Sarcoidosis affects the lungs most commonly and can present with cutaneous lesions. It can also involve the bone marrow in rare instances, often presenting with non-specific symptoms such as fever and malaise, with occasional haematological abnormalities. The authors present the case of a 41-year-old caucasian female who was diagnosed with scar sarcoidosis, but who also reported fatigue, night sweats and polyarthralgia. No haematological abnormalities or lung involvement were detected. A magnetic resonance scan of the spine, performed due to disc prolapses, demonstrated areas of bone oedema and stress response that were reported as a possible sarcoid infiltration of the bone marrow. An improvement occurred after 8 weeks, despite conservative treatment. Bone marrow involvement in sarcoidosis is rarely reported, and was an accidental finding here. Due to the non-specific presentation, cases such as this are potentially underdiagnosed and should be considered in patients with systemic symptoms, regardless of their haematological status.
This case report provides a different perspective on the management of a patient with a psychotic illness. The detained patient, a man aged 50, had specific delusional beliefs about toxins affecting his kidneys, such that he needed to drink water to ‘detoxify’ himself. This resulted in him developing life-threatening hyponatraemia. It became clear that he was very resistant to taking oral medication and was reluctant to engage with any psychological treatment. A novel approach was considered, involving the ‘off licence’ use of short acting intramuscular olanzapine for the successful treatment of the psychotic illness. The case demonstrates the safe use of intramuscular olanzapine for 155 days, which is the longest reported case for the use of intramuscular olanzapine for the treatment of a psychotic illness. The individual was later discharged on oral olanzapine.
Hypertriglyceridaemia (HTG) causes up to 10% of all cases of acute pancreatitis (AP). It is the third most common cause after gallstones and alcohol. Despite this frequency, there are no clear guidelines for its specific management, mainly due to the paucity of evidence. The authors present a case and discussion of hypertriglyceridaemic pancreatitis (HTGP) complicated by an acute cerebral infarct. The patient’s subsequent death secondary to cerebral infarction opens the discussion as to whether HTG should be more urgently treated.
Ring-shaped lateral meniscus is a rare clinical entity that is usually asymptomatic. Moreover, diagnosis is always based on arthroscopic exploration of lateral meniscus. MRI has not been proven useful so far because the inner portion of the ring-shaped lateral meniscus is usually misinterpreted as a bucket-handle tear. The authors report a case of a 16-year-old girl with ring-shaped lateral meniscus in combination with a meniscal cyst. MRI demonstrated a cyst arising from lateral meniscus and meniscal tissue into the inner portion of the lateral compartment mimicking displaced meniscal fragment. Bucket-handle tears have not been reported to cause or accompany meniscal cysts. As a result the diagnosis of a ring-shaped lateral meniscus along with meniscal cyst was assumed based on MRI and confirmed during arthroscopy. The patient was treated with arthroscopic partial lateral meniscectomy and intra-articular cyst debridement.
Pituitary metastasis is an infrequent clinical problem occurring in 1%–5% of various autopsy series. Differentiated thyroid carcinoma as the primary malignancy was reported in only 2.1% of the cases. A 53-year-old Filipina presented with 7 months history of progressive loss of vision and headaches. She underwent thyroidectomy 2 years prior to admission for an enlarging neck mass. After then, she was lost to follow-up. Physical examination revealed visual field loss, galactorrhea and a 3×4 cm firm suprasternal mass. Imaging showed a 4.5×5×5 cm mass in the sphenoid and ethmoid sinuses with extension into the sella and suprasellar regions. Biopsy of the mass was consistent with papillary thyroid carcinoma, metastatic. For that, she underwent completion thyroidectomy, followed by surgical debulking of the sellar mass. Postoperatively, there was minimal improvement in vision and 13 months after, she is still on constant follow-up in our clinic, and is due for radioiodine therapy.
All three siblings (one female/two males) of a family presented successively with cerebrovascular events at the ages of 55, 63 and 65. The first one manifested extensive left subcortical haemorrhage and both the second and third patient, showed left lacunar ischemic stroke. Their mother had died from vascular dementia at the age of 60 after several subcortical ischaemic strokes. Their maternal grandfather had died in his fifties from haemorrhagic stroke. All of them showed extensive white matter involvement. The genetic study revealed a mutation in exon 11 of the Notch3 gene in two family members. They were diagnosed with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). Although CADASIL is a well-established disease, little is known about this disorder. The fact that all three siblings presented with CADASIL successively may appear disheartening, further studies are needed in order to control the clinical course of this devastating and unavoidable disorder.
