A 73-year-old man with a series of longstanding comorbidities, including diabetes mellitus, asthma, hypertension, chronic kidney disease and ischaemic heart disease, presented to accident and emergency with two episodes of collapse and exacerbation of asthma. Two weeks beforehand, the patient had just returned from a symptomless holiday in Bangladesh, with symptoms of cough, shortness of breath and acute onset of confusion arising a week later prior to admission. On examination, he was tachypnoeic with widespread polyphonic wheeze on auscultation but apyrexial.

He was stabilised and admitted on the basis of acute on chronic kidney injury with metabolic acidosis and possible low-respiratory tract infection. His treatment was started with augmentin, bronchodilators and steroids. Chest x-ray and blood cultures revealed to be clear. However suddenly, with 4 days of good recovery, metabolic acidosis worsened and the decreased creatine levels suddenly rose from 395 to 656 mmol/l over 1 week. Simultaneously, he suffered...]]> 2013-05-24T22:13:33-07:00 info:doi/10.1136/bcr-2013-009375 hwp:master-id:casereports;bcr-2013-009375 BMJ Publishing Group Ltd 2013-05-24 case-report 2013 may24 1 bcr2013009375 bcr2013009375 http://casereports.bmj.com/cgi/content/short/2013/may24_1/bcr2013009400?rss=1 Description

A 63-year-old woman presented with multiple painful pustular lesions over both her feet. The patient reported that the lesions used to exacerbate every 1 week in a month for the last 10 years. She claimed to receive several courses of unsuccessful treatment attempts including various medication and off-label drugs. On examination, she had multiple erythematous pustular lesions of 2–7 mm in diameter over the plantar surfaces of her feet (figure 1). Additionally, similar lesions overlying a desquamated skin were evident on the palmar aspect of her hands (figure 2). Histopathological examination revealed hyperkeratosis with orthoheratosis, acanthosis, spongiosis and papillomatosis. A subgranular pustule, filled with polymorph nuclear neutrophils, was also observed within the epidermis. A diagnosis of pustulosis palmaris et plantaris (PPP) was made. The differential diagnosis of this rare entity should include acute generalised exanthematous pustulosis, acrodermatitis continua, infected eczema, pompholyx and tinea pedis et manuum....]]> 2013-05-24T22:13:33-07:00 info:doi/10.1136/bcr-2013-009400 hwp:master-id:casereports;bcr-2013-009400 BMJ Publishing Group Ltd 2013-05-24 case-report 2013 may24 1 bcr2013009400 bcr2013009400 http://casereports.bmj.com/cgi/content/short/2013/may24_1/bcr2013009410?rss=1 Peritoneal dialysis-related peritonitis remains a major complication of peritoneal dialysis in patients with end-stage renal disease. Chryseobacterium indologenes is a rare organism that has been reported to cause infections mostly in hospitalised patients with severe underlying diseases. We report the first case of C indologenes peritonitis in a patient on peritoneal dialysis outside of Asia. Our patient with end-stage renal disease on peritoneal dialysis grew C indologenes from peritoneal fluid when he presented with abdominal pain and cloudy effluent. The patient responded well to intraperitoneal antibiotic therapy. Tenckhoff catheter did not require removal. This case demonstrates the importance of considering rare causes of peritonitis, such as C indologenes, in patients on peritoneal dialysis. Given the resistance of such organisms to commonly used broad-spectrum antibiotics, antimicrobial susceptibility testing must be assessed as early as possible to assure appropriate antibiotic coverage to avoid untreated peritonitis leading to peritoneal dialysis failure.

A 24-year-old woman presented with palpitations. She had a history of rheumatic heart disease with mild mitral stenosis and moderate mitral regurgitation. ECG (figure 1) showed atrial fibrillation with aberrant conduction suggestive of ‘Ashman's phenomenon’.

Figure 1

ECG showing atrial fibrillation with aberrant conduction in sixth and 14th beat (black arrows). Note the variation in cycle length (R–R duration) in the preceding beats, that is, short–long–short cycle (black star).

Ashman phenomenon, first reported in 1947 by Gouaux and Ashman,1 is a physiological aberrancy of conduction of the ventricle as a result of a change in the QRS cycle length. Ashman beat is typically seen in atrial fibrillation when a relatively long cycle is followed by a relatively short cycle. It can also be seen in other supraventricular tachyarrhythmias. The Fisch criteria for the diagnosis of Ashman phenomenon includes—a...]]> 2013-05-24T22:13:33-07:00 info:doi/10.1136/bcr-2013-009660 hwp:master-id:casereports;bcr-2013-009660 BMJ Publishing Group Ltd 2013-05-24 case-report 2013 may24 1 bcr2013009660 bcr2013009660 http://casereports.bmj.com/cgi/content/short/2013/may24_1/bcr2013009678?rss=1 Description

