Purulent pericarditis

Background  Bacterial pericarditis has become a clinical rarity since the onset of antimicrobial therapy, yet remains fatal in a large majority of cases. Aim  We present the case of a 57-year-old male, admitted with a short history of pleuritic chest pain and dyspnoea. Investigations led to diagnosis of pyopericardium, most likely secondary to fistulating thoracic malignancy. Despite maximum medical treatment this condition proved fatal. Conclusion  This case highlights the still unfortunately poor prognosis of purulent pericarditis in the antibiotic era. Underlying aetiological factors should be searched for and eliminated where possible when a diagnosis of purulent pericarditis is made     

Solitary neurofibroma of the pancreas body not associated with type 1 neurofibromatosis

Neurofibromas arise from peripheral nerve cells. They are rarely found within the pancreas, especially not associated with type I neurofibromatosis. Here, we report a case of a neurofibroma in a 44-year-old woman who initially presented with epigastralgia. Imaging revealed one large cystic mass of 5.7 × 8 × 5.8 cm in the pancreatic body, which was resected with distal pancreatectomy. The postoperative course of treatment was without complication, and no signs of recurrence were observed after 1 year and 6 months’ follow-up.     

Endoscopically assisted minimally invasive surgery for gallstones

Background  We present a case report of Bouveret syndrome followed by a review of the recent literature regarding the management of this condition. Bouveret syndrome is a form of gastric outlet obstruction secondary to a gallstone which has eroded through the gallbladder into the duodenum. It is an uncommon variant of gallstone ileus. Endoscopic methods have been described to extract the stone from the duodenum. Methods   This is a case of an 85-year-old female patient who presented with a 1-week history of nausea, intermittent bilious vomiting and anorexia. Imaging confirmed the diagnosis of Bouveret syndrome caused by two large gallstones. Conventional endoscopic methods successfully extracted the impacted stones from the duodenum into the stomach but were unable to extract the stones from the stomach. A mini-transverse laparotomy and gastrotomy were performed to finally extract the stones.     

Malignant solitary fibrous tumor of the urinary bladder

A 67-year-old man was examined for persistent pain over his lower abdomen and was found to have a large pelvic tumor. During surgery, we detected a 16 × 9 × 9 cm³ urinary bladder tumor with small intestinal adhesions, and performed partial cystectomy and segmental resection. Histological and immunohistochemical examinations established the diagnosis of malignant solitary fibrous tumor (SFT). Only 10 cases of urinary bladder SFT have been reported in the English literature; our patient is the second one with malignancy and had a longer follow-up period than the other case.     

Two case reports of pneumomediastinum

Background  We present two cases of pneumomediastinum in patients who presented to the accident and emergency department of a large teaching hospital. One case had a history of inhalational drug abuse, which may have contributed to the event, while the other had no obvious precipitating factors. Aims  To evaluate the presenting symptoms, physical signs, diagnosis and management of pneumomediastinum with a review of the literature. Methods  We describe two cases of pneumomediastinum with a literature review. Conclusions  Pneumomediastinum is an uncommon entity, first described almost 400 years ago. It presents with relatively non-specific symptoms and signs and will require radiological investigations to clarify the diagnosis. Treatment is conservative but will require close observation for the development of complications and occult visceral perforation. Complete resolution can be expected.     

Persistent exudative retinal detachment after photodynamic therapy and intravitreal bevacizumab injection for multiple retinal capillary hemangiomas in a patient with von Hippel–Lindau disease

Photodynamic therapy (PDT) has been used in treating peripheral retinal capillary hemangioma (RCH) with satisfactory results. We report a rare case of von Hippel-Lindau (VHL) disease with three large peripheral RCHs, treated with PDT and intravitreal bevacizumab injection (IVB), who developed persistent bullous exudative retinal detachment (RD) despite significant tumor regression. The patient is a sporadic case of VHL disease, with a de novo nonsense mutation in codon 161 with C → T transition at nucleotide position 694 of the VHL gene. Multiple RCHs were noted in both eyes. Four small RCHs were found in the left eye and were treated with laser photocoagulation. Three large RCHs in the peripheral retina of the right eye were complicated with cystoid macular edema and subretinal fluid accumulation. The RCHs were treated with PDT combined with IVB, and bullous exudative RD developed on the second day after treatment. Three months after PDT, the tumors had regressed significantly, but exudative RD persisted, despite multiple IVB and intravitreal triamcinolone acetonide injection (IVTA). External drainage with sclera buckling, IVB, and IVTA were performed, and the retina attached after surgical intervention. The application of PDT in the treatment of RCHs and its possible complications are discussed.     

