BMJ Case Reports Last 6 Issues

Acute corneal hydrops mimicking full thickness perforation

SW, C., MB, P., S, A., KL, T. — 2012-05-15T01:45:22-07:00

A 26-year-old Caucasian female with keratoconus presented with an acutely painful and red left eye. Visual acuity on presentation was 3/60. Slit lamp examination revealed localised Descemet’s membrane break with iris partially plugging it. There was a bulging stromal cyst which would intermittently flatten and reform. The appearance when the cyst was flattened mimicked a full thickness corneal perforation. However, no obvious overlying epithelial defect was detected and an intermittent leakage through micro-perforations in the corneal epithelium was the probable cause of the variable appearance. The anterior chamber reformed and iris plug freed following an insertion of a bandage contact lens and taped eyelid. On follow-up, the Descement’s membrane had healed with visual acuity improving to 6/18. Our case illustrates the importance of identifying corneal hydrops mimicking a full thickness perforation as conservative management has a greater chance of recovery.

Incarcerated foreign body in the vagina - a metal bangle used as a pessary

Dasari, P., Sagili, H. — 2012-05-15T01:45:23-07:00

Long-forgotten vaginal pessaries get incarcerated in the vagina and their removal poses problems. A 60-year-old postmenopausal woman presented with foul smelling purulent discharge per vaginum and stress incontinence. Speculum examination revealed foul smelling white discharge per vaginum and a friable vaginal wall which bled on touch. The anterior portion of a metal ring deeply embedded in the vagina was seen. The cervix appeared normal. Attempts of removal by traction under local infiltration failed and resulted in bleeding. Biopsy from the tissue covering the ring reported no evidence of malignancy. She was treated with broad-spectrum antibiotics for 1 week and the metallic ring was removed without any complications under general anaesthesia using electrocautery. It was found to be a metallic bangle with design. It is essential to gently cauterise and release the fibrosis over the incarcerated foreign body to achieve safe removal.

Single incision thoracoscopic sympathectomy for hyperhidrosis

Unal, O., Citgez, B., Battal, M., Karatepe, O. — 2012-05-15T01:45:23-07:00

Thoracal sympatectomy for hyperhidrosis and vasospastic vascular diseases is a rare method of surgical treatment. Three patients (1 male, 2 female; mean age 27.6; between 25 and 30) with palmar hyperhidrosis and/or axillary and dorsal hyperhidrosis who underwent single port thoracoscopic sympatectomy were analysed for age, sex, time of operation room, intraoperative and postoperative complications and length of hospital stay. Mean operating room time was 70 min (between 30 and 120 min). Mean length of hospital stay was 1 day. No postoperative complications were noted. Single incision laparoscopic surgery for hyperhidrosis is a safe method of treatment and an alternative to laparoscopy.

Neonatal lupus syndrome in a Nigerian child

Abiodun, M., Adelowo, O. — 2012-05-15T01:45:23-07:00

Neonatal lupus is a rare syndrome resulting from passively transferred maternal autoantibodies during pregnancy. A male infant was delivered at term to a 29-year-old primiparous woman who was diagnosed of systemic lupus erythematosus 2 years earlier and had detectable levels of autoantibodies (antinuclear antibody (ANA), anti-dsDNA, anti-Ro and anti-La/SSB) in second trimester. However, the pregnancy was otherwise uneventful. He presented at the age of 8 week with a widespread hypopigmented macular rash on the trunk and patchy alopecia involving the hair line and the occipito-parietal regions of 3 weeks duration, anaemia and symptomatic thrombocytopaenia. Serologic test for autoantibodies was positive for ANA and anti-La/SSB. Further evaluation was normal. He was managed conservatively with blood products and topical corticosteroids. Mother was also advised to avoid direct exposure to sunlight and fluorescent light. Haematological parameters gradually normalised over 2 months and the skin lesions resolved completely by the age of 6 months.

Tumefactive demyelination associated with systemic lupus erythematosus

Verma, R., Arya, K. — 2012-05-15T01:45:23-07:00

Systemic lupus erythematosus (SLE) is a chronic inflammatory multi-system disease characterised by varied clinical manifestation and immunological abnormalities. The clinical presentation of the disorder has wide spectra, from an asymptomatic presentation to a severe life-threatening disease affecting several organs. The sole manifestation of lupus erythematosus could be neurological syndrome, where diagnosis of SLE is difficult to establish. The authors intended to report a young female, who initially developed left-sided hemiparesis due to tumefactive demyelination, later on diagnosed as case of SLE. The association of tumefactive demyelination and SLE has not been previously reported in the literature.

Recurrent ectopic pregnancy in a woman suffering from infertility due to male factor presented with heterotopic pregnancy

Chaudhari, H. D., Gandhi, V. S., Banker, H., Suri, A. — 2012-05-15T01:45:23-07:00

Heterotopic pregnancy is the simultaneous occurrence of intrauterine and extrauterine pregnancies. A 27-year-old third gravida with history of two ectopic pregnancies, presented with cramping pain in pelvis radiating to left side and bleeding from vagina. Ultrasonographic diagnosis of heterotopic pregnancy was put forward. Unfortunately intrauterine component of heterotopic pregnancy resulted in blighted ovum and linear salpingostomy was done for left-sided tubal pregnancy.

Spontaneous occlusion of the circle of Willis in a young woman with epilepsy: epileptic-type moyamoya disease

Shrivastava, M. S., Khullar, V., Singh, M., Haneef, M., Nag, N. — 2012-05-15T01:45:23-07:00

The authors report a case of a 31-year-old woman from India with history of seizure disorder who presented with sudden onset right hemiparesis and right-sided upper motor neuron type facial palsy. No identifiable risk factors were noted on admission and all laboratory investigations were negative. MR angiography helped in arriving at the diagnosis of moyamoya disease as the aetiology of her symptoms.

Abdominal swelling in two teenage girls: two case reports of massive ovarian tumours in puberty

Willems, R. P. P., Slangen, B., Busari, J. O. — 2012-05-15T01:45:23-07:00

The following report describes two 15-year-old girls with a giant abdominal swelling. Signs and symptoms differed between those two girls, as serum tumour markers showed different elevation patterns. Additional investigations including a CT scan and a MRI scan were performed and revealed masses originating from the ovary. Histopathological evaluation after cystectomy showed a mature teratoma and a mucinous cystadenoma.

Septic arthritis and osteomyelitis in a 10-year-old boy, caused by Fusobacterium nucleatum, diagnosed with PCR/16S ribosomal bacterial DNA amplification

Kroon, E., Arents, N. A., Halbertsma, F. J. — 2012-05-15T01:45:23-07:00

A 10-year-old boy presented with an atypical non-febrile septic arthritis/osteomyelitis. He was unresponsive to routine antibiotic treatment with flucloxacillin/gentamicin as the pain and fluid collection increased. Synovial fluid cultures are negative and gram stain remained negative. Only after PCR/16S ribosomal bacterial DNA amplification a Fusobacterium nucleatum could be detected, and antibiotic therapy switched to clindamycin with rapid response. Septic osteomyelitis and arthritis are relatively rare but important infections in children needing prompt treatment, and should be considered when a child complaints about joint or bone pain without prior recent trauma. Skin bacteria are the most prevalent causative organisms, whereas Fusobacteria or other anaerobic, Gram-negative microorganisms are very seldom encountered. If cultures remain negative and the patients responds insufficiently to empiric treatment, PCR/16S ribosomal bacterial DNA amplification can be useful to detect the causative microorganisms.

Longitudinally extensive transverse myelitis associated with dengue fever

Larik, A., Chiong, Y., Lee, L. C., Ng, Y. S. — 2012-05-15T01:45:23-07:00

Longitudinally extensive transverse myelitis (LETM) is usually associated with neuromyelitis optica and other autoimmune and inflammatory disorders but this is the first report linking it with dengue fever. Dengue infection can cause a variety of neurological complications which may result in poor recovery and long-term disability. The authors report here a patient who developed LETM in the para-infectious stage of dengue fever. The patient had a complicated clinical course resulting in severe paraparesis and urinary retention. Treatment with immunoglobulins and antiviral agents supported by a spell of early intensive rehabilitation programme produced excellent results in terms of recovery.

