Skin disease... what in the world is this?

A nine -year old girl was brought in by her mother with the complaint of itchy lesion around her mouth  for about a week then later the right corner of the mouth became ulcerated. They have been to a clinic and the lesion had not improved.

Dry,ulcerated lips and corner of mouth of a 9-year old girl

The girl looked sullen, obviously unhappy with her appearance. On further questioning there appeared to be no systemic problems like loss of appetite, recent weight loss, fever or any other medical conditions. I asked about allergy history and it seemed no evidence of this. What about lipstick? The mother said the child had not started to use it. I did think of the girl being assaulted in the mouth but there was no evidence of a bruise.

Then my attending nurse asked the girl whether she had been sucking at pickled mangoes sold by street vendors. Then the mother recalled that the girl had eaten a lot of pickled mangoes and she noticed the mouth had swollen. The girl admitted of it being itchy and she kept rubbing at it ( and I guessed they must have applied some over-the- counter medications as well). She must have been allergic to the chemical used to pickle the mangoes, a kind of contact dermatitis. She was treated along that line.

Psoriasis....That's it

Flat, thickened coin-like and discoloured

This  48 year old lady patient  admitted she had been having treatment for her skin disease for several years in the private sector. From the history, I gathered that she had been shopping for doctors. When she first came to see me,  there was a patch of thickened,scaly and discoloured skin which looked like an allergic reaction which had been invaded by fungal infection on her left forearm. There were smaller coin-like lesions in her left foot, below the ankle and heel. They looked thickened and flat but scale-free with  darkened border.

Elevated,thickened with dark discolouration

She had come to the clinic and saw several doctors who prescribed an anti-allergic treatment, all of them had diagnosed it as an allergic dermatitis  and advised her not to take allergy-causing food such as egg, seafood and peanuts. Her condition, nevertheless, recurred unabated and persisted.

When she first came to see me, I also diagnosed it as an allergic skin condition mixed with a fungal infection and proceeded to treat her as such. she came back a month later and this time complained of intense itching and provided another information that the affected areas  were very  itchy especially after bathing.

Then she showed me newer crops of similar patches but this time on her right arm. She said that was how the big one started . I took one look at this newer lesion which was obviously not treated with all sorts of cream and oil like the earlier ones, meaning to say the appearance was in its natural state, it had not been altered by 'treatment' cream and the rest of the potion she had been applying all these years.

Newly erupted  red skin lesions with silvery scales

It was red and had silvery scales..yes, it was psoriasis, a chronic skin condition of unknown cause but seems to run in a family. When asked whether any other of her family members suffering from the same disorder, she denied.

Anyway, an appropriate treatment for psoriasis was initiated and she was advised that this skin disease was a persistent one, remitting and exacerbating. The treatment was only to relieve the symptoms, making her life more bearable with less itchiness. It may remit for a period, depending on an individual.

But for this kind of patient with low education, they find it hard to understand the concept of hereditary or chronic disease. Medically the disease requires continuous treatment. In this case, the use of emollient and specified solution known to reduce the eruptions and scaling of the upper layer of the skin. The characteristic of this lesion is that it can appear to heal for a long time and then it undergoes an  exacerbation. Unless a patient understand the nature of this skin condition, they will forever look for a cure and be stressed at the same time. Apparently stress  has been noted to worsen  the condition.

I asked her whether she had been overly stressed for the last few weeks ( to help explain for the newer lesions which I did not see four weeks earlier). Yes, she had been highly stressed having to look after her child who was hospitalised  for the last two weeks  following an accident.

As responsible doctors, we have to educate patient on the condition so that they are not bewildered by  its persistence. And that they would apply the standard treatment and not use hazardous cream and oil which could complicate  therapy.

Skin Disease and.... Yes, Cats Again

I have seen many patients especially women and children with skin diseases which if you do not ask more questions during history-taking, you will miss treating them definitively. As it is well known, many people with asthma are actually allergic to cat's danders in their home and frequent asthmatic attacks coupled with temperature changes is the usual feature in such cases.

