AN UNUSUAL PRESENTATION OF THYROGLOSSAL DUCT CYST

Thyroglossal duct cyst usually presents as a painless swelling in the mid-line of the neck. This is the first documented case of an acute presentation of hoarseness and multi-loculated swelling. It also contrasts the limitations of ultrasonography with the accuracy of magnetic resonance imaging in such atypical swellings.     

AN UNUSUAL PRESENTATION OF BILATERAL TUBAL ECTOPIC PREGNANCY

The diagnosis of ectopic pregnancy is sometimes difficult on clinical grounds because of the varied presentation. The clinical triad of amenorrhoea, abnormal vaginal bleeding and lower abdominal pain often raises the suspicion of the diagnosis. There are, however, instances where one or other feature of the triad may be absent. The present case report illustrates an example of bilateral tubal ectopic pregnancies presenting without amenorrhoea. In this case the presentation was similar to an acute gastrointestinal problem.     

HEPATIC ARTERY ANEURYSM: AN UNUSUAL PRESENTATION

SUMMARY The natural history of visceral artery aneurysms, and in particular those of the hepatic artery, is unclear. The clinical presentation can include upper abdominal pain, bleeding into the gastrointestinal tract, and obstructive jaundice. We present the case of a middle-aged woman with right upper quadrant pain and a palpable mass, in whom a thrombosed hepatic artery aneurysm was found to be the cause.     

AN UNUSUAL PRESENTATION OF GAS GANGRENE COMPLICATED BY PENICILLIN ALLERGY

SUMMARY A case is reported of non-clostridial gas gangrene that presented in a similar way to deep venous thrombosis and then developed into septic shock. Management was complicated by penicillin allergy.     

AN UNUSUAL PRESENTATION OF POLYMYALGIA RHEUMATICA WITH SEVERE MUSCLE WEAKNESS

An 83-year-old woman suddenly developed profound weakness of proximal and distal muscles in both upper limbs. Electromyography revealed abnormal changes but serum creatine kinase was normal. The weakness responded dramatically to steroid therapy. These unusual features of polymyalgia rheumatica are discussed.     

OBSTRUCTIVE JAUNDICE DUE TO INTRACHOLEDOCHAL BLOOD CLOT: AN UNUSUAL EARLY PRESENTATION OF PRIMARY HEPATIC CARCINOMA

SUMMARY We report a case of early presentation of a hepatocellular carcinoma with obstructive jaundice, due to obstruction of the common bile duct by a blood clot. The possibility of preoperative diagnosis, the surgical treatment and the postoperative outcome are discussed.     

UNUSUAL PRESENTATION OF A NASAL (ANTROCHOANAL) POLYP

SUMMARY A case is described of expulsion of an autoamputated antrochoanal nasal polyp per mouth in a young patient. This rare complication of a nasal polyp is potentially dangerous.     

AN UNUSUAL CAUSE OF DYSPHAGIA

SUMMARY We report a rare case of a bronchogenic cyst in an adult presenting with dysphagia. The benign nature of the lesion was established preoperatively by a series of radiological investigations. This enabled surgical planning and prediction of prognosis. The presentation, radiological findings and its differential diagnosis are discussed.     

RECTOPERINEAL FISTULA: AN UNUSUAL CAUSE OF ANOGENITAL DISCHARGE

SUMMARY The serendipitous presentation of a rectoperineal fistula in a 34-year-old nulliparous woman is described. This surgically correctable cause of an anogenital discharge posed a risk (if unrecognised) of producing a rectovaginal fistula at the time of vaginal delivery.     

PYODERMA GANGRENOSUM: AN UNUSUAL CAUSE OF PERIAURAL ULCERATION

SUMMARY A case of pyoderma gangrenosum affecting the pinna and neck of a diabetic patient is reported. Appearances were suggestive of malignant otitis externa. A small biopsy resulted in rapid and aggressive exacerbation of the lesion. Pyoderma gangrenosum, although uncommon, should be considered as a cause of ulceration, particularly when the ulcer yields no growth on culture in a non-dependent area.     

