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1.  Multiple idiopathic arterial aneurysms masquerading as aortic dissection 
BMJ Case Reports  2013;2013:bcr2012008030.
We report the case of a 58-year-old lady who presented with abdominal pain and backache. Although initial evaluation was strongly suggestive of abdominal aortic dissection, she was ultimately found to have multiple arterial aneurysms. Work-up for underlying vasculitis was negative. Surgical repair was planned and the patient was referred to a cardiovascular surgeon. This case highlights the importance of careful radiological assessment in patients with suspected aortic dissection.
doi:10.1136/bcr-2012-008030
PMCID: PMC3604198  PMID: 23420724
2.  An unusual and deadly cause for massive haemoptysis 
BMJ Case Reports  2013;2013:bcr2012008160.
We report a 47-year-old man with diabetics presenting with massive haemoptysis. Physical examination showed moderate pallor, but was otherwise normal. Evaluation showed normal bleeding and clotting parameters. Aerobic cultures of sputum samples and acid-fast staining were negative. CT showed fusiform aneurysmal dilation of the descending thoracic aorta compressing the left main bronchus with secondary collapse of the left lower and lingular lobes. Massive haemoptysis was attributed to probable erosion of the aneurysm into the left main bronchus. Retrospective questioning failed to elicit pathognomic symptoms of aortic aneurysm including chest pain. While in the hospital, the patient had another bout of massive haemoptysis, requiring endotracheal intubation for airway protection. Chest x-ray revealed homogeneous opacification of the left hemithorax. The patient was treated with antitussives and blood transfusions and referred to a higher centre for endovascular stent grafting of the aneurysm and simultaneous surgical repair of the left main bronchus. Aortic aneurysm is a rare but deadly cause for haemoptysis, as rapid exsanguination can lead to cardiovascular collapse and death.
doi:10.1136/bcr-2012-008160
PMCID: PMC3603801  PMID: 23413292
3.  Right-sided infective endocarditis presenting with purpuric skin rash and cardiac failure in a patient without fever 
BMJ Case Reports  2013;2013:bcr2012007841.
We describe the case of a 70-year-old woman who presented with symptoms of cardiac failure, and was found on clinical examination to have a purpuric rash over her lower extremities. Further evaluation of cardiac failure revealed tricuspid regurgitation with two large tricuspid valve vegetations. Blood cultures yielded a growth of Streptococcus viridans. She was treated with an intravenous ceftriaxone and gentamicin and made a complete recovery with resolution of the rash.
doi:10.1136/bcr-2012-007841
PMCID: PMC3603787  PMID: 23355575
4.  Primary abdominal nocardiosis masquerading as tubercular pelvic inflammatory disease in an immunocompetent individual 
BMJ Case Reports  2013;2013:bcr2012008076.
We report the case of a 30-year-old housewife who presented with fever and lower abdominal pain, and was diagnosed with an adnexal collection. Initial evaluation was suggestive of tubercular pelvic inflammatory disease (PID). Subsequently, from a culture of pus aspirated from the collection grew out Nocardia species. She was treated with amikacin and cotrimoxazole and made a complete recovery. Clinical and laboratory evaluation for immunosuppression was negative. Primary abdominal nocardiosis is an unusual cause for PID and an important differential diagnosis for tuberculosis.
doi:10.1136/bcr-2012-008076
PMCID: PMC3603827  PMID: 23355581
5.  Leucocytoclastic vasculitis as a late complication of clopidogrel therapy 
BMJ Case Reports  2013;2013:bcr2012007861.