A clue to the diagnosis of TAPVD

Jones, A. J., Zieba, K., Starling, L., Longman, J. — 2012-05-15T01:45:23-07:00

Total anomalous pulmonary venous drainage (TAPVD) is a rare form of congenital heart disease where all four pulmonary veins drain to the systemic venous circulation. A term infant was found to have low oxygen saturations on the neonatal check and he was admitted to the neonatal intensive care unit. An increasing oxygen requirement necessitated invasive ventilation. A blood gas taken from the umbilical venous catheter (UVC) showed a pO₂ of 28.1kPa – a finding that at the time was considered to be erroneous. An x-ray showed the UVC tip was located in the liver. The following day the baby was transferred to a cardiology centre where a diagnosis of unobstructed infracardiac TAPVD was made on echocardiography. In retrospect the unusually oxygenated venous gas was consistent with pulmonary venous return draining directly to the hepatic venous system. This could have provided a vital clue to diagnosis in a situation where an echocardiogram was not available.

A 6-year-old boy with fever, rash and severe pneumonia

Kongthavonsakul, K., Washington, C. H., Oberdorfer, P. — 2012-05-15T01:45:23-07:00

The authors report a 6-year-old boy with fever, rash and cough. He was diagnosed with severe measles pneumonia and admitted to the paediatric intensive care unit with severe dyspnoea 8 days after symptom onset. He received intravenous antibiotics and high dose vitamin A. Three days later, he had recovered and was discharged home. He had not been vaccinated for measles, mumps and rubella according to the schedule. This case highlights the need for rapid diagnosis, appropriate treatment and determination of vaccination status of children with measles in order to prevent complications.

A complex case of congenital cystic renal disease

2012-05-15T01:45:23-07:00

This case outlines the potential complexity of autosomal recessive polycystic kidney disease (ARPKD). It highlights the challenges involved in managing this condition, some of the complications faced and areas of uncertainty in the decision making process. With a paucity of published paediatric cases on this subject, this should add to the pool of information currently available.

Electrocardiographic changes in an athlete before and after detraining

Ghani, S., Sharma, S. — 2012-05-08T08:02:42-07:00

Description

A young Caucasian female professional athlete underwent a 12-lead ECG as a part of preparticipation cardiovascular screening. She trained and exercised for an average 20 h per week. There were no symptoms or relevant family history reported, and cardiovascular examination was normal. The ECG exhibited T-wave inversion in the inferior and lateral leads (figure 1). These ECG findings were considered abnormal, and warranted further investigations based on recent guidelines from the European Society of Cardiology.1 The echocardiogram showed normal left ventricular cavity size of 42 mm in diastole, maximal wall thickness of 10 mm and preserved bi-ventricular function. Further investigations including exercise stress test, 24-h ECG and cardiac MR scan with gadolinium enhancement were also normal, and did not suggest any phenotypic features of an underlying cardiomyopathy. A repeat ECG after a 6-week period of detraining (figure 2) was normal with...

Autoimmune pernicious anaemia as a cause of collapse, heart failure and marked panyctopaenia in a young patient

Carey, J., Hack, E. — 2012-05-08T08:02:42-07:00

A 35-year-old woman with a history of vitiligo, hypothyroidism and amenorrhoea presented with collapse and clinical features of cardiac failure. Laboratory investigations revealed pancytopaenia, the cause of which was found to be vitamin B12 deficiency due to pernicious anaemia. Treatment with intramuscular hydroxycobalamin was commenced and the patient improved steadily with concomitant improvement in her haematological indices. Clinical features of pernicious anaemia which can include marked pancytopaenia, diagnostic approach, associated conditions and approach to treatment are discussed. The importance of surveillance for gastrointestinal malignancy is emphasised.

Acute scoliosis in a 3-year-old boy

Malhotra, R., Murali-Ganesh, R., Dunkley, C., Desai, V. — 2012-05-08T08:02:42-07:00

The case describes the presentation of a fit and well 3-year-old boy to the emergency department of a district general hospital after he developed an acute scoliosis overnight. There was no history of trauma, his observations were normal and he had non-specific symptoms of lethargy and reduced appetite, but no fevers or respiratory distress. Bloods showed raised inflammatory markers and he was referred to orthopaedics as a septic disc as there was some spinal tenderness. An urgent MRI was considered initially but on further examination there was some reduced air entry on the left lung base which a chest radiograph confirmed as a left-sided pneumonia. A diagnosis of pneumonia and secondary functional scoliosis was made. The child was admitted under paediatrics and made a full recovery on antibiotics. At 8 weeks follow-up there was resolution of scoliosis clinically and radiologically.

Cervical lymphadenopathy: metastasis of papillary carcinoma or ectopic thyroid tissue?

Simion, N. I., Muntean, V. — 2012-05-08T08:02:42-07:00

Papillary thyroid carcinoma frequently metastasises to the regional neck lymph nodes. However, cervical lymph node metastases as sole manifestation of occult papillary thyroid carcinoma are observed rarely. The authors report the case of a 52-year-old man presenting for slowly enlarging neck region and shortness of breath, with an insidious history for 15 years. Thyroid imaging showed a goitre predominantly of the right lobe, but histopathological finding revealed a multi-centric thyroid papillary carcinoma with lymph node metastasis.

Complicated septic cervical and lumbar discitis

Idris, S., Collum, N. — 2012-05-08T08:02:42-07:00

A 69-year-old lady presented with back pain for 5 days associated with spiking temperatures, lower limb weakness and urinary retention. Urgent MRI showed discitis at the disc between cervical vertebra seven (C7), thoracic vertebra one (T1) and lumbar vertebra three and four (L3-4), associated dural inflammation, stenosis of the cervical spinal canal and cervical cord oedema at the level of C3. No definite epidural abscess was seen. She was transferred to the spinal unit for observation. Following transfer she rapidly developed respiratory compromise and required emergency spinal decompression later that day.

Complication of etanercept treatment for rheumatoid arthritis - purulent pericarditis caused by a commensal organism

Taylor, G. K., Elliott, L., Sosin, M. D., Soo, S. S. — 2012-05-08T08:02:42-07:00

The patient presented with increasing fatigue and dyspnoea. The patient had medical history of rheumatoid arthritis for which she had been taking methotrexate for the past 15 years and etanercept for the past 6 years. Initial diagnosis was cardiac failure but further investigation by echocardiogram revealed a large pericardial effusion. Empirical piperacillin-tazobactam was started due to moderately raised inflammatory markers. Four hundred millilitre of frank pus was aspirated from the pericardial sac and antimicrobial treatment was changed to meropenem. Gram positive cocci were seen in the initial Gram stain, but conventional cultures remained negative. However, 16S ribosomal RNA gene sequencing of the pus sample detected the presence of Parvimonas micra genome. Reaccumulation of the effusion required further drainage where again P micra was detected by 16S ribosomal RNA gene sequencing. Two weeks of meropenem was completed followed by treatment with benzylpenicillin and metronidazole.

Life-threatening hyperkalemia - an overlooked acute kidney injury with a serum creatinine rise in the 'normal' range

Latus, J., Braun, N., Alscher, M. D., Kimmel, M. — 2012-05-08T08:02:42-07:00

A 76-year-old woman (51 kg, 158 cm, body mass index 20.5) was admitted to the hospital because of an acute kidney injury with hyperkalemia. On admission, she reported progredient muscle weakness of all limbs for several days. Serum potassium level was dramatically elevated and ECG showed QRS with a ‘sine-wave’ pattern and haemodialysis was started. 45 days ago, Hartmann’s operation was done because of stenosing sigmoid diverticulitis. At this time, the serum creatinine was 0.4 mg/dl (‘normal’ 0.5–1.2). Thereafter, she got severe ‘high output-ileostoma’ with severe intestinal fluid losses and treatment with potassium supplementation and spironolactone was started by the surgeons. She was discharged with elevated serum potassium levels and serum creatinine of 1.0 mg/dl (‘normal’ range (0.5–1.2 mg/dl)). This case illustrates impressively the lack of serum creatinine as an ideal kidney function test, because it is depending on muscle mass and there is no interindividual normal range.

Pilocarpine induced acute angle closure

Day, A. C., Nolan, W., Malik, A., Viswanathan, A. C., Foster, P. J. — 2012-05-08T08:02:42-07:00

A 34-year-old Caucasian female with advanced primary angle closure glaucoma developed acute angle closure following administration of g.pilocarpine 2% given as preparation for laser peripheral iridotomies. Subsequent investigations supported an underlying diagnosis of spherophakia with no systemic associations. She required peripheral iridotomies, bilateral clear lens extractions and left cyclodiode laser to control her intraocular pressures. This case highlights the situations when pilocarpine should be given with caution and also the increasing role of phacoemulsification as an alternative to filtration surgery in primary angle closure glaucoma management.

