for both scoring systems were calculated. RESULTS: Only 192 out of the 200 patients who satisfied the inclusion and exclusion criteria were included in the analysis. At the optimal cut-off threshold score of 7.5 derived from the ROC, the sensitivity, specificity, PPV, NPV and diagnostic accuracy of the RIPASA score were 98.0 percent, 81.3 percent, 85.3 percent, 97.4 percent and 91.8 percent, respectively. At the cut-off threshold score of 7.0 for the Alvarado score, the sensitivity, specificity, PPV, NPV and diagnostic accuracy were 68.3 percent, 87.9 percent, 86.3 percent, 71.4 percent and 86.5 percent, respectively. The RIPASA score correctly classified 98 percent of all patients confirmed with histological acute appendicitis to the high-probability group (RIPASA score greater than 7.5) compared with 68.3 percent with the Alvarado score (Alvarado score greater than 7.0; p-value less than 0.0001). CONCLUSION: The RIPASA score at a cut-off threshold total score of 7.5 is a better diagnostic scoring system than the Alvarado score for the diagnosis of acute appendicitis in our local setting.

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In regions where chronic hepatitis B infections are still endemic, autoimmune hepatitis (AIH) is considered rare, and it is even rarer in the paediatric population. AIH in the paediatric population is categorised into type 1 and 2, which are differentiated by their autoantibody profiles. We present two cases of paediatric type 1 AIH. Two girls aged 11 and 15 years were referred to our hospital with chronic liver disease, one of whom had decompensated disease. Both patients were started on prednisolone. The patient with advanced liver disease died from complications due to infections that included the pandemic novel influenza A H1N1, while the other patient responded to treatment. These two cases serve to highlight the importance of considering AIH in any paediatric patient presenting with features of chronic liver disease, as the response to treatment is good.

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INTRODUCTION: Tuberculous appendix is surprisingly rare, even in countries where this infection is common. We report our experience with tuberculous appendix over a 15-year period. METHODS: A search for cases of tuberculous appendix was conducted from January 1995 to December 2009 on the databases of the National Tuberculosis Centre and the Departments of Pathology and Surgery of Raja Isteri Pengiran Anak Saleha Hospital. RESULTS: There were five cases of tuberculous appendix, giving a cumulative incidence of 0.08 percent of all appendectomies (n is 6,593), 0.2 percent of tuberculosis (TB) cases (n is 2,876) and 8.6 percent of abdominal TB (n is 58). Three patients were male and two were female, with a median age of 27 (range 25-48) years. Four patients presented with symptoms of acute appendicitis and one with an appendiceal mass following treatment for acute gastroenteritis. Only one patient had constitutional symptoms. Four patients had appendectomies (one laparoscopic and three open) within the same admission and one had interval appendectomy. Operative findings included perforated appendix (n is 1), appendiceal mass (n is 1) and acute appendicitis (n is 3). In all cases, the diagnoses were made only after review of the histology. None of the patients had pulmonary TB. Delay in initiating anti-TB treatment in one patient resulted in the development of an ileocutaneous fistula following appendectomy. This was resolved by excision, followed by anti-TB treatment. CONCLUSION: Tuberculous appendix can present as acute appendicitis, and the diagnosis is often made after surgery. Any delay in treatment can lead to significant complications.

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Gastrointestinal cancer is common, and is a significant cause of morbidity and mortality. The synchronous occurrence of two different malignancies is not uncommon, but that of more than two malignancies is extremely rare. Such occurrences often pose diagnostic and therapeutic challenges. We report the case of an elderly man who was previously treated for gastric cancer 13 years ago, and who was later diagnosed with synchronous triple gastrointestinal malignancies consisting of hepatocellular carcinoma, a gastric collision tumour with adenocarcinoma and a large B cell lymphoma. The patient's condition progressed rapidly, and he died four weeks after the diagnosis.

