Sultan Qaboos University Medical Journal, an internationally peer-reviewed multidisciplinary journal, is published quarterly in print and online with free access to full text articles. Its aims are: to be an internationally recognised regional medium of biomedical communication; to encourage medical research and publication in Oman, the Gulf and further afield, and to create awareness of new developments among health professionals in Oman and beyond. SQUMJ is listed in PubMed and indexed in SCOPUS, the Directory of Open Access Journals, the Al Manhal database of Arab journals and the WHO Index Medicus for the Eastern Mediterranean Region. SQUMJ DOES NOT CHARGE AUTHORS FOR SUBMISSION OR PUBLICATION.
SQUMJ is an Open Access Journal. This means that all content is freely available without charge to the user or his/her institution. Users are allowed to read, download, copy, distribute, print, search, or link to the full texts of the articles in this journal without asking prior permission from the publisher or the author. This is in accordance with the Budapest Open Access Initiative (BOAI) definition of open access.
Deciphering the Role of the Barr Body in Malignancy
An insight into head and neck cancer(Review) Deepti Sharma, George Koshy, Shruti Gupta, Bhushan Sharma, Sonal Grover
ABSTRACT: X chromosome inactivation is the epitome of epigenetic regulation and long non-coding ribonucleic acid function. The differentiation status of cells has been ascribed to X chromosome activity, with two active X chromosomes generally only observed in undifferentiated or poorly differentiated cells. Recently, several studies have indicated that the reactivation of an inactive X chromosome or X chromosome multiplication correlates with the development of malignancy; however, this concept is still controversial. This review sought to shed light on the role of the X chromosome in cancer development. In particular, there is a need for further exploration of the expression patterns of X-linked genes in cancer cells, especially those in head and neck squamous cell carcinoma (HNSCC), in order to identify different prognostic subpopulations with distinct clinical implications. This article proposes a functional relationship between the loss of the Barr body and the disproportional expression of X-linked genes in HNSCC development.
Keywords: Sex Chromatin; X Chromosome; Lyonization; X-Linked Genes; Cell Differentiation; Cancer; Squamous Cell Carcinoma, Head And Neck.
Troponin Testing in the Emergency Department
Real world experience(Original Study) Mohammed Al-Maskari, Mahmoud Al-Makhdami, Hatim Al-Lawati, Hafidh Al-Hadi, Sunil K. Nadar
ABSTRACT:Objectives: The aim of this study was to examine patterns of troponin testing in the emergency department of a large tertiary care hospital in Oman and to determine its effect on patient management, including length of hospital stay (LOS). Methods: This retrospective study analysed the medical records of all adult patients undergoing troponin testing in the emergency department of the Sultan Qaboos University Hospital, Muscat, Oman, during the month of July 2015. Patients who presented with an ST-elevation myocardial infarction were excluded. Results: A total of 4,845 patients attended the emergency department during the study period; of these, troponin tests were ordered for 588 patients. The majority of the patients had negative troponin test results (81.3%). Chest pain, palpitations and breathlessness were the most common presenting complaints for those with positive troponin results. However, 41.8% of patients did not have any cardiac symptoms. Individuals with positive troponin tests had a significantly longer LOS compared to those with negative tests (mean: three versus one day; P = 0.001). In total, only 28.2% of those with positive troponin test results had final diagnoses associated with a cardiac condition, such as heart failure, an acute coronary syndrome (ACS), atrial fibrillation or other types of arrhythmia. Conclusion: A positive troponin test was associated with increased LOS; however, only a small proportion of these patients had a final diagnosis associated with a cardiac condition. Guidelines should be provided to ensure that troponin testing is performed only in cases where an ACS is suspected.