Mycobacterium intracellulare infection in non-HIV infected patient in a region with a high burden of tuberculosis

Haraka, F., Rutaihwa, L. K., Battegay, M., Reither, K. — 2012-05-08T08:02:42-07:00

Data on non-tuberculous Mycobacteria (NTM) infection in non-HIV patients in Tanzania are scarce. However, NTM infections are emerging in Africa as in many parts of the world. Healthcare providers and physicians working in high tuberculosis incidence regions should also consider NTM as one of the differential diagnosis. A 35-year-old Tanzanian man presented with history of cough, fever, chest pain and night sweats for 4 weeks. The patient had a history of tuberculosis 4 years ago. On physical examination, there were no significant findings. Sputum smears were positive for acid fast bacilli, while Xpert MTB/RIF showed negative results. Culture and subsequent differentiation confirmed Mycobacterium intracellulare infection. With no specific national guidelines at our setting the patient received standard antituberculosis treatment and is kept under close follow-up.

Mesenteric paraganglioma's: an important differential diagnosis in intra-abdominal tumours

Jacob, N. C., Howard, M., Kelly, M., Hale, P. C. — 2012-05-08T08:02:42-07:00

Description

We present the case of a 63-year-old lady who complained of feeling constantly tired and lethargic, and was found to have iron deficiency anaemia. There was no history of per vaginal bleeding. Examination was normal apart from a large, mobile, firm, well-defined abdominal mass in the upper abdomen approximately 10cm in diameter. The abdominal CT scan revealed a large intra-abdominal tumour (figure 1). Histology of the specimen obtained by surgical resection revealed this to be a mesenteric paraganglioma (figure 2). To the best of our knowledge, there are eight other reported cases of mesenteric paraganglioma’s. Ninety per cent of these sympathetic tissue tumours arise from the adrenals and are called phaeochromocytomas. Paraganglioma’s are extra-adrenal phaeochromocytoma’s, of which 85% arise in the abdomen, 12% in the thorax and the remaining 3% in the head and neck.1 Paraganglioma’s that hypersecrete catecholamines may cause...

Congenital cytomegalovirus infection associated with development of neonatal emphysematous lung disease

Staunton, B. H., Crabbe, D., Cullinane, C., Smith, D. — 2012-05-08T08:02:42-07:00

A 26-week-gestation infant developed cystic lung changes which required lobar resection at 6 weeks of age. Lung histology showed cytomegalovirus (CMV) inclusion bodies. The authors present the radiology and histology images of this case and review the literature regarding congenital CMV infection and cystic lung disease. Lung disease caused by CMV is typically a diffuse pneumonitis. This is the first reported case of congenital CMV infection causing emphysematous lung disease to develop in the neonatal period. The case raises awareness of CMV as a possible cause of cystic lung lesions in newborns.

Hypersensitivity reaction to human papillomavirus vaccine due to polysorbate 80

Badiu, I., Geuna, M., Heffler, E., Rolla, G. — 2012-05-08T08:02:42-07:00

A 17-year-old girl reported generalised urticaria, eyelid angioedema, rhino-conjunctivitis, dyspnoea and wheezing 1 h after third intramuscular administration of quadrivalent human papilloma virus vaccine (Gardasil). She was treated with antihistamine, and corticosteroids with prompt relief of rhinitis and dyspnoea, while urticaria and angioedema lasted 24 h. Intradermal test with Gardasil, which contains polysorbate 80 (PS80), resulted positive, while skin tests with the bivalent vaccine were negative. Prick test performed with PS80 resulted positive in the patient and negative in ten healthy controls. The CD203 basophil activation test result was negative for PS80 at all the tested dilutions and specific IgE was not found. As flu vaccine was recommended, the authors skin tested two flu vaccine, one containing PS80 (Fluarix, GSK), which resulted positive and another flu vaccine with no adjuvant or preservative (Vaxigrip, Sanofi Pasteur MSD), which gave negative results. The patient then received Vaxigrip without adverse reactions.

Crouzon syndrome

Khandelwal, R., Agrawal, P., Majumdar, M. R. — 2012-05-08T08:02:42-07:00

Description

A 10-year-old female presented with history of prominent eyes since birth. She also gave history of deviation and occasional dislocation of left eye which she is able to retroplace on her own. Bilateral proptosis with large degree of exotropia left eye was seen in primary gaze. She had normal intellectual capacity with vision of 20/50 in right eye and Counting Fingers (CF) in left eye. She had midfacial hypoplasia, hypertelorism and dental abnormalities (Figure 1–3). Her cornea had no signs of exposure keratitis and fundus did not reveal any abnormality.

Figure 1

Anterior view of a 10-year-old female with Crouzon syndrome. Note the acrocephaly, proptosis, strabismus, hypertelorism, parrot-beaked nose and maxillary hypoplasia characteristic of this syndrome.

Figure 2

Oblique view: shallow orbit with midfacial hypoplasia.

Figure...

The thrombosed brachial-cephalic fistula used for renal dialysis - A cautionary note

Davies, L. l., Fitchett, J. M., Dunsby, A.-M., Champ, C., Lewis, M. H. — 2012-05-08T08:02:43-07:00

Arteriovenous fistulae (AVF) are commonly required for dialysis prior to renal transplantation, and are subsequently left insitu, even if thrombosed. The authors present one of two patients in whom progressive digital ischaemia occurred, and was initially overlooked, many years following formation of an AVF. The patient was surgically explored and clot protruding from the thrombosed vein into the brachial artery was noted. The arterial defect was closed with a vein patch and histological examination of the fistula confirmed clot. The patient recovered satisfactorily and remained well 6 months postoperatively. The authors would suggest that embolisation from a thrombosed AVF does occur, has a significant morbidity and can lead to digital loss. Furthermore, transplant patients are usually long suffering and will often put up with what they describe as ‘aches and pains’ as part of their illness. The authors suggest those patients suffering with evidence of ischaemia warrant excision of the fistula.

Extra-pulmonary primary multidrug-resistant tubercular lymphadenitis in an HIV negative patient

Kant, S., Saheer, S., Hassan, G., Parengal, J. — 2012-05-08T08:02:43-07:00

A 28-year-old woman without any history of prior antituberculosis treatment presented with cervical lymphadenopathy and a cold abscess near medial end of clavicle of 5 months duration. Pus culture and sensitivity revealed Mycobacterium tuberculosis resistant to rifampicin and isoniazid. Thus she was diagnosed as a case of primary multidrug-resistant tuberculosis and treated with second line drugs according to culture susceptibility pattern. On completion of therapy, patent showed good clinical response. This case highlights the observation that even extra-pulmonary primary multidrug-resistant tuberculosis can be successfully treated with currently available second line drugs.

Stroke preceding autoimmune encephalitis with neuronal potassium channel antibody

Simal, P., Garcia-Garcia, A. M., Serna-Candel, C., Egido, J. A. — 2012-05-08T08:02:43-07:00

Autoimmune encephalitis related to voltage-gated potassium channel (VGKC) antibodies can occur as a complication of cancer but, more frequently, as a non-paraneoplastic disorder. The prompt recognition and treatment could mitigate the morbidity associated with this entity, but the broad-spectrum of neurological manifestations often makes the diagnosis a challenge. The authors describe, here, a unique case of autoimmune encephalitis related to VGKC antibodies preceded by an ischaemic stroke. Conditions associated with the stroke (infection, seizures, metabolic disturbances) had delayed the diagnosis. The authors suggest that autoimmune encephalitis needs to be taken into consideration as part of a differential diagnosis in patients with prolonged encephalopathy following an ischaemic stroke. Infection may trigger an inflammatory response. In addition, the rupture of blood brain barrier that occurs in stroke may have a pathogenic role by allowing antibodies to gain access to the central nervous system.

Disseminated histoplasma and CMV infection presenting as subacute intestinal obstruction in an immunocompromised patient

Shahani, L. — 2012-05-08T08:02:43-07:00

Histoplasma in patients with impaired cellular immunity can disseminate to various organs and is known as progressive disseminated histoplasmosis. Similarly cytomegalovirus (CMV) is the most common opportunistic pathogen in an immunocompromised host. The authors report an older male with symptoms and radiological evidence of subacute intestinal obstruction. The patient had concerns for compromised immune system as he was on chronic prednisone and methotrexate therapy. Follow-up colonoscopy revealed a stricture in the proximal ascending colon. Biopsy of the stricture revealed ulcer with granulomatous inflammation including well-formed granulomas and an infiltrate of histiocytes within the lamina propria. Special stains on the specimen showed fungal structures consistent with Histoplasma capsulatum. Immunochemistry showed presence of CMV in the tissue. The patient had good response to antimicrobial therapy and did not have progression of intestinal obstruction. This case highlights the need to consider infectious pathology in immunocompromised patients presenting with obstructive symptoms.