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Gastric cancer is a common gastrointestinal cancer and is an important cause of cancer mortality. Unfortunately, it is often diagnosed late due to delayed presentation. We report the case of a 48-year-old man who was diagnosed with diffuse infiltrating gastric adenocarcinoma and who had initially declined surgery. The patient presented again the following year, and the repeat evaluations showed similar findings. Despite this, the patient continued to decline interventions. Six years later, as his symptoms increased, the patient finally underwent surgery. Histology revealed a diffuse infiltrating stage T3 tumour, with significant desmoplastic reaction and negative lymphadenopathies. Seven years after the surgery, the patient remained well and recurrence-free. This case highlights that some cancers have an indolent course, and even with significant delay, curative interventions can still be performed.

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Aorto-enteric fistulas are rare and are associated with significant mortality. Infective causes usually occur within the setting of post-graft repair. Aorto-enteric fistula secondary to tuberculosis is extremely rare despite the high prevalence of this infection. Unfortunately, the diagnosis is often not suspected until surgery or at post-mortem. We report a case of an elderly Malay man presenting with massive gastrointestinal bleeding secondary to a tuberculous aorto-duodenal fistula in association with a saccular abdominal aortic aneurysm. This was successfully managed with an aortobifemoral graft repair and standard anti-tuberculous treatment for six months. A literature review of this rare condition is presented.

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BACKGROUND: Granulomatous mastitis is a rare benign breast condition commonly affecting women of child-bearing age. It is characterised histopathologically by the presence granuloma and microabscess formation. It is frequently mistaken for inflammatory breast carcinoma both clinically and mammographically. The aim of this study was to retrospectively review the clinical presentation, radiological investigation, histopathological features, treatment and outcome of granulomatous mastitis of women presenting to Ripas Hospital between October 1997 and June 2009. RESULTS: Forty-three patients with a mean age of 34 years presented with a diagnosis of granulomatous mastitis. All patients presented with a palpable breast lump; 24 (56%) patients also experienced pain in the lump and 3 (7%) patients also had associated nipple discharge on presentation. The role of radiological imaging is found to be limited in differentiating GM from other inflammatory and malignant conditions of the breast. Forty (93%) patients underwent a surgical procedure as the main treatment; in the form of excision or incision and drainage of the breast lesions. Mean follow-up was 15 (range 1-80) months with recurrence in 10 (23%) patients. CONCLUSION: Granulomatous mastitis presents clinically with a palpable breast lump. The diagnosis is often only made histopathologically after surgical excision or core biopsy. Complete surgical excision or incision and drainage of the lesion are the main treatment modalities. Treatment with corticosteroids and immunosuppression remains controversial and there is tendency for this condition to recur after treatment.

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Post-mortem injuries caused by terrestrial and aquatic animals are commonly encountered in forensic practice. We present a case where an autopsy of a body recovered from the sea showed post-mortem injuries and numerous crustaceans in the heart and lungs. They have gained access to these organs via oro-nasal route and subsequent penetration through mediastinal soft tissues and migration down the trachea.

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BACKGROUND: Lipoblastoma is a rare, benign, encapsulated tumor arising from embryonic white fat. On histology they typically contain variably differentiated adipocytes, primitive mesenchymal cells, myxoid matrix, and fibrous trabeculae. The tumor occurs primarily in infancy and early childhood. It often occurs in the extremities and trunk, and rarely develops in the head and neck and other sites. METHODS: Ten cases of histopathologically proven lipoblastoma presenting to our hospital during a 6-year period (2003-2008) were reviewed retrospectively for their clinical presentations, treatment, postoperative outcome, and follow-up. RESULTS: There were five males and five females ranging in age from 6 months to 20 years. The commonest presentation was a painless rapidly growing mass. Tumors occurred in an extremity (n = 5), head and neck (n = 3), trunk (n = 1), and retroperitoneum (n = 1). Preoperative diagnosis was accurate in only one case. The largest tumor measuring 25-cm x 20-cm x 7-cm and weighing 1.9 kg was excised from the retroperitoneum. All patients underwent complete surgical excision. Patient follow-up period ranging from 9 to 76 months showed no recurrences and no metastases. CONCLUSIONS: Lipoblastoma behaves benignly, occurs in both superficial and deep sites, and occasionally attains large size. Complete surgical excision is the treatment of choice and long-term follow-up is required because there is a reported tendency for these tumors to recur.