We describe a case of leucocytoclastic vasculitis manifested as exanthematous rash in a 57-year-old woman on long-term therapy with clopidogrel. The diagnosis was confirmed by skin biopsy. The patient was managed symptomatically with oral antihistaminics and topical steroids in consultation with dermatologists. Clopidogrel therapy was discontinued on suspicion of drug-induced vasculitis. The rash resolved completely within 2 weeks of withdrawal of clopidogrel, satisfying criteria for a probable adverse drug reaction. Leucocytoclastic vasculitis is an unusual adverse effect of clopidogrel therapy and even rarer as a late complication.
doi:10.1136/bcr-2012-007861
PMCID: PMC3604531  PMID: 23329717
6.  Amlodipine poisoning revisited: Acidosis, acute kidney injury and acute respiratory distress syndrome 
We report the case of an 18-year-old girl presenting with shock following ingestion of 85 mg of amlodipine and 850 mg of atenolol with suicidal intent. Subsequently, the patient developed severe metabolic acidosis, acute kidney injury, and acute respiratory distress syndrome, which were managed conservatively. The patient ultimately made a full recovery. Given the popularity of amlodipine and atenolol as antihypertensive drugs in this part of the world, it is likely that more such cases will be encountered in the future. Physicians should be aware of the severe complications that can develop with amlodipine overdose.
doi:10.4103/0972-5229.136078
PMCID: PMC4118515  PMID: 25097362
Acidosis; acute respiratory distress syndrome; amlodipine; poisoning
7.  Adenocarcinoma of lung masquerading as systemic auto-immune disease 
BMJ Case Reports  2012;2012:bcr0220125822.
A 40-year-old previously healthy male presented with acute onset painless dimness of vision in both eyes since the past week and low-grade fever, anorexia and weight loss for the past 1 month. He had been evaluated at a local hospital and diagnosed to have a posterior cerebral artery territory infarct on the left side on the strength of cranial CT. Shortly after receiving antiplatelets and warfarin he had developed severe coagulopathy as evidenced by haematemesis, epistaxis and haematuria. Preliminary investigation revealed prolonged clotting parameters, renal failure and anaemia. Cerebral MRI showed multiple areas of cortical haemorrhage. In the course of his hospital stay, he developed further stigmata of auto-immunity including Coomb’s positive haemolytic anaemia, recurrent venous thromboses and a palpable purpuric truncal rash. He was eventually diagnosed to have an adenocarcinoma of the lung, and was subsequently referred to an oncologist for further therapy.
doi:10.1136/bcr.02.2012.5822
PMCID: PMC3387439  PMID: 22707679
8.  Tuberculous mediastinal abscess as a paradoxical reaction in an immunocompetent individual 
BMJ Case Reports  2012;2012:bcr0120125498.
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.
doi:10.1136/bcr.01.2012.5498
PMCID: PMC3339156  PMID: 22604761
9.  An unusual cause for hyponatremia with seizures 
BMJ Case Reports  2012;2012:bcr0920114784.
A 50-year-old Asian Indian female with known hypertension presented with persistent vomiting but no other symptoms of meningism. Clinical examination and basic laboratory parameters were entirely normal except for significant hyponatremia. Further investigation was suggestive of the syndrome of inappropriate antidiuretic hormone (SIADH) secretion. Subsequently, despite steady correction of hyponatremia, the patient developed generalised seizures. Cerebrospinal fluid (CSF) analysis performed was inconclusive. Screening for a chronic meningitis underlying SIADH, yielded positive blood and CSF titres for venereal disease research laboratory (VDRL), which were confirmed by Treponema pallidum haemagglutination (TPHA). The patient was treated for neurosyphilis and made a complete recovery. Hyponatremia resolved and she had no further episodes of seizures. She was tested for HIV infection which was negative. On follow-up, she remained TPHA positive but VDRL titres became negative.
doi:10.1136/bcr.09.2011.4784
PMCID: PMC3316798  PMID: 22605698
10.  Ketosis-prone type 2 diabetes mellitus in a patient with Sheehan’s syndrome: a rare convergence of two distinct endocrine entities 
BMJ Case Reports  2012;2012:bcr1120115131.