Lymphangioleiomyomatosis: a radiological diagnosis.

Shahani, L. — 2012-05-08T08:02:43-07:00

Description

Lymphangioleiomyomatosis (LAM) is a rare disease which predominantly affects young females and is commonly found in association with tuberous sclerosis.1 The clinical features result from progressive cystic destruction of the lungs and the accumulation of LAM cells within the lungs and axial lymphatics.2 The gold standard for the diagnosis of LAM is a tissue biopsy which shows nodular infiltration by abnormal smooth muscle cells, termed LAM cells. Not all patients with LAM require tissue biopsy for a definitive diagnosis as the disease has a characteristic CAT appearance in the majority of cases. The author reports a 34-year-old non-smoking African–American female who presented to the clinic with progressive shortness of breath. CAT scan chest showed multiple well-defined thin walled bilateral lung cysts which are randomly distributed throughout the lungs with normal intervening lung parenchyma consistent with LAM (figure 1). There were no...

Acute community acquired Aspergillus pneumonia in a presumed immunocompetent host

Sridhar, V., Rajagopalan, N., C, S., Patil, M., Varghese, J. — 2012-05-08T08:02:43-07:00

Infection from Aspergillus results in a wide range of diseases from simple Aspergillus pneumonia to fatal invasive Aspergillosis. Though the fungus is known to predominantly affect the immunocompromised host, it has also been known to cause acute pneumonia in immunocompetent hosts which is invariably fatal. It presents as an acute pneumonia with bilateral chest infiltrates on radiograph. Early clinical suspicion and microbiological identification by measures such as broncho alveolar lavage and initiation of therapy with voricanozole significantly increase the chances of survival. In this article the authors discuss a case of acute community acquired Aspergillus pneumonia in an immunocompetent host who survived due to early identification and prompt treatment with appropriate antifungal medication.

Diphtheroids as a cause of endocarditis in a haemodialysis patient

Nagassar, R. P., Nicholson, A. M., Williams, W., Bridgelal-Nagassar, R. J. — 2012-05-08T08:02:43-07:00

The authors report a fatal case of Corynebacterium sp. endocarditis. Corynebacterium spp. are non-sporulating, pleomorphic Gram-positive bacilli. In particular the authors have identified a species of Corynebacterium very closely related to C striatum. This is C simulans. The authors were able to identify the genus and species using various phenotypic tests. Highlighted here is the importance of identifying diphtheroids as a significant pathogen in the appropriate setting and the need to start antibiotic therapy if this is suspected.

Paediatric acute basilar thrombosis successfully treated with intravenous alteplase

Rego Sousa, P., Vasconcellos, R. — 2012-05-08T08:02:43-07:00

Acute ischaemic stroke has significant attendant morbidity and is one of the top ten causes of childhood death. It requires prompt investigation and management, however little is known about the safety and efficacy of acute thrombolytic therapies in childhood arterial ischaemic stroke. The authors report a case of a 13-year-old girl with an acute basilar thrombosis, successfully treated with intravenous recombinant tissue plasminogen activator and discuss the management of paediatric arterial ischaemic stroke.

Palatal avulsion injury by a foreign body in a child

Alabi, S. B., Aremu, S. K., Abdulkadir, A. Y., Legbo, J. N., Akande, H. J. — 2012-05-08T08:02:43-07:00

A 6-year-old girl who claimed to have fallen while playing with metal rod that resulted in palatal avulsion injuries was presented. Neither of the parents was around when the incidence happened. She was brought to the hospital because of pain, bleeding from the mouth, drooling of saliva mixed with blood and inability to feed or phonate appropriately. Examinations of the oral cavity revealed a triangular area of avulsion in the posterior aspect of the hard palate extending to the soft palate. She had examination under anaesthesia and wound repaired with 3-0 vicryl interrupted sutures after thorough wound debridement. She did well and was discharged from the clinic.

Paediatric talus fracture

Byrne, A.-M., Stephens, M. — 2012-05-08T08:02:43-07:00

Paediatric talus fractures are rare injuries resulting from axial loading of the talus against the anterior tibia with the foot in dorsiflexion. Skeletally immature bone is less brittle, with higher elastic resistance than adult bone, thus the paediatric talus can sustain higher forces before fractures occur. However, displaced paediatric talus fractures and those associated with high-energy trauma have been associated with complications including avascular necrosis, arthrosis, delayed union, neurapraxia and the need for revision surgery. The authors present the rare case of a talar neck fracture in a skeletally immature young girl, initially missed on radiological review. However, clinical suspicion on the part of the emergency physician, repeat examination and further radiographic imaging revealed this rare paediatric injury.

Intravenous immunoglobulin in treatment of Clostridium difficile colitis

Shahani, L., Koirala, J. — 2012-05-08T08:02:43-07:00

Clostridium difficile infection is the most common infectious cause of healthcare-acquired diarrhoea. Severe infections cause therapeutic challenges for healthcare providers. Various novel treatment modalities are currently being explored for treatment of severe disease. The authors report a 70-year-old female who presented to the emergency room with 1 week history of fever, watery diarrhoea, diffuse abdominal pain and weakness. C difficile toxin was detected in the stool and abdominal CAT scan showed extensive colonic wall thickening. The patient was started on intravenous metronidazole along with oral vancomycin. Due to the severity of the infection the patient was given intravenous immunoglobin for 4 consecutive days. The patient had vast improvement in her clinical symptoms with resolution of the multi-organ system failure. It is currently considered that the predominant intravenous immunoglobin’s mechanism of action is through binding and neutralisation of toxin A by IgG antitoxin A antibodies.

An unusual case of hyperthyroidism associated with jaundice and hypercalcaemia

Klangjareonchai, T. — 2012-05-08T08:02:43-07:00

A 51-year-old woman with rheumatoid arthritis presented with a 3 month history of painless jaundice and significant weight loss and constipation. Laboratory values were consistent with hyperthyroidism, cholestatic jaundice and parathyroid hormone-independent hypercalcaemia. Three months after beginning of methimazole, euthyroidism was achieved and serum adjusted calcium, total and direct bilirubin levels were normal.

Isolated bilateral upper lobar anomalous pulmonary venous connection - a rare anomaly confirmed on CT imaging

Gupta, M. K., Shetty, R., Pande, N., Shenoy, P. — 2012-05-08T08:02:43-07:00

Description

We are reporting a case of a 5-year-old asymptomatic boy who had grade 3 ejection systolic murmur in pulmonary area on cardiac examination. 2D echocardiography showed dilated right atrium (RA) and right ventricle (RV) suggesting increased pulmonary to systemic flow. Suprasternal echocardiographic view raised doubt of vertical vein. There was no visible atrial septic defect (ASD) or significant pulmonary arterial hypertension. Partial anomalous pulmonary venous connection (PAPVC) was suspected without an associated ASD. This pulmonary venous anomaly is extremely rare and difficult to diagnose. Clinically, PAPVC is often asymptomatic and tends to go unnoticed until adulthood, and usually diagnosed during investigation of another illness.1 Left untreated, long-standing PAPVC predisposes the patient to right-sided volume overload, tricuspid regurgitation, arrhythmias, pulmonary hypertension, irreversible pulmonary vascular disease, right ventricular dysfunction/ failure. The development of symptoms and complications from PAPVC depends on the shunt fraction and thus on the...

A father with postpartum psychosis

Shahani, L. — 2012-05-08T08:02:43-07:00

Postpartum psychosis is a rare, however severe mood disorder in the perinatal period. It is most commonly associated with postpartum bipolar disorder. The author reports a case where a male patient with psychosis was admitted to the psychiatric unit 5 days after his wife gave birth to their male child. The patient was very concerned about the well being of his child and was afraid that something bad would happen to his child. The patient was diagnosed with an acute manic episode with psychotic symptoms and treated with olanzapine and lithium. The patient has been continued on therapeutic dose of lithium without any relapse of the symptoms, 3 months after the initial episode. The role of psychological stress in precipitating such a severe mood or psychotic disorder needs to be highlighted.

