Background: Gargling had been reported to have significant roles in the prevention and treatment of respiratory tract infections. The purpose of this study was to assess the ability of regular gargling to eliminate SARS-CoV-2 in the oropharynx and nasopharynx. Methodology: This pilot, open labeled, randomized, parallel study compared the effect of 30 seconds, 3 times/day gargling using 1% povidone-iodine (PVP-I), essential oils and tap water on SARS-CoV-2 viral clearance among COVID-19 patients in a tertiary hospital in Kuala Lumpur. Progress was monitored by day 4,6 and 12 PCR (Ct value), gargling and symptoms diary as well as clinical observations. Results: Five confirmed Stage 1 COVID-19 patients were recruited for each arm. The age range was from 22 to 56 years old. The majority were males. Two respondents had co-morbidities, which were asthma and obesity. Viral clearance was achieved at day 6 in 100%, 80%, 20% and 0% for 1% PVP-I, essential oils, tap water and control group respectively. Analysis of 1% PVP-I group versus control group showed significant p-value for comparison of PCR results on Day 4, Day 6 and Day 12. Conclusions: This preliminary study showed that gargling with 1% PVP-I and essential oils show great potential to be part of the treatment and management of Stage 1 COVID-19. Larger studies are required to ascertain the benefit of gargling for different stages of COVID-19 patients. This study was registered in clinicaltrial.gov ( NCT04410159 ).

Pleural infection is a common clinical condition leading to hospitalisation. In the last decade, advances in pleural research have led to a paradigm shift in the treatment of complex effusion from a surgical approach to a less invasive non-surgical approach using a combination of intrapleural fibrinolytics and pulmozyme (DNase). We report 3 patients with pleural infection. Intercostal chest catheter failed to drain the complex effusion. They were subsequently treated with a modified short-course regimen of alteplase and DNase. They received 3 cycles of 16 mg alteplase with 5 mg DNase each within 24 hours and all three had a favourable outcome with no adverse effects. This modified regimen appears effective with good safety profile and adds to the current literature on the safety and effectiveness of different dose combinations of alteplase and DNase.

Pleural infection is an important clinical problem with significant morbidity. In poorly draining complex pleural effusions, the current management favours a less invasive image‐guided placement of smaller bore catheters and adjunctive intrapleural fibrinolysis therapy (IPFT). We describe our experience of using IPFT in three patients with different bleeding risks with complex pleural effusions. The first was a 30‐year‐old with transfusion‐dependent β‐thalassemia with haemoglobin of 7.8 g/dL; second was an 87‐year‐old on dabigatran with haemoglobin of 10 g/dL; and the third was an 80‐year‐old with diffuse large B‐cell lymphoma with haemoglobin of 8.6 g/dL. All three patients received three doses of alteplase and deoxyribonuclease (DNase) without any adverse effects of bleeding and had resolution of the effusion. This case series is an addition to the current literature on the safety of IPFT and we highlight the use of IPFT in patients with low baseline haemoglobin and on anticoagulation therapy.

Tuberculous pleurisy is extra‐pulmonary tuberculosis caused by Mycobacterium tuberculosis (MTB), which is one of the main cause of pleural effusions in developing countries. Intercostal chest catheter is useful for drainage of infected pleural fluid and facilitates sepsis control. However, management might be challenging in complex tuberculous pleural effusion as the septations within the effusion hinder pleural drainage. Intrapleural fibrinolysis therapy improved infected fluid drainage and septic parameter in parapneumonic effusions; however, there seems to be little data on its use in tuberculous pleurisy. In our case series of seven patients with complex tuberculous pleurisy, the use of intrapleural alteplase and deoxyribonuclease (DNase) facilitated fluid drainage which resulted in clinical and radiological improvement. These medications should not be confined to bacterial aetiology only as our case series highlights that in complex tuberculous pleurisy, intrapleural alteplase and DNase may be used as an adjunctive treatment which are proven to be successful and safe.

Background: Hepatitis B infection is a significant worldwide health issue, predispose to the development of liver cirrhosis and hepatocellular carcinoma. Entecavir is a potent oral antiviral agent of high genetic barrier for the treatment of chronic hepatitis B infection. Cutaneous adverse reaction associated with entecavir has rarely been reported in literature. As our knowledge, this case was the first case reported on entecavir induced lichenoid drug eruption. Case presentation: 55 year old gentlemen presented with generalised pruritic erythematous rash on trunk and extremities. Six weeks prior to his consultation, antiviral agent entecavir was commenced for his chronic hepatitis B infection. Skin biopsy revealed acanthosis and focal lymphocytes with moderate perivascular lymphocyte infiltration. Skin condition recovered completely after caesation of offending drug and short course of oral corticosteroids. Conclusion: This case highlight the awareness of clinicians on the spectrum of cutaneous drug reaction related to entecavir therapy.

Left ventricular thrombus is a major complication following myocardial infarction, particularly in patients with anterior myocardial infarction or dilated cardiomyopathies regardless of coronary reperfusion therapy. Embolization of mural thrombus is one of the major causes of large vessel occlusion ischemic stroke. A combination therapy of antiplatelet (single or dual antiplatelet) and anticoagulant is mandatory in the management of myocardial infarction and left ventricular thrombus with or without stroke. To our knowledge, there are no guidelines on the optimal regimen (dual or triple therapies) and timing of administration in cases of cardio-cerebral infarction. It is difficult for clinicians to balance the risks of intracranial hemorrhage and coronary stent thrombosis. Here, we describe the case of a gentleman who had recently undergone coronary intervention and presented with ischemic stroke and left ventricular thrombus, along with the management challenges in this scenario.