Epidemiology of Chronic Hepatitis C Infections at a Tertiary Care Centre in Oman
(Original Study) Said A. Al-Busafi, Halima Al-Shuaili, Heba Omar, Haifa Al-Zuhaibi, L. Jeyaseelan, Khalid Al-Naamani
ABSTRACT:Objectives: Chronic hepatitis C (CHC) is a leading cause of liver cirrhosis and hepatocellular carcinoma (HCC) worldwide. However, there is a lack of data regarding the epidemiology of CHC in Oman. This study aimed to describe the clinicopathological characteristics and outcomes of CHC-infected patients at a tertiary care hospital in Oman. Methods: This retrospective descriptive hospital-based study included all CHC-infected patients who presented to the Sultan Qaboos University Hospital (SQUH) in Muscat, Oman, between January 2010 and December 2015. The baseline demographic, clinical, laboratory and radiological data of the patients were analysed. Results: A total of 603 CHC-infected patients were identified during the study period; of these, 65.8% were male and the mean age was 44.8 ± 16.5 years. The main risk factors associated with CHC infection were intravenous drug abuse (23.9%) and a history of blood transfusions (20.7%). The most prevalent virus genotypes were 1 and 3 (44.0% and 35.1%, respectively). Upon initial presentation, 33.0% of the cohort had liver cirrhosis; of these, 48.7% had decompensated cirrhosis and 23.1% had HCCs. Liver transplantation was only performed for 7.5% of the cirrhosis patients, mostly as a curative treatment for HCC. Conclusion: The implementation of national policies to prevent hepatitis C transmission and encourage the early screening of at-risk patients is recommended to reduce the burden and consequences of this disease in Oman. Keywords: Chronic Hepatitis C; Hepatocellular Carcinoma; Liver Cirrhosis; Infectious Disease Transmission; Genotypes; Oman.
Interpreting Neonatal Growth Parameters in Oman
Are we doing it right?(Original Study) Reem M. Abdulrahim, Ahmed B. Idris, Asad Ur-Rahman, Mohamed Abdellatif, Nigel Fuller
ABSTRACT:Objectives: This study aimed to compare reference anthropometric measures of Omani neonates with the international standard growth charts of the World Health Organization (WHO) in order to determine the appropriateness of these growth charts to assess the growth of Omani neonates. Methods: This cross-sectional study included all healthy full-term Omani neonates born between November 2014 and November 2015 at the Sultan Qaboos University Hospital, Muscat, Oman. Birth weight, length and head circumference measurements were identified and compared to those of the 2006 WHO growth charts. Results: A total of 2,766 full-term neonates were included in the study, of which 1,401 (50.7%) were male and 1,365 (49.3%) were female. Mean birth weights for Omani males and females were 3.16 ± 0.39 kg and 3.06 ± 0.38 kg, respectively; these were significantly lower than the WHO standard measurements (P <0.001). Similarly, the mean head circumferences of Omani males and females (33.8 ± 1.27 cm and 33.3 ± 1.26 cm, respectively) were significantly lower than those reported in the WHO growth charts (P <0.001). In contrast, mean lengths for Omani males and females (52.0 ± 2.62 cm and 51.4 ± 2.64 cm, respectively) were significantly higher than the WHO standard measurements (P <0.001). Conclusion: The WHO growth charts might not be appropriate for use with Omani neonates; possible alternatives should therefore be considered, such as national growth charts based on local data.
Keywords: Anthropometry; Growth Charts; Neonates; World Health Organization; Oman.
Discrepancies Between Planned and Actual Operating Room Turnaround Times at a Large Rural Hospital in Germany
(Original Study) Regula Morgenegg, Franziska Heinze, Katharina Wieferich, Ralf Schiffer, Frank Stueber, Markus M. Luedi, Dietrich Doll
ABSTRACT:Objectives: While several factors have been shown to influence operating room (OR) turnaround times, few comparisons of planned and actual OR turnaround times have been performed. This study aimed to compare planned and actual OR turnaround times at a large rural hospital in Northern Germany. Methods: This retrospective study examined the OR turnaround data of 875 elective surgery cases scheduled at the Marienhospital, Vechta, Germany, between July and October 2014. The frequency distributions of planned and actual OR turnaround times were compared and correlations between turnaround times and various factors were established, including the time of day of the procedure, patient age and the planned duration of the surgery. Results: There was a significant difference between mean planned and actual OR turnaround times (0.32 versus 0.64 hours; P <0.001). In addition, significant correlations were noted between actual OR turnaround times and the time of day of the surgery, patient age, actual duration of the procedure and staffing changes affecting the surgeon or the medical specialty of the surgery (P <0.001 each). The quotient of actual/planned OR turnaround times ranged from 1.733–3.000. Conclusion: Significant discrepancies between planned and actual OR turnaround times were noted during the study period. Such findings may be potentially used in future studies to establish a tool to improve OR planning, measure OR management performance and enable benchmarking.
Keywords: Operating Room, organization and administration; Patient Care Management; Strategic Planning; Time Management; Quality Control; Germany.