HORNER'S SYNDROME: AN UNUSUAL IATROGENIC COMPLICATION OF PNEUMOTHORAX

SUMMARY A patient is reported with spontaneous pneumothorax in whom a Horner's syndrome occurred as a complication of drainage tube thoracostomy. Ascending sympathetic fibres lie in close contact with the parietal pleura at the apex of the hemithorax and may be damaged by an inappropriately positioned thoracostomy tube. It is suggested that drainage tubes found to be sited medially at the apex of the hemithorax should be immediately repositioned to avoid this complication.     

AN UNUSUAL CASE OF LEFT PARADUODENAL HERNIA

Paraduodenal hernias are the commonest form of intra-abdominal hernia. We report on a rare paraduodenal hernia involving the duodenojejunal recess.     

PRIMARY CEREBRAL MALIGNANT MELANOMA: AN UNUSUAL CAUSE OF DYSPRAXIA

SUMMARY Primary intracranial melanomas are rare and occur mainly in young adults. Originating from leptomeningeal melanoblasts and extending into the parenchyma, the tumours closely resemble meningiomas, from which they are radiologically difficult to distinguish despite progress in neuroimaging. Definitive diagnosis is usually made on histopathological examination, though confirmed only after post-mortem examination in some cases. Prolonged disease-free periods, and in rare cases long-term survival, are possible following successful total surgical excision. This case presented with typical clinical features but, at 79 years old, an unusual age.     

DIAPHRAGMATIC HERNIATION OF THE LARGE BOWEL ASSOCIATED WITH UNUSUAL CLINICAL AND ELECTROCARDIOGRAPHIC PRESENTATION

SUMMARY This is the first case reported of combined hiatus hernia of the stomach and herniation of the splenic flexure of the colon through the oesophageal hiatus. It was associated with unusual clinical and electrocardiographic findings. We postulate that these were the result of an increase in intrathoracic pressure induced by the herniating structures.     

POSTERIOR VOCAL CORD ADHESION: AN UNUSUAL COMPLICATION OF ENDOTRACHEAL INTUBATION

SUMMARY A case is presented of a patient who required endotracheal intubation followed by tracheostomy and who consequently developed an adhesion between the vocal processes, which was identified and divided at direct laryngoscopy.     

AN UNUSUAL CASE OF ILEOCAECAL TUBERCULOSIS IN AN 80-YEAR-OLD CAUCASIAN MALE

An 80-year-old Caucasian male presented with a seven-week history of diarrhoea and weight loss. Distal duodenal biopsies showed partial villous atrophy but he failed to respond to a gluten-free diet. Subsequently he developed a right iliac fossa mass associated with radiological evidence of ileocaecal ulceration. Colonoscopic biopsies from the caecum showed non-caseating granulomata and Ziehl-Neelsen (ZN) staining and culture for acid-fast bacilli (AFB) were negative. Crohn's disease was diagnosed and he was started on steroids. Although he showed an initial response, his condition then deteriorated and he died after six weeks. ZN staining of tissue at postmortem showed AFBs. Although a rare diagnosis in the UK, a high index of suspicion should be maintained for ileocaecal TB in patients with appropriate clinical features, even if classical risk factors for TB are absent.     

BLUNT LARYNGEAL TRAUMA: AN UNUSUAL CASE

Local external evidence of neck trauma – bruising, subcutaneous emphysema, cuts, abrasions and so on – signs of upper airway obstruction, dysphonia and dysphagia are the hallmarks of laryngotracheal lesions. Such lesions tend to occur after motor vehicle accidents and usually require surgery. We describe a case of blunt laryngeal trauma, resulting from an unusual mechanism, which healed spontaneously.     

PLEXIFORM NEUROFIBROMA: AN UNUSUAL CAUSE OF NECK LUMP IN A CHILD

SUMMARY Although relatively rare, neurofibromas have been described in many different sites. We present the unusual case of an 8-year-old girl with a plexiform neurofibroma situated deep to the sternomastoid muscle, and review the current literature with particular regard to the pathology and site of neurofibromas.     

COARCTATION OF THE AORTA: AN UNUSUAL CAUSE OF HYPERTENSION IN A 73-YEAR-OLD WOMAN

CLINICAL MESSAGE Secondary causes of hypertension should be considered when blood pressure control is difficult in elderly patients.