A 52-year-old man, chronic smoker presented with a condition of a large, painless, foul-smelling mass in his penis of about 2 years. On detailed history, the patient revealed that in spite of applying various non-specific ointments and creams, the growth was gradually increasing in size. On physical examination, a large, exophytic, variegated growth measuring 10 cm at the largest diameter with papillary multilobulated surface was evident (figure 1). Some areas showed necrotic and ulcerated friable areas (figure 2). The growth entirely covered the glans, corona and some part of the distal penile shaft with sideways extension (figure 3). Surprisingly in spite of such large growth, the inguinal lymph nodes were not enlarged on palpation. Distant metastasis were excluded on the basis of chest radiography and CT of the abdomen. Preoperative biopsy revealed a condyloma acuminatum without malignancy or atypia. Partial penectomy was performed....]]> 2013-05-24T22:13:33-07:00 info:doi/10.1136/bcr-2013-009678 hwp:master-id:casereports;bcr-2013-009678 BMJ Publishing Group Ltd 2013-05-24 case-report 2013 may24 1 bcr2013009678 bcr2013009678 http://casereports.bmj.com/cgi/content/short/2013/may24_1/bcr2013009706?rss=1 A 73-year-old man presented acutely with upper gastrointestinal (GI) haemorrhage. Upper GI endoscopy was suggestive of a pancreatic or submucosal duodenal neoplasm invading the stomach. He underwent laparoscopically assisted distal gastrectomy. Histopathological examination showed the rare entity of primary gastric squamous cell carcinoma. He underwent adjuvant chemotherapy and remains disease free at 6 months.

A 65-year-old man has been experiencing recurrent generalised tonic-clonic seizures since few months. He has a slowly progressive cognitive decline since many years. There is spastic left-sided hemiparesis. His elder sister says that his left side has been weak since birth. The family denied any history of head trauma. He was neither hypertensive nor diabetic. They reside in a village near Iraq–Iran border. His blood tests and 12-lead ECG were unremarkable. An urgent non-contrast CT scan of the brain was performed (figure 1). A diagnosis of symptomatic seizures secondary to an old right middle cerebral artery territory ischaemic stroke was made and he was treated accordingly. However, his MRI examination of the brain, which was performed 2 weeks later, uncovers the correct culprit (figure 2).

Figure 1

Non-contrast CT scan of the brain of the patient at the time of A&E admission. Note the...]]> 2013-05-24T22:13:34-07:00 info:doi/10.1136/bcr-2013-009847 hwp:master-id:casereports;bcr-2013-009847 BMJ Publishing Group Ltd 2013-05-24 case-report 2013 may24 1 bcr2013009847 bcr2013009847 http://casereports.bmj.com/cgi/content/short/2013/may24_1/bcr2013009858?rss=1 Dental implants treatment have become a common modality of treatment nowadays for the replacement of missing tooth/teeth, but there have been failures due to a number of reasons; one of the rare problems is the fracture of the dental implants fixture. It is of prime importance to understand the type/system of the implant to be placed in a site and the amount and direction of occlusal forces incurred after the loading of prosthesis.

A 14-year-old North Indian boy presented with a one-year history of multiple hospitalisation anamnesis for recurrent melaena and anaemia. He had received iron supplementation and whole-blood transfusions of more than 10 units for the last 1 year. On physical examination, we observed multiple dark blue, soft, lobulated lesions (5–20 mm) on his palm, sole and extremities which were present for the last 2 years (figure 1). With the application of direct pressure the contained blood emptied leaving behind a wrinkled sac. Doppler ultrasonography of the above-mentioned skin lesions suggested multiple dilated venous lesions filled with blood without any arteriovenous communication. Mucous surfaces of the patient were free of bleb-like lesions and were severely pale. His haemoglobin level was 7 g/dl, with hypochromic microcytosis indicating iron deficiency. Occult blood analysis of the stool was positive on many occasions. Oesophagogastroduodenoscopy revealed bluish venous malformations in stomach and proximal duodenum. Colonoscopy revealed...]]> 2013-05-23T21:46:16-07:00 info:doi/10.1136/bcr-2013-009064 hwp:master-id:casereports;bcr-2013-009064 BMJ Publishing Group Ltd 2013-05-23 case-report 2013 may23 1 bcr2013009064 bcr2013009064 http://casereports.bmj.com/cgi/content/short/2013/may23_1/bcr2013009157?rss=1 Multiple solitary plasmacytoma (MSP) is a rare plasma cell dyscrasia, characterised by multiple lesions of neoplastic monoclonal plasma cells. It differs from multiple myeloma by the lack of hypercalcaemia, renal insufficiency, anaemia and pathological monoclonal plasmocytosis on a random bone biopsy. We present the case of an MSP described for the first time in a patient on peritoneal dialysis. There are only few cases of MSP described in literature, and we performed a review of these cases trying to systematise the topic. The increasing clinical use of CT, MRI and positron emission tomography will enhance in the future the correct diagnosis of MSP.

A 60-year-old woman was referred to our emergency services with a 2-day history of abnormal facial movements. She had been in a recent road traffic accident following which she developed subarachnoid haemorrhage and had seizures. She was on oral diphenylhydantoin sodium 100 mg thrice daily for the last 17 days. She was not on antipsychotics or any other antidopaminergic drugs.