A 36-year-old housewife, previously diagnosed with Sheehan’s syndrome on glucocorticoid and thyroxine replacement therapy, presented with unprovoked diabetic ketoacidosis. Ketoacidosis was corrected with intravenous fluids and insulin therapy. Further evaluation was suggestive of type 2 diabetes mellitus. On follow-up, she experienced repeated episodes of hypoglycaemia and insulin was tapered and stopped. Adequate glycaemic control was maintained with metformin monotherapy.
doi:10.1136/bcr.11.2011.5131
PMCID: PMC3263140  PMID: 22665875
11.  Rhabdomyolysis with acute kidney injury in a case of hanging 
BMJ Case Reports  2011;2011:bcr0920114817.
Although well-known as a complication of other hypoxic conditions such as near drowning, status asthmaticus and carbon monoxide poisoning, rhabdomyolysis has not been reported in patients with hanging. The authors report a case of partial hanging complicated by rhabdomyolysis and acute kidney injury.
doi:10.1136/bcr.09.2011.4817
PMCID: PMC3207804  PMID: 22675110
12.  Phenytoin induced Stevens-Johnson syndrome exacerbated by cefepime 
Steven Johnson syndrome (SJS) is a rare drug induced mucocutaneous reaction. Here, we present an elaborate report of a 28-year-old female patient who developed Phenytoin induced SJS, which was exacerbated by cefepime.
doi:10.4103/0976-500X.119719
PMCID: PMC3826009  PMID: 24250210
Cefepime; phenytoin; Steven Johnson syndrome
13.  Excellent Tolerance to Cilnidipine in Hypertensives with Amlodipine - Induced Edema 
Background:
Ankle edema is a common adverse effect of amlodipine, an L-type calcium channel blocker (CCB). Cilnidipine is a newer L/N-type CCB, approved for treatment of essential hypertension.
Aim:
This study was designed to determine whether cilnidipine can produce resolution of amlodipine-induced edema while maintaining adequate control of hypertension.
Materials and Methods:
A prospective study was performed on 27 patients with essential hypertension with amlodipine-induced edema. Concomitant nephropathy, cardiac failure, hepatic cirrhosis, or other causes of edema, and secondary hypertension were excluded by appropriate tests. Amlodipine therapy was substituted in all the cases with an efficacy-equivalent dose of cilnidipine. Clinical assessment of ankle edema and measurement of bilateral ankle circumference, body weight, blood pressure, and pulse rate were performed at onset of the study and after 4 weeks of cilnidipine therapy.
Results:
At completion of the study, edema had resolved in all the patients. There was a significant decrease in bilateral ankle circumference and body weight (P < 0.001). There was no significant change in mean arterial blood pressure and pulse rate.
Conclusions:
Therapy with cilnidipine resulted in complete resolution of amlodipine-induced edema in all the cases without significant worsening of hypertension or tachycardia. Cilnidipine is an acceptable alternative antihypertensive for patients with amlodipine-induced edema.
doi:10.4103/1947-2714.106203
PMCID: PMC3560139  PMID: 23378956
Ankle edema; Calcium channel blocker; Cilnidipine; Hypertension; L/N-type calcium channel
14.  Carotid stenting in a nonagenarian patient with symptomatic carotid stenosis 
The Australasian Medical Journal  2012;5(10):528-530.
Carotid artery stenosis is a disabling disease in all age groups. Elderly people are more prone to recurrent strokes due to advancing age and multiple co-morbidities. Treatment options for symptomatic carotid stenosis in the very elderly are the same as in younger patients although with a higher operative risk. We describe a successful case of carotid artery stenting in a nonagenarian with symptomatic carotid artery stenosis, a subgroup for whom treatment options are rarely discussed in guidelines.
doi:10.4066/AMJ.2012.1278
PMCID: PMC3494823  PMID: 23173015
Carotid artery stenosis; nonagenarian; carotid artery stenting
15.  An unusual cause for recurrent jaundice in an otherwise healthy male 
The Australasian Medical Journal  2012;5(10):541-543.