Day case shoulder surgery: satisfactory pain control without regional anaesthesia. A prospective analysis of a perioperative protocol

Background  Pain control is an issue which may limit patients’ acceptance of day case shoulder surgery. This study prospectively examined the outcome of a protocol for day case shoulder surgery to determine if satisfactory pain relief could be achieved without regional anaesthesia. Methods  Patients attended for pre-assessment and were informed about the procedure and day case protocol. Anaesthesia used was either a regional anaesthetic block or subacromial bursal block. Patients were discharged with a standard pain pack. All 117 operations were performed arthroscopically. Patients were contacted 24 h following surgery by an independent observer. Results  Based on 90 completed surveys, all patients were satisfied. Pain was well controlled in 85% of patients but 50% of the remaining patients did not take the prescribed pain pack. Problems other than pain were seen in only 4% of patients. No patients required overnight admission. Conclusion  Our study indicates a very high level of patient satisfaction and good pain relief without the use of regional anaesthesia for patients undergoing shoulder surgery as a day case.     

Adverse reaction to Bacille-Calmette-Guérin vaccine in a HIV positive healthcare worker

Background  The Bacille-Calmette-Guérin (BCG) vaccine is used in Mycobacterium tuberculosis prophylaxis in at risk tuberculin-negative healthcare workers. Its use is contraindicated however in individuals with HIV infection. Aims  We herein highlight the case of a healthcare worker who developed a localised reaction at a BCG vaccination site and who was subsequently found to be HIV positive. Conclusion  This case emphasises the importance of eliciting risk factors for immunocompromise in individuals for whom BCG vaccination is being considered.     

Perforated retrocaecal appendix presenting as right lumbar abscess

Background  Acute appendicitis is common in older patients, however, the presentation may differ from the younger population and it is often complicated by coexistent disease and delays in presentation. Aims  This case report describes an unusual presentation of acute appendicitis in an elderly patient and also demonstrates a unique anatomical pathway of disease extension. In addition, this case report highlights the advantages of CT in preoperative evaluation and subsequent management of these protean presentations of acute appendicitis. Methods  This report describes a case of an asymptomatic retrocaecal perforated appendicitis which presented clinically as a right lumbar abscess with surrounding cellulitis, and was further complicated by a concomitant new diagnosis of type 2 diabetes mellitus in a 66-year-old male. Conclusion  Elderly or immunocompromised patients presenting with cellulitis or a cutaneous abscess of the abdominal wall or lumbar region may benefit from an abdominal CT to demonstrate an intraperitoneal source of sepsis.     

Murder,mercury, mental illness: infanticide in nineteenth-century Ireland

Background  Infanticide has been described in almost every human society. Aims  To present a case of infanticide from nineteenth-century Ireland and explore related diagnostic, therapeutic and judicial issues. Methods  This paper uses original archival material from the Central Mental Hospital, Dublin to present a case of infanticide and inform an exploration of related issues. Results  In 1892, ‘Dora’, a thirty-four year old servant from Dublin, was found guilty of the murder of her eight-month old child and sentenced to indefinite detention at the Central Mental Hospital, Ireland’s only inpatient forensic psychiatry facility. The subsequent experiences of Dora (“a case of melancholia”) illustrate many of the diagnostic, therapeutic and judicial issues surrounding infanticide in nineteenth-century Ireland. Conclusions  There were strong links between social circumstances and infanticide in nineteenth-century Ireland, compounded by myriad diagnostic and therapeutic challenges associated with forensic psychiatric committal and lengthy detention in poorly-therapeutic facilities .     