Rosuvastatin-induced pemphigoid

Murad, A. A., Connolly, M., Tobin, A.-M. — 2012-05-08T08:02:43-07:00

Statins are widely prescribed medications and very well tolerated. Rosuvastatin is another member of this drug used to treat dyslipidaemia. It is a competitive inhibitor of the enzyme 3-hydroxy-3-methylglutaryl coenzyme A reductase. Immunobullous disease is usually idiopathic but can be drug-induced. Both idiopathic and iatrogenic forms share common clinical and immunohistological features. The authors report a case of pemphigoid induced by rosuvastatin, a commonly prescribed medication. To our knowledge, there is limited report on rosuvastatin associated with pemphigoid in the literature.

Lymphangioleiomyomatosis: a radiological diagnosis

Shahani, L. — 2012-05-08T08:02:43-07:00

Description

Lymphangioleiomyomatosis (LAM) is a rare disease which predominantly affects young females and is commonly found in association with tuberous sclerosis.1 The clinical features result from progressive cystic destruction of the lungs and the accumulation of LAM cells within the lungs and axial lymphatics.2 The gold standard for the diagnosis of LAM is a tissue biopsy which shows nodular infiltration by abnormal smooth muscle cells, termed LAM cells. Not all patients with LAM require tissue biopsy for a definitive diagnosis as the disease has a characteristic computerised axial tomography (CAT) appearance in the majority of cases. The author reports a 34-year-old non-smoking African–American female who presented to the clinic with progressive shortness of breath (Figure 1). CAT scan chest showed multiple well-defined thin-walled bilateral lung cysts which are randomly distributed throughout the lungs with normal intervening lung parenchyma consistent with LAM. There...

Visceral leishmaniasis in immunosuppressed Caucasian patient

TOQEER, M., Rahman, N., Whitehead, M. W., Lockwood, D. — 2012-05-08T08:02:43-07:00

A 64-year-old man was admitted with fever, weight loss, fatigue and night sweats. He was known to have rheumatoid arthritis and had been taking methotrexate for 1 year. He had worked in Saudi Arabia until 1994 and had been living in Spain for 6 months every year. Clinical examination showed an enlarged spleen. Routine investigations showed pancytopaenia. Serial blood cultures were negative. CT scan confirmed splenomegaly and was otherwise unremarkable. Bone marrow biopsy revealed Leishmania amastigote consistent with a diagnosis of visceral leishmaniasis. After discussing with the hospital for tropical diseases (HTD), he was started on liposomal amphotericin B. Following two infusions of amphotericin B, he started improving as his fever, night sweats and weakness had settled. He was then discharged and followed up in HTD clinic 4 weeks later where he was found to be consistently improving.

Ulcerative colitis presenting as acute infectious gastroenteritis with a paralytic ileus

Schoenmaker, S. G., Tjon a Ten, W. E. — 2012-05-08T08:02:43-07:00

A 15-year-old girl who presented with signs of acute infectious gastroenteritis, just as two members of her family is described. As the patient did not improve, a sigmoidoscopy was performed and the diagnosis of ulcerative colitis (UC) was made. Our hypothesis is that an infection triggered the development of UC. Her paralytic ileus was probably triggered by the increased nitric oxide produced in the macrophages and smooth muscles of the inflamed bowel.

CMV infection complicating the diagnosis of Crohn's disease in an immunocompetent patient

Shahani, L. — 2012-05-08T08:02:43-07:00

Cytomegalovirus (CMV) affects the gastrointestinal tract commonly; however CMV colitis is uncommon in patients who are not severely immunocompromised. The author reports a 51-year-old Caucasian female who was admitted to the hospital with exacerbation of her chronic diarrhoea. CAT scan of the abdomen and pelvis showed thickening of the wall of the terminal ileum with inflammatory stranding and follow-up colonoscopy showed extensive circumferential ulceration in the terminal ileum. Biopsies confirmed diagnosis of CMV infection and the patient was started on appropriate antimicrobial agents. CMV viremia showed response to the medication; however the patient’s intestinal symptoms failed to improve. Nodular lesions consistent with erythema nodusum were noticed and promethus test was consistent with Crohn’s disease. The patient showed good response to immunosuppressive therapy. CMV infections are known to exacerbate symptoms of inflammatory bowel disease and hence Crohn’s disease should be suspected in an immunocompetent patient presenting with CMV ileitis.

Erectile dysfunction as an initial presentation of diabetes discovered by taking sexual history

Hirooka, N., Lapp, D. P. — 2012-05-08T08:02:43-07:00

This case, as an important clinical reminder, will illustrate improvement of a patient’s quality of life and care in chronic diseases through sexual history taking in the primary care setting. The case report also includes recommended investigation for erectile dysfunction (ED). Family physicians need to maintain awareness of sexual dysfunction as part of the history taking during a general medical investigation to avoid leaving sexual issues untreated including ED. If left untreated, ED can lead to psychological trauma, frustration and lower self-esteem. Additionally, ED is associated with major comorbidities such as cardiovascular disease, hypertension, dyslipidaemia, psychological conditions and diabetes mellitus. Thus, appropriately identifying this medical condition may lead prompt diagnoses and treatment of other major diseases.

Small bowel evisceration through the anus - report of a case and review of literature

Berwin, J. T., Ho, T. K., D'Souza, R. — 2012-05-08T08:02:43-07:00

An 84-year-old lady with a history of chronic recurrent rectal prolapse, presented to accident and emergency with a significant portion of small bowel and mesentery protruding out of her anus. The small bowel was not contained within peritoneum, nor was this a pararectal herniation. On examination of the rectum, a longitudinal tear was found in the anterior rectal wall, through which the small bowel had prolapsed. Hours after reducing the small bowel back into the anus, it prolapsed a second time. Due to multiple co-morbidities, this patient was not fit for surgery. The defect was temporarily repaired on the ward and the patient treated with aggressive antibiotic therapy. The patient continued to deteriorate, became septic, acidotic, hypotensive and died a day later.

Traumatic left anterior descending to pulmonary trunk fistula

Rajendran, S., Zhou, W., Juli, C., Punjabi, P. — 2012-05-08T08:02:43-07:00

Description

A young man in his late 20s, presented with new-onset exertional angina. Five months earlier, the patient had presented to the trauma unit with a penetrating injury to the left chest and cardiac arrest due to cardiac tamponade. The patient had undergone emergency median sternotomy for repair of a 15 mm laceration to the right ventricular outflow tract. On examination, he had normal vital signs with no abnormal heart sounds or signs of heart failure. ECG was normal. Cardiac catheterisation demonstrated a communication between the proximal left anterior descending coronary artery (LAD) just before its first diagonal branch and the pulmonary trunk (PT) (figure 1, upper arrow). A small blind-ended myocardial defect was also visible transiently at the same site (figure 1, lower arrow). Both defects were dynamically occluded during systole (figure 1). The LAD-PT fistula measured 8 mm in diameter...

Intraventricular metastases from small cell carcinoma of the lung

Una, E. — 2012-05-08T08:02:43-07:00

Small cell lung carcinoma (SCLC) represents 15–20% of all lung cancers. It is characterised by rapid growth and early metastatic dissemination. Generally, the prognosis of these patients is poor. When brain metastases develop, the prognosis is even poorer. Most of these cases present parenchymal metastases; however, intraventricular dissemination may also occur although it is very uncommon. To our knowledge the case reported here is the first showing multiple synchronic intraventricular dissemination from SCLC.

Acute paradoxical reaction of cervical tuberculous lymphadenitis prompted by a misuse of etimicin sulphate

Jiao, Y., Chen, J., Zeng, X. — 2012-05-08T08:02:43-07:00

A 45-year-old HIV-negative man was treated with intravenous etimicin sulphate for an unintentionally found, non-tender neck mass at a local outpatient clinic. His symptoms seemed improved initially. However, the unilateral mass subsequently became enlarged quickly and painful. Spontaneous discharge occurred after admission to our department. The smear of the pus from surgical drainage was positive for acid-fast bacilli and the presence of Mycobacterium tuberculosis was confirmed by culture. He was diagnosed with an acute paradoxical reaction (PR) of cervical tuberculous lymphadenitis. Our case was unusual in that acute PR of tuberculosis was caused by receiving single aminoglycoside agent which has not been proven to have therapeutic effect on TB infection and it is also the first case of PR induced by etimicin. The patient recovered well from a 6-month antituberculosis chemotherapy.