A 41-year-old Asian-Indian male presented with recurrent episodes of jaundice over the past six months. Physical examination was normal, barring mild icterus. Laboratory parameters revealed indirect hyperbilirubinemia. Further evaluation yielded a diagnosis of severe nutritional vitamin B12 deficiency. Indirect hyperbilirubinemia was ascribed to ineffective erythropoiesis. Underlying Gilbert's syndrome was ruled out by provocative testing with lipid-restricted diet. Presentation of severe vitamin B12 deficiency with isolated hyperbilirubinemia without concomitant major haematologic or neurologic dysfunction is unusual and potentially underdiagnosed. Awareness of this possibility can permit early diagnosis of vitamin B12 deficiency and forestall development of severe haematologic and neurologic sequelae.
doi:10.4066/AMJ.2012.1404
PMCID: PMC3494826  PMID: 23173018
Recurrent jaundice; indirect hyperbilirubinemia; vitamin B12 deficiency; ineffective erythropoiesis
16.  Correlation of epicardial fat and anthropometric measurements in Asian-Indians: A community based study 
Avicenna Journal of Medicine  2012;2(4):89-93.
BACKGROUND:
It is increasingly evident that visceral adipose tissue plays a leading role in the pathogenesis of the metabolic syndrome. Unfortunately, accurate quantification of intra-abdominal visceral fat is cumbersome and expensive. Epicardial fat represents the component of visceral fat distributed around the heart, and is readily and non-invasively assessed by echocardiography.
AIMS:
To determine the correlation of epicardial fat with anthropometric parameters in a healthy population of Asian-Indians.
MATERIALS AND METHODS:
A prospective, cross-sectional study was conducted as part of a community outreach program from December to March 2011. Individuals over 18 years of age were included in the study. Anthropometric data was collected for all patients. Epicardial fat was assessed in parasternal long and short axes.
RESULTS:
350 healthy individuals were included in the study. Of them, 66.7% were males. Mean age was 42.7 ± 15.3 years (range 18-84). Mean body-mass index (BMI) and waist circumference were 23.3 ± 4.5 kg/m2 (range 15.2-34.3) and 80.2 ± 13.3 cm (range 43-115) respectively. Mean epicardial fat in both axes was 2.6 ± 1.3 mm (range 0.3-7.0). Epicardial fat measured in both axes correlated well with weight (r = 0.399, P < 0.001), waist circumference (r = 0.522, P < 0.001) and BMI (r = 0.471, P < 0.001). Epicardial fat also correlated with age (r = 0.559, P < 0.001).
CONCLUSIONS:
There is an excellent correlation between epicardial fat measured by echocardiography and anthropometric parameters of metabolic syndrome.
doi:10.4103/2231-0770.110739
PMCID: PMC3696206  PMID: 23826555
Anthropometric measurements; epicardial fat; metabolic syndrome visceral fat
17.  Cranial melioidosis with extradural extension after a fall in the bathroom 
The Australasian Medical Journal  2012;5(8):455-458.
A 32-year-old diabetic male, with a past history of head injury and seizures, presented with a painful swelling over his forehead present for the past three months. Cranial MRI demonstrated the presence of a scalp collection with extradural extension through a bony defect. Biopsy from the area showed caseating necrosis suggestive of tuberculosis. Although the patient failed to return for initiation of anti-tubercular therapy for the next 11 months, the swelling did not progress, and there were no constitutional symptoms. The indolent nature of the swelling prompted re-evaluation and delayed cultures of pus from the collection grew Burkholderia pseudomallei.
doi:10.4066/AMJ.2012.1374
PMCID: PMC3442190  PMID: 23024720
Cranial epidural abscess; melioidosis; Burkholderia pseudomallei
18.  A rare case of seronegative culture-­proven infection with Brucella suis 
The Australasian Medical Journal  2012;5(7):340-343.