Ifosfamide (IFA) is a powerful chemotherapeutic drug that is active against a variety of paediatric malignancies. However, renal toxicities such as haemorrhagic cystitis and Fanconi syndrome are major hazards that hinder its use in clinical practice. The authors present a case of a patient treated for Wilms’ tumour with IFA who developed rickets with Fanconi syndrome. Patients undergoing IFA treatment must be carefully monitored for the development of iatrogenic complications. Recent studies have improved our understanding of the underlying pathomechanism of IFA induced Fanconi syndrome, and selective renal protection against during chemotherapy with IFA may be possible soon.
Special needs individuals are children or adults who are prevented by a physical or mental condition from full participation in the normal range of activities of their age groups. They usually exhibit high treatment needs because of an increased prevalence and severity of trauma. This paper presents a case report and review of treatment strategy of repositioning, splinting of permanent incisors in a 13-year-old boy with Down’s syndrome sustaining trauma led to intrusive luxation of maxillary incisors. The intruded incisors were immediately repositioned and splinted with composite within hours.
The following case describes a head injury in an older male patient in which a large wooden foreign body, forming a subcutaneous tract in the scalp, was mistaken for a depressed skull fracture on initial clinical assessment. This foreign body was not visualised on CT brain imaging until specialised views were used retrospectively, after surgical exploration of the scalp laceration. Appropriate radiological techniques for the detection of radiolucent foreign bodies are discussed.
Methaemoglobinaemia is rare. Acute myocardial infarction (AMI) is common. The authors present a unique case of methaemaglobinaemia masquerading as an AMI. A middle-aged male was urgently referred to a tertiary cardiac centre for primary percutaneous coronary intervention with acute chest pain, cyanosis and tachycardia. However, on arrival, his ECG was felt to be within normal limits. Similarly unremarkable, were his echocardiogram and routine blood tests. Arterial blood gas analysis revealed a methaemaglobinaemia of 28.5% which normalised spontaneously. This was thought to be secondary to the use of smelling salts, inhaled earlier that day in the gymnasium. This is the first reported case of smelling salts inducing methaemaglobinaemia and of methaemaglobinaemia mimicking an AMI.
Uterine myxoid leiomyosarcoma is an exceptionally unusual variant of leiomyosarcoma with only 34 cases having been reported in the literature. The authors describe a case of myxoid leiomyosaroma with an underlying haematological profile that has not been described previously. A 38-year-old Caucasian woman with a known uterine fibroid discovered during pregnancy presented to the emergency department with heavy per vaginal bleeding. On examination, she had a large abdominal mass. She had a haemoglobin level of 5.2, platelets of 16 and a low white cell count. She received multiple blood and platelet transfusions, despite which her haemoglobin and platelet count levels remained low. She underwent two bone marrow biopsies, which were inconclusive. She underwent laparotomy for abdominal hysterectomy, bilateral salphingo-oohphorectomy, omentectomy and appendicectomy. Histological examination showed uterine myxoid leiomyosarcoma (International Federation of Gynaecology and Obstetrics stage IIIA). Her haematological profile improved significantly following surgical resection of the tumour, reappearing with the recurrence of the disease. The authors hence, consider that pancytopaenia in this patient was a manifestation of paraneoplastic syndrome.
A 57-year-old gentleman was admitted for relapse of psychotic symptoms. He had prior diagnosis of schizophrenia and Parkinson’s disease. His psychotropic medications were adjusted but his neurological symptoms worsened, mainly dysphagia. His speech and mobility also posed significant problem. Neurology department was contacted for joint management. In the event of resolution of psychotic symptoms, he was transferred to the neurology department for further management. His medication for Parkinson’s disease was reviewed; a percutaneous endoscopic gastrostomy tube was inserted in stomach for feeding as dysphagia did not improve. He was transferred back to psychiatry unit for further adjustment in psychotropic medication in order to see a possible improvement in dysphagia. Minor adjustment was done in this regard in view of his mental health stability. Change of medication was not possible for the possible side effects and patient’s compliance issue. He was discharged with adequate plans; follow-up arrangement and suggestions for further management.
A man in his 60s presents with chronic dyspnoea and cough for 3 years. EKG and nuclear stress test were not diagnostic. An echocardiogram revealed moderate pericardial effusion. His symptoms improved with ibuprofen temporarily and a repeat echocardiogram showed resolution of the effusion. However, when his symptoms recurred, re-imaging showed a large intracardiac tumour causing right ventricular outflow obstruction. Subsequent histological examination revealed metastatic paraganglioma. He was found to carry a germline mutation in the SDHB gene which is associated with higher malignant risk. Knowledge of his underlying mutation allowed the patient and his family to receive appropriate gene-specific counselling and surveillance.