Mortality Rate and Years of Life Lost Due to Prostate Cancer in Yazd Province, Iran
A 10-year study(Original Study) Mojtaba Mirzaei, Mahboobehsadat Mirzadeh, Mohsen Mirzaei
ABSTRACT:Objectives: Prostate cancer is a leading cause of cancer-related deaths. The number of deaths and years of life lost (YLL) due to a disease can be used to monitor health status, assess healthcare needs and determine the prioritisation and allocation of health resources within a population; in addition, the latter calculation can serve as a baseline indicator of premature mortality. This study aimed to measure prostate cancer-related mortality and YLL in Yazd Province, Iran. Methods: This study included all prostate cancer-related deaths in Yazd Province reported between March 2001 and March 2010. Mortality data were obtained from a provincial death registration system which integrates data from different sources. YLL was calculated based on an individual’s age at death and their life expectancy according to age group. Results: During the study period, prostate cancer was the fourth most common fatal cancer among men, resulting in 324 deaths or 10.0% of all cancer-related deaths. The crude mortality rate per 100,000 individuals increased from 4.7 in 2001 to 8.8 in 2010. Premature deaths caused 1,358.7 YLL and the YLL caused by prostate cancer deaths more than doubled from 94.7 in 2001 to 196.5 in 2010. Conclusion: Due to changes in population structure, it is likely that the burden of prostate cancer will continue to increase in Yazd Province. As such, it is necessary that the national health system implements screening programmes and improves public awareness of prostate cancer-associated risk factors. Keywords: Prostate Cancer; Years of Potential Life Lost; Mortality; Health Status Indicators; Iran.
Distribution of Trauma Care Facilities in Oman in Relation to High-Incidence Road Traffic Injury Sites
Pilot study(Original Study) Sara M. Al-Kindi, Ahmed A. Naiem, Kadhim M. Taqi, Najla M. Al-Gheiti, Ikhtiyar S. Al-Toobi, Nasra Q. Al-Busaidi, Ahmed Z. Al-Harthy, Alaa M. Taqi, Sharif A. Ba-Alawi, Hani A. Al-Qadhi
ABSTRACT:Objectives: Road traffic injuries (RTIs) are considered a major public health problem worldwide. In Oman, high numbers of RTIs and RTI-related deaths are frequently registered. This study aimed to evaluate the distribution of trauma care facilities in Oman with regards to their proximity to RTI-prevalent areas. Methods: This descriptive pilot study analysed RTI data recorded in the national Royal Oman Police registry from January to December 2014. The distribution of trauma care facilities was analysed by calculating distances between areas of peak RTI incidence and the closest trauma centre using Google Earth and Google Maps software (Google Inc., Googleplex, Mountain View, California, USA). Results: A total of 32 trauma care facilities were identified. Four facilities (12.5%) were categorised as class V trauma centres. Of the facilities in Muscat, 42.9% were ranked as class IV or V. There were no class IV or V facilities in Musandam, Al-Wusta or Al-Buraimi. General surgery, orthopaedic surgery and neurosurgery services were available in 68.8%, 59.3% and 12.5% of the centres, respectively. Emergency services were available in 75.0% of the facilities. Intensive care units were available in 11 facilities, with four located in Muscat. The mean distance between a RTI hotspot and the nearest trauma care facility was 34.7 km; however, the mean distance to the nearest class IV or V facility was 83.3 km. Conclusion: The distribution and quality of trauma care facilities in Oman needs modification. It is recommended that certain centres upgrade their levels of trauma care in order to reduce RTI-associated morbidity and mortality in Oman.
Keywords: Traffic Accidents; Motor Vehicles; Trauma Centers; Public Health; Emergency Medical Services; Oman.