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INTRODUCTION: The incidence of colorectal cancer (CRC) is reported to be increasing. This study assessed the incidence and trend of CRCs in Brunei Darussalam, a developing nation. METHODS: All histologically-confirmed CRCs over a 22-year period (1986-2007) were identified from the National Cancer and the Department of Pathology registries and retrospectively reviewed. RESULTS: There was a total of 576 (male 59.0 percent, mean age 59.6 +/- 14.8 years, adenocarcinoma 97.6 percent, rectum 31.4 percent) CRCs diagnosed during this period. There was an increasing trend in the mean age at diagnosis, 55.2 +/- 17.5 years in 1986 to 62.0 +/- 13.0 years in 2007, but this was not significant (p-value equals 0.150, ANOVA). 18.8 percent were diagnosed in patients aged 45 years or below. There was no difference in the age at diagnosis between the genders (p-value equals to 0.432) and tumour sites, colon vs. rectum (p-value equals to 0.279). Overall, there was an increase in the age standardised rate (ASR) from 10.36 (1986-90) to 13.75 (1991-95), 15.90 (1996-2000), 16.87 (2001-05) and 24.31 per 100,000 (2006-07). Among the ethnic groups, the Chinese had higher ASRs (41.44) compared to the Malays (including the indigenous groups) with 15.46 per 100,000. The mean age of the Chinese (62.6 +/- 14.0 years) was significantly higher than that of the Malays (58.2 +/- 14.9 years, p-value equals to 0.001) at diagnosis. The age-specific incidence rates for the genders were comparable, except for the age groups of older than 55-59 years, where the rate for males was higher. CONCLUSION: The incidence of CRC is increasing in our local setting with differences observed among the ethnic groups. The Chinese had a higher incidence but developed CRC at a later age. These have important implications if screening for CRC is to be considered in our local setting.

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Obstructive jaundice is common and in most cases due to stone diseases or malignancies. Malignancies are important causes and are often unresectable at the time of diagnosis. Similarly, it is also important to consider infective causes such as tuberculosis (TB), particularly in endemic areas or in patients with risk factors. Although rare, the possibilities for the coexistence of different pathologies need to be considered as the treatment required will be different. We report a 67-year-old man with unexpected findings of obstructive jaundice secondary to biliary TB and an early ampullary tumour.

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During the five-year period from January 1985 to December 1989 a total of 27,208 women, representing 44.0% of the total female population over age 15 years in Brunei Darussalam, underwent a cytologic examination. The majority of them were Malays (62.32%), followed by Chinese (22.23%), while the remainder were the expatriate population living in the country. High grade squamous intraepithelial lesion (moderate dysplasia) was detected in 88 women (3.3/1,000), high grade squamous intraepithelial lesion (carcinoma in situ) was seen in 32 women (1.22/1,000), and invasive carcinoma was found in 43 women (1.37/1,000). The overall detection rate for cervical cancer was 2.79/1,000 women in the population screened. In Brunei Darussalam Malay women marry at an early age, 44% by the age of 19 years, leading to sexual contact before the age of 20. However, the incidence of cervical cancer is low among them. This could be because they belong to the Orthodox Muslim Society, in which promiscuity is not permitted. Hence, multiple sex partners could be an important factor in the etiology of cervical cancer, confirming the current trend of thought that cervical cancer is a sexually transmitted disease. A comparison of the epidemiologic risk factors among the various races living in Brunei Darussalam is made.

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