The authors describe a rare case of metastatic bronchogenic adenocarcinoma in a 55-year-old man presenting with concomittant solitary lytic skull lesion and ischaemic stroke. Metastatic bronchogenic carcinoma is known to present as lytic skull lesions. Primary brain tumours are also known to cause ischaemic brain injury. An underlying stroke risk may be exagerated by cranial tumour surgery. Patients with brain tumours are well known to be predisposed to an increased risk of developing thromboembolic disease. It is unusual to see metastatic bronchogenic adenocarcinoma presenting as ischaemic stroke with a background of concomittant cerebral metastasis. The aetio-pathogenesis of this rare occurrence is discussed with a review of literature.
Nitrobenzene is a nitrite compound often used in polishes or solvents. Its toxic effects are due to its ability to induce methaemoglobinaemia. The clinical presentation of this poisoning varies according to the concentration of methaemoglobin level in blood. The importance of early identification of the compound on the basis of clinical suspicion corroborative with methaemoglobin level with timely intervention is required to prevent fatal outcome. It is also important to take care of the secondary cycling of nitrobenzene from body stores to prevent secondary recurrence of symptoms in patients after heavy exposure. Here author reports a rare case of accidental poisoning with nitrobenzene presented with respiratory distress and cyanosis. On investigation, he was diagnosed to have cardiogenic pulmonary oedema and multiorgan dysfunction. The urgent institution of methylene blue as specific antidote along with haemodynamic and ventilatory support was proved crucial for life saving of the patient.
The authors present a case of lupus mastitis which was initially diagnosed following an incisional biopsy of a breast lump, with similar pathology found 2 years later after an ultrasound guided biopsy of the same lump. The woman had been diagnosed 7 years before with systemic lupus erythematosus. The radiological and pathological features are presented in this report with discussion of similar cases in the literature.
Rowell syndrome is a very controversial condition and though defining diagnosing criteria exist, many previously published cases lack one or more of these criteria. It represents the combination of cutaneous lupus erythematosus and erythema multiforme in one single individual. In order to discuss relevance of diagnostic and defining criteria the authors use a case seen in our outpatient service that was primarily diagnosed as Rowell syndrome. But due to lacking criteria, the authors rediagnosed this patient as an unusual variation of lupus erythematosus.
The authors report the case of a 27-year-old male with ventriculoperitoneal shunt (VPS) for hydrocephalus presenting with episodic transient binocular visual loss (TBVL) and headache. Complete physical, bedside shunt examination and funduscopy were unremarkable. Laboratory investigation, shunt series and imaging studies failed to reveal any acute abnormalities. Interrogation of the shunt system identified a valve malfunction which was corrected with resultant symptomatic relief and the patient was discharged home in stable condition. VPS malfunction occurs secondary to infection or mechanical failure such as obstruction, tubing fracture, shunt migration and over drainage. Resultant raised intracranial pressure leads to symptoms of headache, nausea, vomiting and gait abnormalities. Visual defects including blindness has been occasionally reported from shunt malfunction. Rare complications include cerebrospinal fluid oedema, colonic perforation, paraparesis and parkinsonism. TBVL due to shunt malfunction remains an uncommon presentation and requires a high index of clinical suspicion while evaluating these patients.
A 56-year-old patient presented with shock and severe abdominal pain. Initial blood tests, erect chest x-ray and focused ultrasound were not diagnostic. CT imaging demonstrated bleeding from a superior mesenteric artery aneurysm. Operative treatment with ligation of the bleeding point and packing of the abdomen successfully controlled the bleeding. He eventually made a full recovery.
A 36-year-old man presented to the emergency department acutely unwell after being found collapsed while running a halfmarathon. He presented with a reduced Glasgow coma score, was tachycardic, agitated, hypoxic and profusely sweating. He had taken a ‘supplement’ given to him prior to the race by a friend, as he was concerned about not finishing. This contained both caffeine and a large dose of ephedrine (60 mg in total). After initial resuscitation he was intubated, and was transferred to critical care. He subsequently developed rhabdomyolysis, requiring haemofiltration.
Tuberculosis is highly prevalent in developing countries. Meningitis is by far the most frequent manifestation of tuberculosis in the central nervous system. Infrequently they may present as intracranial masses. Intracranial tuberculomas, either multiple or single, pose great diagnostic challenge because the appearance may resemble many other non-infectious and infectious conditions and particularly in patients without constitutional symptoms or evidence of tuberculosis elsewhere in the body. Here the author highlights an unusual presentation of intracranial tuberculomas in the form of pseudodementia where other constitutional symptoms were absent.