On examination, she was conscious and alert. Her pulse rate was 80/min, regular, blood pressure 120/80 mm Hg and temperature 98.4°F. Higher mental functions were normal and cranial nerves examination was normal. Her pupils were equal and normal reacting to light. Abnormal dyskinetic movements of face, perioral area, eye lids, nystagmus and choreiform movement of the tongue were present (video 1). At times she found it difficult to keep her tongue inside her mouth or to talk properly. These symptoms were absent during sleep. No palatal or ocular myoclonus was seen....]]> 2013-05-23T21:46:16-07:00 info:doi/10.1136/bcr-2013-009246 hwp:master-id:casereports;bcr-2013-009246 BMJ Publishing Group Ltd 2013-05-23 case-report 2013 may23 1 bcr2013009246 bcr2013009246 http://casereports.bmj.com/cgi/content/short/2013/may23_1/bcr2013009355?rss=1 Description

Odontoma is perhaps more accurately defined as a hamartoma than a true neoplasm.1 The term odontoma was first coined by Broca in 1866, who defined it as a tumour formed by overgrowth of complete dental tissue.2 Odontoma has also been defined as ‘tumour’ that has developed and differentiated enough to produce enamel and dentin.3 Odontomas are usually composed of different dental tissues, including enamel, dentine, cementum and in some cases, pulp tissue.4

Although usually located pericoronally to an impacted tooth, odontoma may also arise from odontogenic progenitor cells within the periodontal ligaments and become located between the tooth root and are not associated with disturbance in eruption.5 Odontomas exhibit complete epithelial and mesenchymal differentiation to the point that enamel and dentin are formed. Gabell, James and Payne grouped odontoma according to their developmental origin: epithelial, composite (epithelial...]]> 2013-05-23T21:46:16-07:00 info:doi/10.1136/bcr-2013-009355 hwp:master-id:casereports;bcr-2013-009355 BMJ Publishing Group Ltd 2013-05-23 case-report 2013 may23 1 bcr2013009355 bcr2013009355 http://casereports.bmj.com/cgi/content/short/2013/may23_1/bcr2013009431?rss=1 Pulmonary thromboembolism (PTE) can result in significant adverse maternal and fetal outcomes. Monteplase—a recombinant tissue plasminogen activator—is considered effective for the treatment of PTE; however, only a few reports have described cases wherein surgical procedures were performed following treatment with monteplase. Here, we present a patient diagnosed with a massive PTE at 28 weeks of gestation leading to maternal cardiac arrest and intrauterine fetal death. The patient was treated with percutaneous cardiopulmonary support and monteplase. Thrombolysis was achieved 30 min after its administration. The patient went into spontaneous labour and delivered a stillborn vaginally. Using gauze tamponade and uterotonic agents, haemostasis was achieved after 4 h, and bleeding completely ceased after 7 h. Thus, we suggest that a thrombolytic agent can be administered in critical cases, even if delivery is expected shortly.

A 65-year-old female patient came to our dental clinic with a request for the replacement of missing teeth. Intraoral examination revealed mostly edentulous jaws with just a few retained teeth, namely the mandibular right and left first and second premolars, maxillary left canine and right second and third molars. The edentulous areas showed no soft tissue abnormality or bony expansion. Supra-erupted maxillary right molars and grade-I mobile mandibular left premolars showed proximal caries. Clinical examination was unremarkable with no specific signs and symptoms and no evidence of lymphadenopathy. The patient revealed an unremarkable medical history. A routine pretreatment orthopantomographic (OPG) radiological examination (figure 1) revealed two coincidental pathologies. A dome-shaped, solitary, curved, homogeneous and slightly radiopaque mass, having a smooth, uniform and well-defined outline, was seen to arise from the floor of the right maxillary sinus, above the molars. It was broad based, with the...]]> 2013-05-23T21:46:16-07:00 info:doi/10.1136/bcr-2013-009575 hwp:master-id:casereports;bcr-2013-009575 BMJ Publishing Group Ltd 2013-05-23 case-report 2013 may23 1 bcr2013009575 bcr2013009575 http://casereports.bmj.com/cgi/content/short/2013/may23_1/bcr2013009693?rss=1 ‘Legal highs’ are substances of synthetic or natural origin having psychotropic properties. ‘Legal highs’ are often new and, in many cases, the actual chemical ingredients in a branded product can be changed without notifications and the risks are unpredictable. Acute recreational drug toxicity is a common reason for presentation to both hospital and prehospital medical services. It appears that, generally, the pattern of toxicity associated with ‘legal highs’ is broadly similar to that seen with classical stimulant recreational drugs such as cocaine, MDMA (3,4 methylenedioxy-N-methyl amphetamine) and amphetamine. Lack of clear literature pertaining to their chemical properties, pharmacology and toxicology makes an evaluation of their effects difficult. We describe a unique case in which consumption of such a substance led to hospital admission and a diagnosis of ‘lateral medullary stroke’ or ‘Wallenberg syndrome’. We believe that this is the first described case of a ‘legal high’ intake linked to a posterior circulation stroke.