Outdoor cats are also dangerous

I make it my business to go into the home environmental conditions of my patients suffering from asthma. To me they should not have to come and see doctors and other health workers often if they can help control or modify the trigger factors of their malady. Those asthmatic patients in close in contact with cats are counselled accordingly. But believe you me, some of these patients are not able to get rid of their cats due to emotional attachment.

Eschar- like lesions

Lately, I have come across patients, again women and children especially, coming in with strange looking skin lesions over the exposed parts of their bodies, on arms and legs. Some are so bad that they have pus over those lesions surrounded by black ominous looking borders. Some have multiple coin-like lesions and others also suffer from what look like an allergic reaction with numerous small blister-like eruptions.

Multiple skin eruptions which are itchy

My  nurse who herself is a cat-lover ( she bought a Persian cat for RM3k equivalent to approximately USD 970) and also care for other cats, told me about her problem with similar skin lesions ( but not too advanced like some of the patients) till she caged her cats and give them a bath regularly and her lesions gradually disappeared over several months.

Talking to those patients (and their parents) revealed that they all loved cats, even sleeping with them and their cats were of the wandering kind, mixing with all sorts of strays! These animals, while adorable and cute, have fleas and nits whatever you call them, infesting their bodies and unless taken care of, can also infest their human lovers and cause skin reactions.

I have yet to read about these cat-related skin diseases in the literature. But I found this very interesting article here  which makes me cringe and definitely will stay away from cats. The parasite associated with cats are dangerous to human. The parasite, the Toxoplasma gondii is only able to reproduce in a cat's gut and so you had better watch out for cats' droppings.

TM and AXIATA -Profit Taking Ahead of Festive Season

Higher work commitment this year has hampered a lot of my stock tracking activities. Not that I complain as I actually love my work very much and delving into stocks is just a side hobby, giving me something to talk about,whining, whingeing and generally amuse myself as well as creating wealth with a roller-coaster surge of adrenalin. You do need this kind of inflation and deflation of your mood to get the old brain working normally!

Yes, sorry for the digression. As some of my regular blog readers would have known, I like TM stock very much and have invested heavily in it for so many years well before the separation of its international component that now has become Axiata. I must say I have gained the most from this stock and have followed it quite religiously. I sold off all my shares prior to the capital repayment exercise on July 27 this year and made good profit. Following the 30 sen per share capital repayment, the share,  which had appreciated from RM3.60 in Jan 2011 to well above RM6.00 starting in June 2012 before the ex-date of CR, fell around an expected value of about RM5.70. After waiting for more than a week, instead of declining further, it continued to rise! Now, here is when most of us, small time  investors got caught.

Gaming with sharks

The great fund managers, many of them local and foreign, were waiting for the bait to be taken. As the minnows went in, including yours truly, the shares went up wildly, reaching the dizzying price of  RM6.30 in October and in less than 10 days, the sharks moved in to devour the teeming fish and there TM shares crashes to around RM5.60 by 9 Nov. Remember, the festive season is coming, in fact once it is nearing 4 November, small investors should already guard themselves against this selling off ( of any large foreign-held stock for that matter). So, you see Axiata, another favourite foreign-held telco, suffers the same fate over the same narrow window period ( I sold off all my shares at 5.46 last June 2012 to buy MAXIS). Axiata also went up to around 6.30 in October 2012, for which I was rather upset for missing the rally... honestly. And now,  Axiata on 9 Nov 2012 has tumbled down to RM 5.74, is it still going down? And what about TM?

TM STOCK- Beware the 4th of November

Now, I re-purchased my TM shares at RM5.73 in August 2012 and so on paper I am making some losses though I have actually made so much over the years but am still  whingeing over this small losses! The issue is how low will TM go and how long will this take? I am waiting so that I can dollar cost average it!