Sarcomatoid carcinoma of the bladder after simultaneous kidney-pancreas transplant: a case report and review of the literature

McCrea, P. H., Chang, M., Bailley, G., Molinari, M. — 2012-04-30T04:38:15-07:00

Carcinosarcoma and sarcomatoid carcinoma of the bladder after organ transplantation is higher in comparison to the general population but overall occurrence is still very uncommon. Due to the decreased immunitary response effects of antirejection drugs, these cancers have aggressive course and respond poorly to treatment. Bladder drained pancreatic transplants are associated with a number of urologic challenges that can delay the diagnosis and the treatment of malignancies of the genito-urinary system. The authors present a case of a rare sarcomatoid carcinoma of the bladder following bladder drained simultaneous kidney and pancreas transplant and discuss its pathogenesis and clinical management.

Chiari network: a protective filter against pulmonary embolism in a case of polycythaemia

Obaji, S. G., Cooper, R., Somauroo, J. — 2012-04-30T04:38:15-07:00

The Chiari network, a net-like structure within the right atrium, has been described as an embryonic remnant of no clinical significance. Its role in facilitating paradoxical arterial embolic events and as a potential site for thrombus formation however, has been reported in the literature. This case illustrates the protective filter-effect of the Chiari network in a 79-year-old Caucasian man with an unknown diagnosis of polycythaemia rubra vera who presented with clinical signs and symptoms of deep vein thrombosis. Transoesophageal echocardiogram confirmed entrapment of a thrombus within the Chiari network, which was not visualised following treatment on repeat scanning 1 month later. Here the authors describe how the Chiari network may have prevented the occurrence of a fatal massive pulmonary embolism in a patient with a high pro-thrombotic tendency, and review the current literature regarding the action of this anatomic variant as risk factor or protector.

Castleman's disease in a patient with melanoma: the role of VEGF

Shahani, L. — 2012-04-30T04:38:15-07:00

Castleman’s disease is a rare lymphoproliferative disorder characterised by lymph node follicular hyperplasia with abnormal interfollicular vascular growth. The authors report a female patient presenting with erythematous and pruritic skin lesion. A shave biopsy of the lesion revealed a Clark level III melanoma and sentinel lymph node biopsy revealed a microscopic focus. Staging positron emission tomography scan revealed an abnormal soft tissue mass with increased 18F-fluorodeoxyglucose accumulation in the anterior mediastinum, raising suspicions of malignancy. The patient underwent an elective resection of the mass and histological sections revealed features of Castleman’s disease of the hyaline vascular type. Vascular endothelial growth factor (VEGF) has been associated with the increased vessel density in this condition. VEGF secretion by tumour cells in solid tumours such as melanomas could be a predisposing factor for Castleman’s disease. Future research is needed to find an association between VEGF-secreting solid tumours and the development of lymphoproliferative tumours such as Castleman’s disease.

Constrictive pericarditis with a calcified pericardial band at the level of left ventricle causing mid-ventricular obstruction

Gautam, M. P., Gautam, S., Sogunuru, G., Subramanyam, G. — 2012-04-30T04:38:15-07:00

An adolescent presented with insidious onset and gradually progressive distension of abdomen associated with bilateral ankle swelling of few months duration. He had one episode of prolonged low-grade self-limiting febrile illness during childhood but had not consulted to doctor and never had been diagnosed as case of tuberculosis or acute pericarditis. A detail clinical evaluation showed raised central venous pressure, ascites and ankle oedema. Systemic examination was not much informative except ejection systolic murmur in third left intercostal space. Echocardiography and CT scan heart showed localised thickened pericardium with calcific band around the left ventricle at mid ventricle level. The band around the heart caused the heart to have a ‘dumbbell’ appearance with ballooning in apical area and a rare mid-ventricular obstruction in the left. A diagnosis of chronic constrictive pericarditis with calcific band was made and the patient was referred to another centre for cardiac surgery.

Complete heart block as a complicating feature of a mediastinal lymphoma

2012-04-30T04:38:15-07:00

Malignant lymphomas represent about 9% of cardiac neoplasms. Despite its life-threatening nature, the cardiac manifestations are often subclinical. In about 20% of deaths from lymphoma, cardiac involvement is found only in autopsy. The authors present the case of a 77-year-old female admitted due to intense back pain, vomiting, generalised pruritus, fatigue and weight loss. She had a personal history of hypertension and breast cancer was noted 10 years before admission. The thoracoabdominopelvic CT showed a mass in the left atrium with extension to the right atrium and inferior vena cava, and a paravertebral mass at D10-D11 with invasion of the spinal canal and hepatic hilum. The transthoracic paravertebral mass biopsy was compatible with a diffuse large B cell lymphoma. The patient developed a complete atrioventricular block, with haemodynamic instability, requiring urgent chemoreduction of the paracardiac mass and implantation of an epicardial pacemaker.

An adolescent with sickle cell anaemia experiencing disease-related complications: priapism and leg ulcer - a management challenge

Vasconcelos, A., Prior, A. R., Ferrao, A., Morais, A. — 2012-04-30T04:38:15-07:00

Sickle-cell anaemia (SCA) is a multi-system disease, associated with episodes of acute illness and progressive organ damage. Disease severity shows substantial variation and it is often a burden for adolescents. Complications such as leg ulcer and priapism have a significant impact on quality of life. There are still no definitive treatment guidelines available. Considering the embarrassing nature of priapism and the dire consequences for erectile dysfunction, it is important to inform patients, parents and providers about the relationship of SCA to prolonged painful erections. This article will review the pathophysiology and treatment options of SCA focusing the complications of leg ulcers, priapism, cholelithiasis and retinopathy. The case study of a 14-year-old boy is used to present a management challenge of multiple SCA-related complications.

Right upper quadrant pain and mass in a 41-year-old previously healthy man: a presenting feature of HIV-associated extranodal diffuse large B cell lymphoma with cardiac involvement

2012-04-30T04:38:15-07:00

With an increasing pandemic of HIV/AIDS, the incidence of HIV-associated lymphoma is expected to rise. Here, the authors report a case of a 41-year-old man who presented with right upper quadrant pain and mass, and was subsequently diagnosed with HIV-associated diffuse large B cell lymphoma (DLBCL) with cardiac involvement. This case illustrates some of the uncommon and interesting aspects of DLBCL: primary extramedullary extranodal stage IV disease as the presenting feature; cardiac involvement at presentation; DLBCL as the only clue to the diagnosis of HIV; and management of HIV-associated DLBCL. This case is also a reminder of the importance of the routine HIV screening for all patients between the ages of 13–64 years, as advocated by centres of disease control and prevention.

Primary hepatic gastrinoma presenting as vague gastrointestinal symptoms

Lu, X., Aoun, E., Morrissey, S. — 2012-04-30T04:38:15-07:00

A 51-year-old Caucasian female with a 7-year history of intermittent abdominal pain and diarrhoea presented to our service. Before presentation, she had been successfully treated for Helicobacter pylori infection, but later developed new oesophageal ulcerations with exudative lesions that were positive for herpes simplex virus, and candida oesophagitis had developed. Biopsies showed chronic inactive gastritis with gastric intestinal metaplasia. MRI revealed a solid 3.4x3 cm lesion in the caudate lobe of the liver, with a 7-mm pancreatic cyst. The aspirated pancreatic cyst cytology was benign. On exploratory laporatomy, the lesion appeared confined to the caudate lobe, and a resection was performed. The pathology was consistent with a well-differentiated neuroendocrine carcinoma with vascular invasion and involvement of the liver capsule, although resection margins were negative. The patient had complete symptomatic improvement. This case re-affirms the high index of suspicion needed to make the diagnosis of gastrinoma. If caught in time, surgical removal of primary hepatic gastrinoma can be curative.

Aneurysmal 'pepper-pot' atrial septal defect in an older gentleman with multiple cerebrovascular attacks

Mckay, E. J., Ashrafi, R., Mckay, V., Amadi, A. — 2012-04-30T04:38:15-07:00

Our patient presented to a large university teaching hospital with a history of light-headedness, falls and multiple cerebrovascular ischaemic events. This caused a right sided hemiplegia and the patient experienced significant functional limitation. Extensive investigations were carried out to exclude any causative factors such as carotid artery disease and the patient had all identifiable cardiovascular risk factors identified and modified. No significant pathology was found and a referral was made to the cardiology service. Transthoracic echocardiography revealed a complex type 3 perforate ‘pepper pot’ atrial septal aneurysm with associated thrombus. The patient was commenced on warfarin and appropriate rate limiting medication. After discussion of all interventional modalities, the patient opted for conservative management.