A 57-year-old man reported to the outpatient department with the chief compliant of deformed upper lip which was present since birth. He denied any complaints other than cosmetic ones. On examination, an extra fold of redundant tissue was present on the inner surface of the upper lip. The overlying mucosal tissue appeared intact and smooth with no palpable masses or surface changes (as seen in figure 1). There were no other associated congenital abnormalities. Thus, provisional diagnosis of congenital bilateral upper double lip was made.

Figure 1

Photograph of extraoral view showing an extra fold of redundant tissue on the inner surface of the upper lip with no palpable masses or surface changes.

Double lip may develop in association with Ascher’s syndrome which consists of the triad of blepharochalasis, non-toxic thyroid enlargement and double lip.1 2...]]> 2013-05-22T19:41:59-07:00 info:doi/10.1136/bcr-2013-008664 hwp:master-id:casereports;bcr-2013-008664 BMJ Publishing Group Ltd 2013-05-22 case-report 2013 may22 1 bcr2013008664 bcr2013008664 http://casereports.bmj.com/cgi/content/short/2013/may22_1/bcr2013008692?rss=1 There is no formal association between premature coronary artery disease (CAD) and Prader-Willi syndrome despite its association with hyperlipidaemia, diabetes mellitus and hypertension. A 36-year-old man with Prader-Willi syndrome presented with acute breathlessness. Inflammatory markers were borderline elevated and chest radiography demonstrated unilateral diffuse alveolar shadowing. Bronchopneumonia was diagnosed and despite treatment with multiple courses of antimicrobial therapy, there was minimal symptomatic and radiographical improvement. A diagnosis of unilateral pulmonary oedema was suspected. Echocardiography was non-diagnostic due to body habitus and coronary angiography was deemed inappropriate due to uncertainty in diagnosis, invasiveness and pre-existing chronic kidney disease. Therefore, cardiac magnetic resonance was performed, confirming severe triple-vessel CAD. This case demonstrates a presentation of heart failure with unilateral chest radiograph changes in a young patient with Prader-Willi syndrome and severe premature CAD detected by multiparametric cardiac magnetic resonance imaging.

A 23-year-old man who had sustained a minor twisting injury 10 days prior, presented with right knee pain and swelling. There was no history of joint problems, infection or bowel problems, nor was there a family history of arthritis. Physical examination showed a large effusion on the right side with lateral joint line tenderness, from which 70 ml of chocolate-coloured, viscous and heavily blood-stained effusion was aspirated (figure 1). His erythrocyte sedimentation rate and the C reactive protein levels were within normal limits. Rheumatoid factor was negative and results of other blood tests, including a clotting screen, were normal.

Figure 1

Shows chocolate-coloured and viscous aspirates in fine-needle aspiration  from the right knee joint.

Plain anteroposterior and lateral radiographs of the right knee joint revealed no bony abnormality. To evaluate his symptoms further, a MRI scan of the knee was performed. Axial...]]> 2013-05-22T19:42:00-07:00 info:doi/10.1136/bcr-2013-009353 hwp:master-id:casereports;bcr-2013-009353 BMJ Publishing Group Ltd 2013-05-22 case-report 2013 may22 1 bcr2013009353 bcr2013009353 http://casereports.bmj.com/cgi/content/short/2013/may22_1/bcr2013009424?rss=1 Friedreich's ataxia (FRDA) is an autosomal recessive inherited disorder characterised by progressive gait and limb ataxia, dysarthria, areflexia, loss of position sense and a progressive motor weakness of central origin. Some observations indicate that all symptoms of FRDA ataxia could be the manifestation of a thiamine deficiency because of enzymatic abnormalities. Two patients with FRDA were under rehabilitative treatment from February 2012 to February 2013. The scale for assessment and rating of ataxia was performed. The patient began an intramuscular therapy with 100 mg of thiamine every 3–5  days. Injection of high-dose thiamine was effective in reversing the motor failure. From this clinical observation, it is reasonable to infer that a thiamine deficiency due to enzymatic abnormalities could cause a selective neuronal damage in the centres that are typically affected by this disease.

A woman diagnosed with breast cancer was previously treated with surgery and chemotherapy before being referred to us for radiotherapy. During planning radiotherapy, an incidental observation was made of a conspicuous discolouration over the dorsal aspect of the left hand (figure 1). On requesting further information, the patient recalled having experienced an incident where "a red coloured drug had leaked out of the vein during chemotherapy."

Figure 1

Discolouration owing to local tissue necrosis over the dorsal aspect of the left hand and forearm owing to an antracycline extravasation event which had occurred a couple of months earlier.

With that information, it could be concurred that the patient had suffered an extravasation of an anthracycline agent such as doxorubicin or epirubicin which is an important part of chemotherapy for breast cancer.