Evaluation of Family Planning Counselling in North Jordan
(Original Study) Abdulhakeem M. Okour, Rami A. Saadeh, Mona Zaqoul
ABSTRACT:Objectives: Counselling plays a key role in enhancing reproductive services, providing contraceptionrelated information and supporting long-term family planning for women of childbearing age. This study aimed to evaluate family planning counselling sessions in selected governmental and private clinics in northern Jordan. Methods: This cross-sectional study was conducted between January and June 2016 in Irbid, Jordan. A total of 200 women attending two private clinics affiliated with the Jordanian Association for Family Planning and Protection (JAFPP) and six governmental clinics were invited to participate in the study. Counselling sessions were attended by an independent observer and evaluated with regards to their compliance with the standard Greet, Ask, Tell, Help, Explain, Return (GATHER) framework. Results: A total of 198 women participated in the study (response rate: 99.0%), including 80 women (40.4%) from JAFPP clinics and 118 (59.6%) from governmental clinics. In total, 42.9% of the counselling sessions were deemed adequate, with providers applying 80% or more of the GATHER framework, while 26.8% of the sessions were deemed semi-adequate and 30.3% were considered inadequate. Counselling services provided in the governmental clinics were significantly less adequate than those provided in JAFPP clinics (P <0.001). Conclusion: The quality of counselling services in governmental family planning centres in Jordan needs to be improved to ensure that women receive the highest possible level of care. Healthcare policymakers should therefore focus on developing and supporting effective family planning counselling services in northern Jordan.
Keywords: Family Planning Services; Counseling; Health Services Evaluation; Community Health Services; Reproductive Health; Jordan.
Diabetes-Related Knowledge and Preventative Practices Among Government Employees with Diabetes in Kuwait
(Original Study) Ahmad J. Abdulsalam, Abdullah E. Al-Daihani, Kostantinos Francis
ABSTRACT:Objectives: Diabetes mellitus (DM)-related knowledge and preventative practices are vital for the successful management of this condition. In Kuwait, few studies have been conducted to evaluate the knowledge and preventative practices of DM patients. This study aimed to assess DM-related knowledge and preventative practices among government employees with DM in Kuwait and to examine associations between DM knowledge, preventative practices and other variables. Methods: This cross-sectional study was conducted in June 2015 and involved 345 employees with DM from 15 government ministries in Kuwait. A self-administered Arabic-language questionnaire was designed to assess DM-related knowledge and preventative practices based on the Diabetes Knowledge Test and the recommendations of the American Diabetes Association, respectively. Results: A total of 312 ministry employees agreed to participate in the study (response rate: 90.4%). The mean age was 45.6 ± 10.6 years. A total of 63.4% were male and 64.1% were Kuwaiti. The median DM knowledge score was 9 out of 14 and the median preventative practice score was 5 out of 14. High knowledge scores were significantly associated with education (β = 1.510; P ≤0.001) and income (β = 0.896; P ≤0.001). High preventative practice scores were significantly associated with income (β = 1.376; P = 0.002), DM duration (β = 0.919; P = 0.026) and knowledge scores (β = 1.783; P = 0.015). Conclusion: Government employees in Kuwait were found to have average DM knowledge and poor preventative practices. It is therefore imperative that policy-makers develop educational and health-promoting campaigns to target government employees with DM in Kuwait. Keywords: Diabetes Mellitus; Knowledge; Primary Prevention; Lifestyle Risk Reduction; Health Education; Kuwait.
Soft Tissue Rosai-Dorfman Disease
Case report(Case Report) Rubyath C. Rajib, Rajasekharan Pillai, Ibrahim A. Sulaiman, Ibrahim Al-Haddabi
ABSTRACT: Rosai-Dorfman disease (RDD) is a rare benign proliferative histiocytic disorder characterised by massive lymphadenopathy. While extranodal involvement can occur in generalised RDD, isolated soft tissue RDD (STRDD) is extremely rare. We report a 17-year-old male patient who presented to the maxillofacial outpatient department of the Sultan Qaboos Hospital, Salalah, Oman, in 2015 with a painless cheek mass which had been slowly growing over the previous two months. Routine histopathological examinations and immunohistochemistry confirmed a diagnosis of STRDD. Currently, surgical excision is considered to be the most effective curative treatment for STRDD, as the outcomes of other treatment modalities are still unknown. Despite its rarity, STRDD should be considered in the differential diagnosis of histiocytic soft tissue lesions.
Keywords: Histiocytosis; Rosai-Dorfman Disease; Emperipolesis; S100 Proteins; Case Report; Oman.