Are the foreign fund managers (who have a penchant for Malaysian telcos),  still waiting for retail investors to go in again and try to reposition their share holdings in TM? See, this hide and seek game, while exciting, could consume your mental energy and make that part of your brain awake and ready for action. But you really can do this if you have all the time in the world in front of that daily live monitor!

AXIATA STOCK - Suffers a similar fate 

This buy and hold strategy (Warren Buffet's Gangnam style!), actually works best for unit trusts with multi-stock portfolios but not really for individual stocks in general. Having acknowledged and despite that,  I am still lovingly holding on to my TM shares and watching closely the frenzy profit taking playing up right in front of me.

What are the lessons here? I would say, be aware of opportune times of profit taking and beat the fund managers at their their own games.... hmmm... but if everyone knows this trick than the market will wise up to it and later this effect will no longer be there:  Haha... then you, smart investors, have to observe a different pattern, I guess.

Astro IPO: My Misadventure

When news of Astro's relisting came out, many of us were elated and made preparation to apply for the IPO. However when the IPO price was declared, there were many negative comments appearing in the mainstream as well as online media. Most reckoned that the price was inflated and not congruent with Astro's growth status and foreseeable future earnings; at RM3.00 per share, it is well above its P/E ratio based on some stock analysts' calculation.

The rising arrow is actually money for the company
 and not for small investors

I read all about these negative write-ups and in fact had advised some relatives not to apply the IPO. Then I read about some big cornerstone investors buying into Astro and was beginning to feel confident that perhaps the analysts and commentators were wrong as after all it's the market which was going to determine the price eventually. I was still not  convinced generally to apply  but somehow the contrarian in me had refused to follow my instinct. It did not help when my earlier IPO applications for Gas Malaysia and IGB Reit were also not successful so my appetite for IPO had not been satiated at that point in time. I must  try my luck again!

And so when the IPO application was opened, I sauntered to the ATM at my bank and proceeded to apply digitally through ESA. Honestly, if I were to withdraw 90k in cash to apply for 30k shares , I would have thought twice but since it was cashless, I did not feel hesitant, just pressed the buttons and Hey Presto! the transaction was done. And yet, after it was completed, I regretted it almost instantly and was hoping my application would not be successful.

ESA so deceptively easy.... cashless!

As you guessed it (otherwise I won't be whining like this!), my application was successful though a fraction was subtracted and some money was refunded to my bank account.

 When I read that the IPO was oversubscribed, I was a little encouraged and rather elated. But my elation was short-lived when Astro made a very poor début on the listing day. I knew it right away that what the people had been saying was true. I did not act fast enough to dispose of the shares at the opening price which was a few cents higher than the IPO because my tendency is always to buy and hold the shares like what I did with PChem and MSM for which I made a decent profit over a year.

The rest is history. Astro stock was battered down with selling off and it closed at 2.67 today! I am flabbergasted. Who are still selling their shares? It doesn't make sense those who buy the shares at RM3.00 would sell them  at a lower price. It must be people who hold these shares before the re-listing, who else could it be??

I am also disappointed with the banks, one of them is CIMB, appointed to evaluate the stock and price it well above the so called "fair value". It reminds me of the Facebook IPO fiasco in US Nasdaq this year where the valuation was done very high based on some assumptions, leading to many investors' losses. I read about this and thought it would not happen here in Malaysia.... how wrong I was!

But people, most of all,  I blame myself for not sticking to my gut feeling. I am glad though I managed to advise my younger relatives not to apply for Astro IPO and they all stayed away. Unfortunately my risk appetite (greed?) got the better of me and now I am stuck with currently  "worthless" shares. And I have no intention of dollar averaging the shares at the moment.  I will, instead, keep these shares hoping that Astro would perform and give decent dividends (which apparently would work out to lowly  2.3%- 3.2%) in the next couple of years. And to the people who gain unfairly from this Astro re-listing  I wish them good luck in their life. Today is their day.

An investor's delight!

By the way, I take comfort in my SkPetro stock, purchased at 1.92 per share, which climbed sharply over the last few days to somehow, on paper, over compensated for my Astro losses. Thanks goodness!