Anthracycline extravasation is a serious event which is accompanied...]]> 2013-05-22T19:42:00-07:00 info:doi/10.1136/bcr-2013-009711 hwp:master-id:casereports;bcr-2013-009711 BMJ Publishing Group Ltd 2013-05-22 case-report 2013 may22 1 bcr2013009711 bcr2013009711 http://casereports.bmj.com/cgi/content/short/2013/may22_1/bcr2013009714?rss=1 We describe a 79-year-old gentleman with a longstanding history of chronic lymphocytic leukaemia who presented with subacute onset of cholestatic jaundice. Comprehensive review of the patient's data and medications failed to reveal any obvious causes. Exhaustive testing including abdominal CT and magnetic resonance cholangiopancreatography failed to reveal any obstruction. A liver biopsy demonstrated scattered non-caseating granulomas. The patient was diagnosed with granulomatous hepatitis and treated with oral steroids and eventually improved. It was thought to be due to paraneoplastic cholestasis as an extrahepatic manifestation of non-Hodgkin's lymphoma.

A 32-year-old man recently had a right-sided hemiparesis; a head CT scan revealed left middle cerebral artery (MCA) territory infarct. The patient was haemodynamically stable, with no clinical evidence of deep venous thrombosis (DVT) and was referred for cardiac evaluation. The patient's routine workup including carotid Doppler was normal. ECG showed normal sinus rhythm.

Two-dimensional transthoracic echocardiography (figures 1 and 2) performed revealed a thrombus attached to the interatrial septum (IAS) prolapsing into the right ventricle through the tricuspid valve and traversing into the left atrium through a foramen ovale and prolapsing into the left ventricle. A soft clot (figure 3) was also identified into the main pulmonary artery. Doppler performed after echocardiography revealed DVT involving the right popliteal vein and common iliac vein. Thus, this patient had an intracardiac thrombus, evidence of pulmonary thromboembolism, left MCA territory infarct and Doppler...]]> 2013-05-22T19:42:01-07:00 info:doi/10.1136/bcr-2013-009818 hwp:master-id:casereports;bcr-2013-009818 BMJ Publishing Group Ltd 2013-05-22 case-report 2013 may22 1 bcr2013009818 bcr2013009818 http://casereports.bmj.com/cgi/content/short/2013/may22_1/bcr2013009819?rss=1 Percutaneous transseptal mitral commissurotomy (PTMC) is the treatment of choice in rheumatic mitral stenosis. The reuse of sterilised PTMC balloon catheters is widely practised to bring down the procedure cost and have proven safety and efficacy. The reused balloons may deform and are prone to rupture causing fatal complications like embolism either of the torn balloon material or air. We report a first case of Accura balloon rupture during PTMC to the best of our knowledge. Fortunately, there was no complication in our patient. Thus, during the balloon preparation it should be examined for any deformity or tear and air should be removed completely to prevent fatal outcome. The repeated use of the hardware should be limited and an informed consent regarding the possible complications of the reused hardware should be taken.

The maxillary central incisors are the teeth most susceptible to fractures caused by direct trauma due to contact sports, road accidents and falls. Aesthetic rehabilitation of crown fractures of the maxillary anterior teeth is one of the greatest challenges to the dentist. One of the options for managing coronal tooth fractures when the tooth fragment is made available by the patient and there is no or minimal violation of the biological width, is the reattachment of the dental fragment.1 Reattachment of fractured tooth fragments can provide good and long-lasting aesthetics because the tooth's original anatomic form, colour and surface texture are maintained. It also restores function, provides a positive psychological response and is a relatively simple procedure.1

A 8-year-old female patient reported to our dental clinic with trauma to maxillary central incisors. Trauma had occurred 30 min earlier while playing in the ground. The...]]> 2013-05-22T19:42:01-07:00 info:doi/10.1136/bcr-2013-009833 hwp:master-id:casereports;bcr-2013-009833 BMJ Publishing Group Ltd 2013-05-22 case-report 2013 may22 1 bcr2013009833 bcr2013009833 http://casereports.bmj.com/cgi/content/short/2013/may22_1/bcr2013009840?rss=1 Description

A 35-year-old woman, apparently normal, who had participated in traditional Devithullal (a religious dance form involving violent head banging for hours at a time) on the evening of the following day developed vomiting, urinary incontinence, altered sensorium and quadriplegia. All blood investigations including thrombophilia workup were normal. CT scanning of the brain was normal. MRI diffusion-weighted image showed the characteristic bilateral ventral pontine hyper intensities (figure 1A) and the apparent diffusion coeffient (ADC) map images showed bilateral ventral pontine hypointensities diagnostic of acute infarction (figure 1B). MR angiogram revealed basilar artery thrombosis (figure 2A,B).

Figure 1

(A) The diffusion-weighted image on the left show the characteristic bilateral ventral hyperintensities in the pontomesenchephalic junction diagnostic of acute infarction (white arrows). (B) Showing bilateral ventral hypointensities in the pontomesenchephalic junction in ADC maps (white arrows) suggesting acute infarction.