Tuberculous mediastinal abscess as a paradoxical reaction in an immunocompetent individual

2012-04-24T07:45:05-07:00

A 22-year-old man, diagnosed 7 weeks before with pulmonary tuberculosis and started on antitubercular therapy, presented with non-exertional retrosternal chest pain since the past week. He was diagnosed on the strength of thoracic radiograms and CT imaging to have a mediastinal abscess, which was percutaneously drained. He was continued on the same regimen of drugs. Analysis of the fluid obtained was suggestive of tuberculous aetiology. Steroids were not required.

A 56-year-old woman with stress-induced hoarseness

Latus, J., Franke, U., Alscher, M. D., Braun, N. — 2012-04-24T07:45:05-07:00

A 56-year-old woman was admitted to hospital due to stress-dependent hoarseness and hypertensive urgency. The patient reported peaks of blood pressure of 210/160 mm Hg in combination with hoarseness. With indirect mirror examination, the ear-nose-and throat doctor diagnosed a paralysis of the vocal cord on the left side. The authors suspected a mass affecting the vagus nerve and performed a CT-scan with iodinated contrast material of the neck and thorax. Surprisingly the CT-scan showed an aneurysm of the aortic arch with a dilatation up to 4.8 cm, a kinking of 120° and a chronic dissection in the aneurysm. During exercise or elevated blood pressure this aneurysm expanded and made a compression of the nervus laryngeus recurrens on the left side. Thus, there is an explanation for the patient’s hoarseness on exertion and during hypertensive urgency.

Late-presenting diaphragmatic hernia associated with intrathoracic kidney: tachypnoea as unique clinical sign

Sesia, S. B., Haecker, F.-M. — 2012-04-24T07:45:05-07:00

Intrathoracic renal ectopia associated with a congenital diaphragmatic hernia represents a very rare congenital malformation. The incidence of intrathoracic renal ectopia with congenital diaphragmatic hernia is reported to be less than 0.25%. The authors report on a 5-month-old female infant with late-presenting congenital diaphragmatic hernia associated with a left-sided intrathoracic ectopic kidney and adrenal gland. While prenatal ultrasound showed no pathology, the postnatal ultrasound assumed a left-sided renal agenesia. After recurrent episodes of tachypnoea, a chest x-ray confirmed the diagnosis of congenital diaphragmatic hernia which was repaired without complications. Intraoperatively, intrathoracic ectopic kidney was diagnosed. The authors discuss embryogenesis, the diagnostic algorithm and therapy as well as follow-up of this rare malformation.

Unraveling the paradox of cardiac tamponade: case presentation and discussion of physiology

Reed, R. M., Ramani, G. V., Hashmi, S. — 2012-04-24T07:45:05-07:00

A 53-year-old man on warfarin for postoperative pulmonary embolism presented with chest pain and was found to be in cardiac tamponade due to an atraumatic haemopericardium. Findings of tamponade and a novel approach to the pathophysiology of pericardial disease to explain these finding are presented.

Oro-dental findings in Bardet-Biedl syndrome

Majumdar, U., Arya, G., Singh, S., Pillai, A., Nair, P. P. — 2012-04-24T07:45:05-07:00

The Bardet–Biedl syndrome (BBS) is a human genetic disorder with an array of clinical features affecting many body systems. BBS is a pleiotropic disorder with mostly monogenic causes. It is also considered a primary ciliopathy syndrome. It is characterised by obesity, pigmentary retinopathy, polydactyly, mental deficiency and hypogonadism and recently a sixth feature, renal disease, has also been described. Since none of the diverse symptoms of BBS by itself is diagnostic of the disorder and many of the symptoms only become apparent over time, diagnosis of the BBS is often delayed until about 9 years of age when visual problems first appear.

Use of once-weekly statin in combination with ezetimibe in a patient with mitochondrial disease

Li, M., Al-Sarraf, A., Mattman, A., Frohlich, J. — 2012-04-24T07:45:05-07:00

The authors describe a patient with personal and family history of muscle pains highly suggestive of mitochondrial disease. She presented with familial combined hyperlipidaemia with family history of premature coronary artery disease. After 4-week therapy of 5 mg of rosuvastatin once a week combined with 10 mg of ezetimibe daily, the low-density lipoprotein cholesterol level was markedly decreased from 3.88 to 2.82 mmol/l (27.3% reduction). She has experienced no adverse effects after 6 month treatment. The results suggest that the combination therapy of low-dose once-weekly rosuvastatin and daily ezetimibe could be used as an effective regimen for patients with mitochondrial disease.

Acute hepatitis E virus infection and autoimmune thyroiditis: yet another trigger?

Dumoulin, F. L., Liese, H. — 2012-04-24T07:45:05-07:00

A middle aged woman, previously healthy with the exception of mild seasonal asthma was presented with signs of acute hepatitis. The further investigation showed acute hepatitis E virus infection associated with autoimmune thyroiditis. Treatment was started with propranolol and carbimazol whereupon hepatitis and hyperthyroidism resolved. The authors think that the observed association of acute hepatitis E virus infection and autoimmune thyroiditis suggests a role of hepatitis E virus as putative trigger of autoimmune thyroiditis. The alternative possibility of thyroid dysfunction due to pre-existing autoantibodies cannot be completely excluded but seems to be unlikely given the very mild course of seasonal asthma in this patient.

Use of phentolamine in the treatment of Epipen induced digital ischaemia

Xu, J., Holt, A. — 2012-04-24T07:45:05-07:00

A 33-year-old lady accidentally injected norepinephrine into her right thumb while cleaning the first aid box where a spare Epipen for her son was kept. She presented with pain, pallor and swelling to the distal phalanx of the right thumb. After a prompt literature search and discussing the case with the National Poisons Information Service, local injection of 0.15 ml (1.5 mg) of phentolamine in 1 ml of 2% lignocaine was advised. Peripheral perfusion was restored immediately after injection and fully recovery was noted at the review clinic the following day. The presentation of this case in the accident and emergency department prompted phone calls and literature search to define the most appropriate evidence-based management for this situation. The authors conclude that local infiltration of phentolamine is the treatment of choice and this highlighted the need for local treatment protocols.

Burns in children: the importance of assessing for non-accidental injuries

Heymann, E., Marsdin, E. L. — 2012-04-18T01:53:09-07:00

Children represent 30% of all burn cases seen by accident and emergency physicians in the UK every year, with toddlers being most at risk within this age group. With the emergence of walking autonomy, the need for constant supervision is sometimes not enough to prevent this type of injury from happening. However, in remembering the importance of children’s health and safety, non-accidental injury is always to remain a differential diagnosis. The authors review a paediatric burns case underlying the importance of keeping an open mind to allow a proper clinical diagnosis to be formed.

An infant with caudal appendage

Shad, J., Biswas, R. — 2012-04-18T01:53:09-07:00

There are several human atavisms that reflect our common genetic heritage with other mammals. One of the most striking is the existence of the rare ‘true human tail’. It is a rare event with fewer than 40 cases reported in the literature. The authors report a case of an infant born with the true tail. A 3-month-old baby girl, presented with an 11 cm long tail, which was successfully surgically removed. Human embryos normally have a prenatal tail, which disappears in the course of embryogenesis by programmed cell death. Recent advances in genetic research reveal that ‘of those organs lost, in evolution, most species carry ‘genetic blue prints’. Thus, rarely the appearance of ancient organs like tail may be the result of re-expression of these switched off gene.

Status of memory loss

Iyer, P. M., Moroney, J., Mullins, G., Farrell, M., Delanty, N. — 2012-04-18T01:53:09-07:00

A 72-year-old woman presented with first onset of seizure with no prior history of cognitive dysfunction. EEG revealed focal non-convulsive status epilepticus. MRI brain showed a left temporal non-enhancing lesion. Temporal pole biopsy showed acute neuronal necrosis and astrocyte hyperplasia together with extensive amyloid plaques and neurofibrillary tangles. Perivascular oligodendroglial hyperplasia was present. Postmortem examination revealed extensive plaque and tangle disease. Perivascular oligodendroglial hyperplasia was limited to the left temporal area. The presence of focal perivascular oligodendroglial hyperplasia in the left temporal cortex, combined with extensive plaque and tangle disease may have contributed to the focal status epilepticus in this patient. Although the presence of focal perivascular oligodendroglial hyperplasia has been reported in cases of temporal lobe epilepsy, it has not been reported as a cause of seizure in patients with Alzheimer’s disease previously. Further studies for clinical-pathologic correlation would be required to confirm this hypothesis.