A Case of Persistent Urogenital Sinus
Pitfalls and challenges in diagnosis(Case Report) Hooi H. Tan, Shung K. Tan, Rajah Shunmugan, Rozman Zakaria, Zakaria Zahari
ABSTRACT: Persistent urogenital sinus (PUGS) is a rare anomaly whereby the urinary and genital tracts fail to separate during embryonic development. We report a three-year-old female child who was referred to the Sabah Women & Children Hospital, Sabah, Malaysia, in 2016 with a pelvic mass. She had been born prematurely at 36 gestational weeks via spontaneous vaginal delivery in 2013 and initially misdiagnosed with neurogenic bladder dysfunction. The external genitalia appeared normal and an initial sonogram and repeat micturating cystourethrograms did not indicate any urogenital anomalies. She therefore underwent clean intermittent catheterisation. Three years later, the diagnosis was corrected following the investigation of a persistent cystic mass posterior to the bladder. At this time, a clinical examination of the perineum showed a single opening into the introitus. Magnetic resonance imaging of the pelvis revealed gross hydrocolpos and a genitogram confirmed a diagnosis of PUGS, for which the patient underwent surgical separation of the urinary and genital tracts.
Keywords: Urogenital Abnormalities; Congenital Defects; Clean Intermittent Catheterization; Hydrocolpos; Cystography; Case Report; Malaysia.
A rare cause of acute flaccid paraplegia(Case Report) Aiman K. Al-Wahaibi, Santosh Kumar, Ali Al-Risi, Farook Wali
ABSTRACT: Acute polyneuropathy is a rare manifestation of severe hyperthyroidism. We report a 22-year-old Omani male who presented to the Sohar Hospital, Sohar, Oman, in 2016 with acute-onset rapidly progressive flaccid areflexic paraplegia as the presenting manifestation of thyrotoxicosis. Nerve conduction studies revealed mixed axonal and demyelinating polyneuropathy in both the motor and sensory nerves. Treatment of the hyperthyroidism with β-blockers and carbimazole along with physiotherapy resulted in the patient’s full recovery and the alleviation of his symptoms. Besides highlighting this rare association, this report underscores the importance of including thyroid function tests in the evaluation of patients with acute polyneuropathy.
Keywords: Thyrotoxicosis; Polyneuropathy; Hyperthyroidism; Flaccid Paraplegia; Case Report; Oman.
Pitting Oedema in a Patient with Lumbar Disc Herniation
Case report of an unusual association(Case Report) Homa Sadeghian and Rouzbeh Motiei-Langroudi
ABSTRACT: Oedema refers to the excessive accumulation of fluid within intercellular tissues as a result of disequilibrium between the capillary hydrostatic and oncotic pressure gradients. Lumbar disc herniation (LDH) commonly causes lower back pain and radicular leg pain. We report a 57-year-old female who presented to the neurosurgery clinic of the Bam University of Medical Sciences, Bam, Iran, in 2015 with pain and pitting oedema in the bilateral lower extremities. Magnetic resonance imaging confirmed a diagnosis of LDH of the L3–L4 and L4–L5 vertebrae. The patient subsequently underwent a bilateral laminotomy and foraminotomy of the involved vertebrae to relieve her pain. Following the surgery, there was a complete resolution of the LDH-related symptoms as well as the oedema. Although LDH has never before been associated with oedema, it may nevertheless cause lower limb oedema in exceptional and rare cases, as highlighted in this patient.
Intravenous Remifentanil Analgaesia for an Obstetric Patient with Type I Neurofibromatosis and a Factor V Leiden Mutation
(Case Report) José L. Gálvez, Carlos L. Errando, Silvia Serrano, Marga Martín-Ayuso, José M. Valverde-Mantecón
ABSTRACT: Type I neurofibromatosis is characterised by altered skin pigmentation and the growth of benign tumours, particularly along the peripheral nerves and central nervous system. We report a 36-year-old primigravida woman in labour who was admitted to the obstetric suite of the Hospital Sant Joan de Déu, Barcelona, Spain, in 2007 with hypothyroidism, type I neurofibromatosis and a factor V Leiden mutation. Due to a lack of cranial and spinal imaging data, an epidural was not indicated; instead, continuous intravenous remifentanil analgaesia was administered. The remifentanil infusion was self-titrated by the patient using a visual analogue scale, with the dosage ranging from 0.01 to 0.25 μg/kg/minute. Due to rotational dystocia, Kjelland-type forceps were used during the delivery. After birth, the infant was found to have Apgar scores of 9 and 10, with no maternal or neonatal adverse effects observed. Although still controversial, remifentanil may be a successful alternative for analgaesia in similar cases; however, the specific risks and benefits for each patient should be considered prior to administration.
Keywords: Obstetrical Analgesia; Drug Contraindications; Type 1 Neurofibromatosis; Factor V Deficiency; Case Report; Spain.