A 52-year-old woman without cardiovascular risk factors was admitted with oppressive chest pain following an emotionally stressed situation. The ECG showed an ST segment elevation in leads V2–V3 and biphasic T-wave in anteroseptal and lateral leads (DI, aVL, V1–V3) (figure 1A). Laboratory test revealed slightly elevated levels of Troponin I (0.068 ng/ml (<0.012 ng/ml)). Transthoracic echocardiography revealed akinesia of the midportion of the septum and free wall of the left ventricle (LV) and normal contractility of the basal and apical region with 68% ejection fraction. The left ventriculogram confirmed the akinesia with compensatory hyperypercontractility of the basal and apical segments (figure 1B). Cronary angiogram showed no coronary disease. She was discharged with carvedilol (3.125 mg/once daily), ramipril (1.25 mg/once daily), aspirin (100 mg/once daily) and atorvastatin (10 mg/once daily). The echocardiogram performed at discharge and follow-up (6 months) showed regression of the wall motion abnormalities.

Figure 1

(A) 12-lead electrocardiogram showing...]]> 2013-05-22T19:42:01-07:00 info:doi/10.1136/bcr-2013-009881 hwp:master-id:casereports;bcr-2013-009881 BMJ Publishing Group Ltd 2013-05-22 case-report 2013 may22 1 bcr2013009881 bcr2013009881 http://casereports.bmj.com/cgi/content/short/2013/may22_1/bcr2013009913?rss=1 Soft tissue enlargements of the oral cavity often present a diagnostic challenge because a diverse group of pathological processes can produce such lesions. Crocker and Hartzell's disease is one of the most common entities responsible for causing soft tissue enlargements. It is a relatively common benign mucocutaneous lesion. Crocker and Hartzell's disease has been referred to by other names such as pregnancy tumour, pyogenic granuloma, granuloma pediculatum benignum, benign vascular tumour and vascular epulis. The incidence is 26.8–32% of all reactive lesions. It is seen mostly in second or third decade of life and commonly seen in women. The most frequently involved site is the maxillary gingiva; other sites are lip, tongue, buccal mucosa and palate. This paper presents a rare case of Crocker and Hartzell's disease found on mandibular anterior gingiva of an 8-year-old male patient.

Hyperdontia is the condition of having supernumerary teeth, or teeth which appear in addition to the regular number of teeth. It is a developmental anomaly and has been argued to arise from multiple aetiologies. The most common site is the maxillary incisor region; but the prevalence of more than three teeth supernumerary tooth is less than 1%. A case of 13 year male patient is reported with a multiple impacted supernumerary tooth in maxillary anterior region hindering the eruption of right permanent central incisor. The supernumerary tooth was treated via surgical approach followed by an interim prosthesis for permanent central incisor which later on erupted in due course of time. Background Supernumerary teeth may be defined as any teeth or tooth substance in excess of the usual configuration of 20 deciduous and 32 permanent teeth.1 The presence of supernumerary teeth in the premaxillary region often poses...]]> 2013-05-22T19:42:01-07:00 info:doi/10.1136/bcr-2013-009995 hwp:master-id:casereports;bcr-2013-009995 BMJ Publishing Group Ltd 2013-05-22 case-report 2013 may22 1 bcr2013009995 bcr2013009995 http://casereports.bmj.com/cgi/content/short/2013/may22_1/bcr2013010029?rss=1 Significant numbers of patients visiting the paediatric dental clinics have aesthetically objectionable brown stains and desire treatment for them. Intrinsic tooth discolouration can be a significant aesthetic, and in some instances, functional, problem. Dental fluorosis, tetracycline staining, localised and chronological hypoplasia, and both amelogenesis and dentinogenesis imperfecta can all produce a cosmetically unsatisfactory dentition. The aetiology of intrinsic discolouration of enamel may sometimes be deduced from the patient's history, and one factor long associated with the problem has been a high level of fluoride intake. Optimal use of topical fluorides leads to a decrease in the caries prevalence but may show an increase in the prevalence of fluorosis staining because of metabolic alterations in the ameloblasts, causing a defective matrix formation and improper calcification. A 12-year-old male patient was screened at the dental clinic for routine dental care. He wanted us to remove and/or minimise the noticeable brown/yellow staining of his teeth. He requested the least invasive and most cost-effective treatment to change his smile. Various treatment modalities are present for the treatment of fluorosis stains. This report discusses the microabrasion technique in the patient having dental fluorosis.

A 42-year-old man was presented to the emergency service with pain and swelling around the right ankle after a motorcycle accident. No significant pathology was identified in the radiographies taken in the emergency service (figure 1). He was diagnosed with ‘soft tissue injury’. He was discharged with the use of non-steroidal anti-inflammatory drug (NSAID), ice and bandage. He was presented to the orthopaedic clinic 10 days later since his complaints persisted. In the physical examination of the limping patient, tenderness was observed during palpation in the medial tarsal region of the right foot. There was no significant swelling or ecchymosis and sensory-motor examination was normal.

Figure 1

Plain radiographs of the patient's foot.

The MR images revealed an isolated non-displaced fracture in the medial cuneiform bone with an associated oedema (figure 2). A short-leg cast was applied for 20 days....]]> 2013-05-22T19:42:01-07:00 info:doi/10.1136/bcr-2013-010093 hwp:master-id:casereports;bcr-2013-010093 BMJ Publishing Group Ltd 2013-05-22 case-report 2013 may22 1 bcr2013010093 bcr2013010093 http://casereports.bmj.com/cgi/content/short/2013/may22_1/bcr2013010095?rss=1 Giant coronary artery aneurysm is an uncommon but well-recognised entity in infants and children with Kawasaki disease. We describe an unusual case of ischaemic cardiomyopathy in an 86-year-old woman owing to giant aneurysm in a dominant right coronary artery discovered with left heart catheterisation and was missed on ECG and nuclear studies. This case highlights the importance of early diagnosis which allows appropriate management. Transcatheter therapy is the main treatment option in this case; however, medical therapy can be used alone with variable results and outcome.