Fat embolism syndrome in a child with dystonia musculorum deformans

Cheung, J. P. Y., Ng, L. M., Chow, W., To, M. — 2012-04-18T01:53:09-07:00

A 16-year-old boy with dystonia musculorum deformans underwent an operation for removal of femoral implants and excision of the prominence at the greater trochanter of the left hip. He was found to have fat embolism syndrome at postoperative day 1 as evidenced by confusion, respiratory symptoms, chest radiograph changes, raised erythrocyte sedimentation rate, thrombocytopenia and fat in the urine and sputum.

Intra and extra-hepatic cystadenoma of the biliary duct. Review of literature and radiological and pathological characteristics of a very rare case

Soochan, D., Keough, V., Wanless, I., Molinari, M. — 2012-04-04T06:42:52-07:00

Painless obstructive jaundice is often associated with a malignant disease of the common bile duct or head of the pancreas. The authors present a unique case of a 62-year-old woman affected by an intrahepatic cystadenoma that extended into the common biliary duct. To our knowledge no previous case reports have been published on similar cases. After undergoing an en-block hepatic and bile duct resection, this patient is doing well without signs of recurrent disease.

Acquired haemophilia secondary to ivabradine presenting with acute respiratory distress syndrome

Riachy, M. A., Nasr, F., Azar, R. — 2012-04-04T06:42:52-07:00

The authors present the case of a 72-year-old patient who presented with severe dyspnoea, scant haemoptysis, pronounced desaturation and bilateral haematomas on the upper limbs. Chest radiography showed bilateral infiltrates mainly in the lower lobes. The patient’s prothrombin time, and platelet count were normal. However, the activated partial thromboplastin time showed a prolongation that was not reversed on a correction study. Factor VIII (FVIII) levels were very low and evidence of FVIII inhibitor was found. The patient had started taking ivabradine 2 months earlier, and the diagnosis of idiosyncratic acquired haemophilia was established. The patient was treated with volume expansion therapy, high levels of oxygen, multiple transfusions, methylprednisolone, desmopressine and rituximab. On the 3rd day, the patient showed progressive amelioration of his dyspnoea, oxygen needs and chest infiltrates. On the 7th day, the patient was discharged.

Tension pneumoperitoneum complicated with tension pneumothorax in a patient with diaphragmatic eventration

Akoglu, H., Coban, E., Guneysel, O. — 2012-04-04T06:42:52-07:00

Tension pneumothorax complicating a pneumoperitoneum is a rare but known entity. However, all previously published articles report an air leak through defects in the diaphragm connecting the pneumoperitoneum and the pneumothorax. Here, the case of a 36-year-old man in whom the pneumoperitoneum acted like a tension pneumothorax because of a congenital eventration of the left diaphragm without penetration is presented. Emergency needle decompression of the abdomen was performed. A gastric ulcer that had passed through the diaphragm to the right lung was diagnosed intraoperatively. Unfortunately, the patient developed a ventricular fibrillation that remained resistant to all resuscitative efforts, and the patient died shortly afterwards.

Metastasis of carcinoma of the lung to a carotid body paraganglioma

Bury, Y., Green, R., Jain, M., Moor, J. — 2012-04-04T06:42:52-07:00

Tumour-to-tumour metastasis is a rare phenomenon, but has been described in the literature in just over 100 cases. It can be particularly puzzling for the reporting pathologists, when encountered unexpectedly in a tumour showing abrupt transition from the usual morphology to another unusual pattern. The literature reports a variety of combinations with carcinoma-to-carcinoma being the most common; and renal cell carcinomas appear to the most common recipient tumours with common donor tumours being breast, lung and renal cell carcinomas. The authors report a case of poorly-differentiated lung carcinoma metastasising into a carotid body paraganglioma. Our case is unique and in our knowledge the first described case of carotid body paraganglioma with metastasis from a lung primary. To the best of our knowledge this is the first report of this interesting biological phenomenon in this combination.

Electrocution-induced atrial fibrillation: a novel cause of a familiar arrhythmia

Langford, A., Dayer, M. — 2012-04-04T06:42:52-07:00

A previously fit and well 40-year-old man presented to the emergency department with palpitations after suffering an 11 000 volt electrical shock from overhead power cables through a mobile crane which he was operating. His ECG demonstrated the presence of new atrial fibrillation at a rate of 80 beats per min. He was haemodynamically stable, and had otherwise only sustained a small exit burn to his left great toe. Routine blood tests including creatine kinase and troponin T were normal. A bolus of intravenous flecainide failed to restore sinus rhythm, but an amiodarone infusion was successful. An electrical shock is a rare cause of atrial fibrillation. There is no consensus over optimal medical management. Numerous treatment plans have been previously employed with varying degrees of success.

Efficacy of ECT in severe obsessive-compulsive disorder with Parkinson's disease

Gadit, A. M., Smigas, T. — 2012-04-04T06:42:52-07:00

A man in his 60’s was admitted following a serious suicide attempt secondary to severe obsession with bowel movements and severe depression. He had multiple previous admissions with similar presentations and responded partially to psychotropic medications. It was transpired that obsessive compulsive disorder preceded depression and being overwhelmed with this obsession related to bowel movement, he decided to end his life. Electro-convulsive therapy was commenced with good results. His obsessive-compulsive disorder came under control to a greater extent and there was an improvement in his mood.

A complicated simple fall - an atypical case of serogroup Y meningococcal pneumonia with secondary septicaemia and literature review

Chan, B., Kudsk-Iversen, S., Balaguruswamy, S., Purewal, T. — 2012-04-04T06:42:52-07:00

An elderly lady was admitted for pain management and rehabilitation following a fall. During her stay she developed a new heart murmur and sepsis. Subacute bacterial endocarditits was excluded, empirical ciprofloxacin was initiated and later converted to aztreonam with gentamicin for clinical deterioration. Subsequent investigations revealed meningococcal Y septicaemia secondary to pneumonia, with a possible oropharynx focus. Upon discharge she had returned to baseline state. The case reflects an unusual and increasing cause of pneumonia. A steady increase of infective serogroup Y isolates over the past 12-years in England, with tendency towards elderly makes it a significant differential among the general medical population. This trend corresponds with the US, but is yet unknown whether to be a periodic cycle or true change in dominance and, or, virulence among serogroups. If the latter were true, it would support the inclusion of serogroups beyond menigitides C in the vaccination program.

Nosocomial meningitis caused by gas producing Klebsiella pneumoniae

Costerus, J. M., van de Beek, D., Brouwer, M. C. — 2012-04-04T06:42:52-07:00

A 40-year-old woman presented with dyspnoea and lowered level of consciousness. Three months before presentation she had underwent craniotomy for an episode of acute subdural hematoma caused by a severe neurotrauma. Her temperature was 37.3°C, she had no focal neurological deficits or neck stiffness, and the score on the Glasgow Coma Scale was 9 (E2M5V2). Cranial CT showed obstruction hydrocephalus with hypodensities consistent with airbubbles in the lateral ventricles, but no air in the proximity of the skull defect resulting from the craniotomy. External ventricular drainage was performed and cerebrospinal fluid (CSF) examination showed 126 327 leucocytes per μl, a protein level of 26.28 g/l and a glucose level of <0.1 mmol/l. CSF culture grew Klebsiella pneumoniae, a gas producing bacterium. Despite antibiotic treatment with meropenem, ceftriaxone and intraventricular gentamicin and supportive therapy, our patient deteriorated and died 3 weeks after admission. The family did not give consent for autopsy.

An unusual cause of limp

Garbash, M., Rajamoorthy, V., Tambe, S., Schofield, J., Pandya, N. — 2012-04-04T06:42:52-07:00

Limp is a common clinical presentation in children, seen both in acute and community practice. The incidence is thought to vary between countries with suggested figures between 1.5 and 3.6 cases of non-traumatic limp per 1000 children. The authors present a case of a 6-year-old girl who attended our accident and emergency department with limp. It has been suggested that the most common diagnoses in our patient’s age group are transient synovitis, septic arthritis, osteomyelitis, Perthe’s disease and fractures or soft tissue injuries. Surprisingly our patient was diagnosed with haemophagocytic lymphohistiocytosis, for which limp is not a recognised presenting feature.