Gingival Leiomyosarcoma in a Young Woman
Case report and literature review(Case Report) Massimo Viviano, Clelia Miracco, Guido Lorenzini, Gennaro Baldino, Serena Cocca
ABSTRACT: Leiomyosarcoma (LMS) is a rare mesenchymal malignancy, of which 3–10% of cases occur in the head and neck region. We report a 22-year-old woman who was referred to the University Hospital of Siena, Italy, in 2016 with an ostensibly benign asymptomatic lump on the mandibular gingiva. The lesion grew rapidly, causing otalgia in the right ear. An excisional biopsy was performed and primary LMS was diagnosed histologically. Subsequently, the patient underwent radical re-excision of the perilesional mucosa, a partial bone resection and the extraction of four teeth. No recurrences or metastases were detectable at a 20-month follow-up. This report discusses the differential diagnosis of LMS with regards to other benign and malignant lesions and reviews the recent literature on primary and secondary oral LMS. Due to its innocuous clinical features—including its asymptomatic nature and presentation at a young age—this aggressive malignancy can go undetected; therefore, an early histopathological diagnosis is crucial.
ABSTRACT: Lipoleiomyomas are an extremely rare form of uterine leiomyoma; moreover, the occurrence of this type of tumour on the broad ligament is even rarer. We report two cases of broad ligament lipoleiomyomas in 15- and 38-year-old female patients who presented to the Lok Nayak Jai Prakash Hospital in New Delhi, India, between 2016 and 2017. In both cases, the preoperative diagnosis was of a solid ovarian malignancy. Most broad ligament tumours are mistaken for ovarian masses as they are difficult to diagnose radiologically.
Keywords: Ovarian Neoplasms; Leiomyoma; Broad Ligament; Thyroid Hormones; Hypothyroidism; Case Report; India.
A rare cause of hoarseness in a patient with a history of pulmonary tuberculosis(Case Report) Rakul Nambiar, Dae Dalus, Anjali Srikumar
ABSTRACT: Hoarseness is a common clinical condition with underlying causes which can vary from reversible and benign to life-threatening and malignant. Cardiovocal syndrome may cause hoarseness secondary to left recurrent laryngeal nerve palsy when the recurrent laryngeal nerve is mechanically affected due to enlarged cardiovascular structures. We report a 28-year-old male who presented to the Government Medical College, Thiruvananthapuram, India, in 2013 with hoarseness. He had undergone irregular treatment for pulmonary tuberculosis (TB) two years previously. Fiber-optic laryngoscopy indicated left vocal cord palsy and a computed tomography scan of the chest revealed features of pulmonary hypertension with extensive enlargement of the pulmonary arteries. An echocardiogram confirmed severe pulmonary arterial hypertension with severe tricuspid regurgitation. He was diagnosed with left recurrent laryngeal palsy secondary to cardiovocal syndrome. Although reports exist of recurrent laryngeal palsy in TB, this case appears to be the first to report cardiovocal syndrome in a patient treated for pulmonary TB.
Keywords: Hoarseness; Pulmonary Tuberculosis; Vocal Cord Paralysis; Cor Pulmonale; Pulmonary Hypertension; Case Report; India.
Calvarial Tuberculosis in a Preschool-Aged Child
An uncommon entity(Case Report) Avradip Santra, Arya Sen, Atri Chatterjee
ABSTRACT: Calvarial tuberculosis is a rare manifestation of tuberculosis, especially in children under five years of age. We report a two-and-a-half-year-old male child who presented to the Nilratan Sircar Medical College, Kolkata, India, in 2015 with frontoparietal fluctuant swelling of three months’ duration. He had also had chronic sinus discharge from the left lower eyelid over the previous six months. Computed tomography of the head revealed a frontal swelling along with erosion of both the outer and inner plates of the left frontal bone. Fine needle aspiration of the pus indicated the presence of acid-fast bacilli. Unfortunately, no primary focus of tuberculosis could be established. The patient improved after one year of antitubercular therapy without requiring any surgical intervention and with no sign of subsequent disease recurrence.
Keywords: Tuberculosis; Skull; Preschool Child; Antitubercular Agents; Case Report; India.
T Cell Large Granular Lymphocyte Leukaemia with Cutaneous Infiltration
(Letter to Editor) Ricardo Ruiz-Villaverde, Ahinoa Bueno-Rodriguez, Paula Aguayo-Carreras, Daniel Sánchez-Cano, Norberto Ortego-Centeno