A previously healthy 6-year-old male child presented in the emergency department with a 4-day history of painless erythematous-papulomacular rash that started on the left side of the forehead. The lesions became blistered and confluent, spreading to the nasal bridge and upper and lower eye lids sparing the tip of the nose (figure 1A).

Figure 1

Herpes zoster involving the ophthalmic branch of the left trigeminal nerve (A). Resolution 20 days after treatment (B).

Varicella vaccine was given at 1 year age and his mother denied any eruptive disease during pregnancy. PCR and Tzanck test confirmed the clinical suspicion of herpes zoster. Oral acyclovir was given for 14 days with excellent results (figure 1B). No ophthalmological complications were present during convalescence time.

Herpes zoster ophthalmicus in children is uncommon and is only barely described in the literature especially in immunosuppressed children. 2013-05-21T23:17:55-07:00 info:doi/10.1136/bcr-2013-009702 hwp:master-id:casereports;bcr-2013-009702 BMJ Publishing Group Ltd 2013-05-21 case-report 2013 may21 1 bcr2013009702 bcr2013009702 http://casereports.bmj.com/cgi/content/short/2013/may21_1/bcr2013009718?rss=1 Pilonidal sinus is a chronic inflammatory condition owing to the subcutaneous trapping of hair. Most commonly it is found in the sacrococcygeal region (natal cleft) but rarely it is found on the penis with very few cases reported in the literature worldwide. We are reporting a case of a pilonidal sinus growing on the distal penile shaft with the sinus opening to the mucosal layer of the foreskin, in a young and fit patient. The cyst was removed with a circumcision and found to contain hair. This was confirmed by histology as a pilonidal sinus cyst.

An 81-year-old gentleman was referred to the medical team by his general practitioner (GP) with a biochemically worsening renal function. Medical history included hypertension, chronic kidney disease and a 67 pack-year smoking history. Significantly, there was a history of angiotensin-converting enzyme inhibitor (ACE-i) use 3 months previously. The patient was otherwise asymptomatic. Admission bloods: Na 135 mmol/l, K 5.7 mmol/l, urea 32.7 mmol/l, creatine 358 μmol/l (baseline 150 μmol/l), estimated-glomerular filtration rate (eGFR) 14ml/min. On examination, there was a large, non-tender pulsatile mass in the abdomen. Otherwise the systems examination was unremarkable. He proceeded to an ultrasound (figure 1) and a CT scan of the abdomen (figure 2) which showed an 11.8 cm diameter abdominal aortic aneurysm (AAA) just below the renal artery level. Both kidneys showed cortical scarring suggestive of chronic parenchymal disease; however, there was no evidence of hydronephrosis. The patient underwent semi-elective AAA repair as an inpatient....]]> 2013-05-20T20:46:53-07:00 info:doi/10.1136/bcr-2013-009125 hwp:master-id:casereports;bcr-2013-009125 BMJ Publishing Group Ltd 2013-05-20 case-report 2013 may20 1 bcr2013009125 bcr2013009125 http://casereports.bmj.com/cgi/content/short/2013/may20_1/bcr2013009137?rss=1 The calcifying odontogenic cyst (COC) occurs mainly as an intraosseous lesion in mandible or maxilla, but the peripheral variation of COC has also been reported. The confusion regarding its nature as cyst or tumour has not been resolved and a vast diversity has been noted in clinicopathological aspects of COC. We report a case of COCs with minimal mural ameloblastomatous proliferation in a 13-year-old girl, who presented with a painless swelling in the left jaw causing mild facial asymmetry.

A 24-year-old woman was admitted to our hospital with high fever and poor general status developing 7 days after emergent caesarean section was performed because of the premature rupture of the membranes. She was admitted to the intensive care unit with a diagnosis of sepsis. Her history revealed one abortus and one stillbirth and no endometriosis. She was dehydrated, with shivering, tachycardia and hypotension. Her alanine transaminase, aspartate aminotransferase, bilirubin, blood urea nitrogen and creatine levels were mildly elevated. Teicoplanin and imipenem were given in adjusted renal doses. Fever reincreased at thetenth day of hospitalisation, and a pain in the left paravertebral region appeared. Contrast-enhanced abdominal CT revealed thrombosis of the left ovarian vein with extension into the left renal vein and inferior caval vein (figures 1 and 2). Protein C and S deficiency was found, and warfarin and enoxaparin were started. The patient...]]> 2013-05-20T20:46:53-07:00 info:doi/10.1136/bcr-2013-009164 hwp:master-id:casereports;bcr-2013-009164 BMJ Publishing Group Ltd 2013-05-20 case-report 2013 may20 1 bcr2013009164 bcr2013009164 http://casereports.bmj.com/cgi/content/short/2013/may20_1/bcr2013009497?rss=1 Osseous hydatidosis is a very severe and recurrent complication of hydatidosis. The two cases reported here illustrate the severity of this invasive and destructive osseous parasitosis located at the femur and the hip joint, which required extensive resection and prosthetic reconstruction. The first case had a long history of liver and lung hydatidosis with a wide ‘en-bloc’ extra-articular resection of the right hip joint including the proximal femur; the second case had an ‘en-bloc’ total femur resection and total femur prosthesis. Preoperative and postoperative chemotherapy with albendazole was combined with surgery and was applied for many months. These two cases occurred several years after the incomplete treatments of recurrent lung or liver hydatidosis and might have been prevented if chemotherapy had been initially applied.

