SINGAPORE (THE NEW PAPER) - When his left knee swelled up, he thought it was a muscle pull from cycling.
But when the pain gave him sleepless nights, and bouts of fever started to hit him, Mr Howard Kuay realised it was far more serious.
The 30-year-old tuition agency owner was eventually diagnosed with a Group B streptococcus (GBS) infection.
He had to go through an operation to cut his ligament and move his knee cap to the side to drain the pus out.
And the most likely cause of the infection?
Eating raw fish.
What is GBS?
GBS stands for Group B streptococcus, a bacteria which is commonly found in our gut and urinary tract without causing disease. GBS is also found in fish, but usually does not pose any risk.
Who is more at risk of GBS infections?
GBS is known to affect mainly newborn babies, the elderly, and people who are immunocompromised, such as patients with cancer. It can infect healthy young and middle-aged adults as well, but this is rare.
What are the signs and symptoms of GBS infections?
The most common symptom is a fever. Other signs and symptoms depend on the site of the bacterial infection.
Can I still eat raw fish (like sashimi) other than the types identified by the Ministry of Health?
Vulnerable groups of people, especially young children, pregnant women, the elderly, and people with chronic illness such as diabetes, should avoid raw food, such as raw oysters and sashimi.
It is important to let the relevant authorities conduct proper investigations to determine the source and extent of this rise in invasive GBS infections in Singapore.
Source: Dr Jolene Oon, associate consultant from the division of infectious diseases at the National University Hospital
"There is a 99 per cent possibility (of that being the cause)," Dr Leong Hoe Nam, who treated Mr Kuay, told The New Paper.
Mr Kuay eats yusheng (raw fish) only once or twice a year. But after he ate it at a hawker centre last month, he was hit by the GBS infection within a week.
Yusheng sold at hawker centres consists of thinly sliced strips of raw fish drenched in sesame oil and light soy sauce, and topped with ginger and chilli.
Said Dr Leong, an infectious diseases specialist in private practice: "He fits nicely into the GBS cohorts that we have been seeing.
"There is a temporal relationship (between eating raw fish and being infected) of within a week, and the progress of the disease is rapid and at the typical sites."
GBS is a common bacterium found in the human gut and urinary tract of about 15 to 30 per cent of adults without causing disease, according to the Ministry of Health (MOH).
It may, however, occasionally cause infection of the skin, joints, heart and brain.
Figures from MOH show that in the first half of the year alone, there have been 238 cases of GBS infections in public hospitals — a spike from the annual average of 150 cases in the past four years.
Mr Kuay was shocked to find out that the most likely cause of the infection was raw fish.
He recounted that his left knee started to swell on July 13.
Then, he thought he had merely pulled a muscle or a ligament as he had been cycling. A Chinese physician he saw on the same day told him the same thing.
But he started getting bouts of fever on top of the pain. "I have broken a bone before, and I can tell you — it hurt more than that," he said.
The first time he heard the words "Group B Streptococcus" was from his physiotherapist, whom he sought help from after the fever spells.
The physiotherapist referred him to an orthopaedic doctor as Mr Kuay’s condition went beyond physical disability.
By then, Mr Kuay’s left knee had swollen to twice its size due to the infection.
On July 15, he underwent the operation to drain out the pus in his swollen knee.
"I immediately texted my friends and said, 'If you’ve (read a report about GBS), please send it to me.' The reports already linked (GBS infections) to raw fish. Only then did I backtrack and realised I did eat raw fish.
He had to be hospitalised for a week before going to Dr Leong for his daily dose of antibiotics, administered intravenously.
At Dr Leong's encouragement to raise awareness of GBS infections, Mr Kuay shared what he went through on Facebook.
After connecting with both friends and strangers about GBS infections, he realised he was one of the luckier sufferers.
"Someone I know had multiple joint pains and was vomiting profusely. Another was infected in the brain and developed meningitis
"An oncologist friend told me, 'Luckily you don’t have to amputate.' He wasn’t joking," Mr Kuay said.
Dr Leong also told him that one of his patients died within three days of being affected.
Mr Kuay said: "I felt grateful that my infection wasn’t as bad. I also thought about those who did get it bad."
He added that the level of awareness of GBS infections should be raised so people can seek help fast if they suspect they are infected.
Though Mr Kuay is finally cleared of his GBS infection (as confirmed by a blood test on Wednesday), the recovery process is a long and arduous one. It will take another two months of physiotherapy sessions twice a week before Mr Kuay gains strength in his left knee again.
More virulent strain of GBS
Group B streptococcus (GBS) infections used to hit mostly those with chronic diseases or the elderly.
Now, it seems that the young and healthy can be infected as well, thanks to a more virulent strain of the bacteria, said infectious diseases specialist Leong Hoe Nam.
"Everyone has an equal chance. There’s no running away.
"This is an unusual strain (of bacteria). We don’t know why it’s causing more aggressive infections. We haven’t worked out the reasons,” said Dr Leong, who works at Rophi Clinic at Mount Elizabeth Novena Specialist Centre.
He told The New Paper about one of his earliest GBS-infected patients, who was hospitalised on Chinese New Year’s Eve.
She had showed up with nausea and vomiting. The next morning, she appeared dull and listless. By afternoon, she needed a machine to help her breathe and her blood pressure was falling.
"She died in the hospital within 36 hours. There was no chance to fight," said Dr Leong.
While the bacteria usually likes to go to the joints, the back and the blood stream, there is no telling where the bacteria will infect, said Dr Leong.
With so much that is unknown about GBS - like why is it found in fish and whether the GBS found in fish and gut are the same strain - the infectious diseases specialist suggested the age-old adage: Prevention is better than cure.
"Stay away from uncooked fish and if you’ve eaten it, go see a doctor," he advised.
Avoid raw Song fish, Toman fish for now
The Ministry of Health launched a probe last month to find if there is any link between Group B streptococcus (GBS) and raw fish consumption. This came after a message, claiming there is a bacteria outbreak linked to eating contaminated raw fish, started circulating online.
Later, the ministry said in a statement that the interim analysis of its investigation on a limited number of identified cases found an association between raw fish consumption and GBS infections.
More cases will need to be studied for a more definite conclusion, the ministry said.
As a precautionary measure, food stalls are advised to stop selling raw dishes using Asian Bighead Carp (Song fish) and Toman fish (Snakehead fish), which are the two types linked to GBS.