And finally,  in  future, I will be more wary of those non-GLC IPO! And respect majority opinion as well as listen to my instinct...... and of course, approach the ATM cautiously.

Cat-lovers, Asthma and Mental Health

Almost always my patients who come to the clinic complaining of frequent intractable chronic cough, congestion and full blown asthma have cats in their houses. Despite my advice for them to remove the furry animals, many have refused to do so citing mutual attraction,love and not having the heart to let the animal go.

Cute  Cats but not for everyone

I have a patient, a man in his thirties, who have been coughing for many months and  TB screening were negative. He kept coming to the clinic and the doctors kept giving him antibiotics and cough mixtures and he was getting desperate as the cough really spoiled his sleep, making him tired and irritable. It did not help that he was working as a construction worker with all those dust surrounding him. One positive thing about him was that he was not a smoker.

One day he turned up with three of his children who had wheezy coughs for days on end and one of them was so bad that I had to order for  prompt nebulisation. Obviously this was one happy family of asthmatics! As usual I asked about whether there were cats in the house. Yes, there were, each child had got one cat each and they sleep with the creature and incidentally one of the children had got a couple of sores on the scalp that appeared to be infected bite by cat's fleas.

I informed the man about the association of wheezing in children and flying cat's danders and the possible effect on the lungs  causing allergic coughs that he had been suffering from but he appeared not to be convinced and even said something like God would help those who protect animals? So I firmly told him that there was no cure for allergy as long as the triggering factors are present in his home. It is a waste of time for him to keep coming to the clinic and receiving medications which has short-lived effectiveness.  The best solution is to identify and avoid those allergens.

I have also advised patients rearing cats on the danger of cat's  parasite called Toxoplasmosis gondii which affect the muscle and the nervous system and could cause long-term health problems especially during pregnancy but not many patients are convinced of this effect. The news article today is relating an association of self harm in people affected by the parasite. this research appears to confirm what has been known anecdotally for years now.

The effects of cat's parasite on the nervous system causing functional  breakdown is really frightening.

Allergy and itchy Mrs G

Mrs G is a a long-time patient of mine. She is a pleasant old lady of 56 who comes to the hypertension clinic regularly without fail and is compliant of her medication as a result her condition is pretty well under control. As I have quite a number of such patients, I put Mrs G on a three-monthly appointment. And Mrs G would always turn up at the appointed date.

So it was rather a surprise when my nurse told me one morning that Mrs G had insisted to see me ahead of her appointment in a month's time. She came into the clinic looking gaunt and depressed. She claimed she had not been able to sleep restfully for the last few weeks because of the annoying itchiness all over her body. She admitted going to see a private doctor on two occasions the past two weeks and paid nearly RM200.00 for an injection and medications but the itchiness had not subsided and she was really miserable. Luckily her son in law who is a driver to a Federal Minister helped foot the bill, otherwise she would be more unhappy as she is a housewife and her husband is a small time contractor.

I took one look at her body and observed the small reddish patches all over and I noticed the good old GP had even given her high dose steroid but to no avail. I asked her about any new medications,foods or chemicals that she started using just prior to the generalised itchiness. She replied no but I insisted that she try hard to remember. For that kind of skin allergy, it must have been something enveloping her body either internally or externally. Then I asked her whether she had just changed her washing powder and Walla! "That's it", she said. her son- in- law had bought a new clothes detergent about three weeks before and since then she had had the problem. I told her simply to get rid of the detergent and use her old one and to rewash all her clothes. I gave her some anti-histamines after the consultation.

A couple of days ago, Mrs G came in for her hypertension appointment looking healthy and lovely and obviously very pleased with herself. She then announced that her itchiness had gone and she could sleep well now after she discarded the culprit washing detergent.

Again here, there is no miracle medicine but just simple history taking and a high index of suspicion regarding the cause of the allergy. Being my long-time patient also help me to make a faster diagnosis of her condition. For an allergic condition, medications are no answers if the trigger ( the offending agent) is still present.