A 22-year-old Bangladeshi man presented to a London district general hospital with a 2 month history of abdominal pain, weight loss, fever and difficulty in walking. His medical history was significant for cervical tuberculous lymphadenitis and he had recently been stepped-down from quadruple therapy with rifampicin, isoniazid, ethambutol and pyrazinamide to dual therapy with rifampicin and isoniazid. On admission, he was febrile and tachycardic. Examination revealed generalised abdominal tenderness with a palpable, fluctuant right flank mass. Inflammatory markers were raised (C reactive protein 287 mg/l, erythrocyte sedimentation rate 121 mm/h) with a normal white cell count (9.4x10⁹/l) and normocytic anaemia (haemoglobin 9.3 g/dl). An abdominal CT was performed which demonstrated a large right-sided psoas abscess measuring 110x190x80 mm with superior displacement of the right kidney (figure 1). No vertebral disease was seen.

Figure 1

Contrast-enhanced CT scans in (A) the coronal plane and (B) the transverse plane, demonstrating a...]]> 2013-05-20T20:46:53-07:00 info:doi/10.1136/bcr-2013-009966 hwp:master-id:casereports;bcr-2013-009966 BMJ Publishing Group Ltd 2013-05-20 case-report 2013 may20 1 bcr2013009966 bcr2013009966 http://casereports.bmj.com/cgi/content/short/2013/may17_1/bcr2012008011?rss=1 A 40-year-old manual labourer presented with easy fatiguability, recurrent vomiting and loss of weight of 3 months, duration. Upon examination, there was significant axillary and cervical lymphadenopathy. No pallor, icterus or clubbing was evident. There was generalised hyperpigmentation and multiple oral ulcers. The blood pressure 90/60 mm Hg in the right upper limb in the supine position. Investigations showed a low serum cortisol. Mantoux test was strongly positive (20 mm).A fine needle aspiration biopsy of the cervical lymph node revealed reactive changes. Bone marrow aspiration and biopsy were normal. Cervical lymph node biopsy showed caseating granulomas suggestive of tuberculous lymphadenitis. A CT scan of the abdomen showed bilaterally enlarged adrenal glands with hypodense areas suggestive of necrosis. He was diagnosed with extrapulmonary disseminated tuberculosis with tuberculous adrenalitis. He was started on directly observed therapy (DOTS) for disseminated tuberculosis and 40 mg of prednisolone. He is improving with treatment.

In October 2012, an asymptomatic 54-year-old man, with a body mass index (BMI) of 50 kg/m², smoking habits, hypertension, dyslipidaemia and family history of coronary artery disease (CAD) presented to us for a clinical work out. Since these conditions indicate high risk of CAD,1 he underwent exercise/rest sestamibi gated single-photon-emission cardiac tomography (G-SPECT). This procedure documented submaximal exercise test and inconclusive anterior wall perfusion defect. A reduced exercise capacity and tissue attenuation characterise obesity and determine doubtful SPECT results (figure 1). A 64-slice cardiac tomography (CT) detected calcium deposits over the anterior descending (LAD) and first diagonal (D1) coronary arteries and lack of visualisation of the distal right coronary artery (RCA), (figure 2). Coronary calcifications can hide the arterial lumen leading to incorrect estimation of stenosis severity.2 Obesity may lead to decreased image quality, owing to ‘noisy image’3...]]> 2013-05-17T20:40:54-07:00 info:doi/10.1136/bcr-2013-009631 hwp:master-id:casereports;bcr-2013-009631 BMJ Publishing Group Ltd 2013-05-17 case-report 2013 may17 1 bcr2013009631 bcr2013009631 http://casereports.bmj.com/cgi/content/short/2013/may17_1/bcr2013009677?rss=1 Filariasis is prevalent in tropical and subtropical areas and is endemic in regions of India. Lymphatic filariasis in India is caused mainly by two species of nematodes: Wuchereria bancrofti and Brugia malayi, which invade the human lymphatic system. We report two cases of superficial cystic lesions of the upper limb revealed on fine needle aspiration (FNA) to be clinically unsuspected filariasis. Despite similar aetiologies, both cases revealed variations in aspirate nature, smear morphology and peripheral blood findings. FNA provides definitive diagnosis and is an important tool for diagnosing soft tissue swellings owing to filariasis.