Brucellosis is a chronic infection produced by members of the Brucella family. Diagnosis of this condition requires either isolation of the organism in culture or positive serological tests.
We describe a 27-year-old male admitted as a case of pyrexia of unknown origin (PUO), who tested negative for Brucella IgM ELISA test on preliminary evaluation but was subsequently diagnosed on the strength of positive blood and bone marrow cultures to be a case of brucellosis secondary to Brucella suis infection. In addition to highlighting the pathogenic potential of an unusual organism, this case demonstrates the unreliability of standard serological tests based on the Brucella melitensis antigen for infection with other species of Brucella.
doi:10.4066/AMJ.2012.1177
PMCID: PMC3412998  PMID: 22905059
Brucella suis; pyrexia of unknown origin; serological tests
19.  Tubercular neuritis: A new manifestation of an ancient disease 
The Australasian Medical Journal  2011;4(12):674-676.
A 25-year-old housewife presented with a burning sensation over both legs for the past 15 months, and fever with weight loss for the past six months. She had noticed a lump in her left breast one month ago. Examination revealed hyperaesthesia and allodynia over the lower limbs. Nerve conduction studies confirmed the presence of sensory neuropathy. Nerve biopsy was suggestive of a chronic axonopathy. Subsequently sputum as well as aspirate from the breast lump tested positive for acid fast bacilli. Treatment with anti-tubercular therapy resulted in full recovery. Peripheral neuropathy is a unique and unusual presentation of tuberculosis.
doi:10.4066/AMJ.2011.1029
PMCID: PMC3413966  PMID: 22905042
peripheral neuropathy; disseminated tuberculosis; sensory polyneuropathy
20.  Large unilateral pleural effusion secondary to Moraxella catarrhalis infection 
The Australasian Medical Journal  2011;4(9):485-487.
A 43-year-old male with chronic kidney disease on maintenance hemodialysis presented with breathlessness, cough and right-sided abdominal pain. Examination revealed a large right-sided pleural effusion and subsequent thoracocentesis yielded an exudate. Although the fluid culture was sterile, sputum culture produced Moraxella catarrhalis. Tuberculosis was ruled out by pleural fluid analysis and pleural biopsy. Antibiotics were administered and subsequent radiograms indicated resolution of the effusion. This is a rare case of a large unilateral pleural effusion secondary to M. catarrhalis infection in a nonsmoker with no pre-existing pulmonary pathology.
doi:10.4066/AMJ.2011.864
PMCID: PMC3562906  PMID: 23393539
Kidney disease; pleural effusion; Moraxella catarrhalis
21.  Lipoid Proteinosis Mimicking Congenital Immunodeficiency: A Case Report 
The Australasian Medical Journal  2011;4(3):155-159.
Lipoid proteinosis is a rare congenital disorder that can present with a variety of symptoms. A nineteen year old Indian male with dysmorphic features was admitted with a twelve year history of recurrent ulcerations over the upper limbs and oral cavity. Although the initial presentation was strongly suggestive of a congenital immune-deficiency syndrome, all investigations for immunodeficiency disorders were negative. Subsequent evaluation yielded a diagnosis of lipoid proteinosis.
doi:10.4066/AMJ.2011.635
PMCID: PMC3562964  PMID: 23390465
Lipoid proteinosis; congenital immunodeficiency syndrome; recurrent ulcerations
22.  Galactorrhea with menstrual irregularity: something other than a prolactinoma? 
We report the case of a 29-year-old female who presented with galactorrhea and irregular menstrual periods. Laboratory tests showed elevated levels of serum prolactin, raising the possibility of a prolactinoma. However, further evaluation revealed an unusual and unexpected cause for her illness.
PMCID: PMC3982619  PMID: 24733533
galactorrhea; hyperprolactinemia; prolactinoma; Wilson’s disease

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