A rare case of arterial thrombosis in a 37-year-old male with Factor V Leiden mutation

Background  The classic triad of symptoms seen in chronic mesenteric ischaemia is post-prandial pain, sitophobia (fear of food) and progressive weight loss. Patients with mesenteric ischaemia secondary to a prothrombotic state such as that rendered by the Factor V Leiden mutation, are substantially younger than the typical elderly patient in whom embolic disease triggered by atrial fibrillation is the main underlying cause. Method  This is one such case report documenting arterial thrombosis in a 37-year-old male with a subsequently identified heterozygous Factor V Leiden mutation. Conclusion  Factor V Leiden mutation is a contributing risk factor in cases of small bowel infarction. The subject matter of this case report was presented at the Royal College of Surgeons in Ireland Charter Day Meeting in February 2007 winning the inaugural national intercollegiate case presentation competition and the Professor Bouchier-Hayes medal on that occasion.     

Propylthiouracil induced C-ANCA positive agranulocytosis complicating Graves’ thyrotoxicosis in pregnancy

Background  Thionamide induced agranulocytosis is associated with the presence of anti-neutrophil cytoplasmic antibodies (ANCA) in some patients. This poses a particular challenge when it occurs during pregnancy. Aims  To report a case of a 31-year-old woman with Graves’ disease who presented at 11 weeks gestation with propylthiouracil induced agranulocytosis. Methods  After cessation of propylthiouracil the patient developed recurrent thyrotoxicosis, and underwent an elective subtotal thyroidectomy at 23 weeks gestation. Results  The patient required postoperative thyroxine replacement therapy. Subsequent pregnancy was uneventful and she delivered a healthy baby boy at 41  weeks gestation. As part of our routine work up for agranulocytosis we measured C-ANCA levels, which were significantly elevated. Conclusion  This case highlights the association of propylthiouracil induced ANCA positivity and agranulocytosis. Second trimester subtotal thyroidectomy was safe and effective in treating this pregnant patient’s thyrotoxicosis.     

Artificial hydroureteronephrosis to facilitate MR urography during pregnancy

Introduction  Insertion of a percutaneous nephrostomy (PCN) catheter decompresses the upper urinary tract, thereby removing the hydroureteronephrosis upon which magnetic resonance (MR) urography is dependent for diagnosing the precise level and cause of ureteric obstruction. Method  We present the case of a young woman who required PCN insertion during pregnancy. Result  Only when unenhanced T2-weighted MR urography was repeated after the creation of an artificial hydronephrosis by an injection of sterile saline via the PCN catheter was the diagnosis of stone in the mid-ureter later made possible. Conclusion  This case highlights an easy solution to a limitation with the use of MR urography during pregnancy, when a physiological hydroureteronephrosis has been relieved by the insertion of a PCN catheter.     

交锁髓内钉治疗尺桡骨骨折的回顾性疗效分析

目的 探讨应用交锁髓内钉治疗尺桡骨骨折的疗效.方法 对11例尺桡骨骨折患者进行闭合复位或有限切开复位、Smith-Nephew髓内钉内固定.结果 随访8～32周,骨折愈合在8～20周,平均12.7周.1例延迟愈合.无骨折不愈合或感染发生.根据Anderson评分标准,优7例,良3例,可1例,优良率达90.9%.结论 交...     

A case of dapsone induced methaemoglobinaemia

Background  We present a case of dapsone induced methaemoglobinaemia that occurred in a patient who presented to the Emergency Department of a University Hospital. It is an uncommon condition that requires specific and urgent treatment in severe cases. Aims  To describe and evaluate the presenting symptoms, signs, diagnosis and management of acquired methaemoglobinaemia. Methods  We describe a case of acquired methaemoglobinaemia as a result of dapsone ingestion with a literature review. Conclusions  Acquired methaemoglobinaemia is an uncommon condition that presents with non-specific signs and symptoms. It is caused by a variety of exogenous agents and results in a “saturation gap” between oxygen saturation on pulse oximetery and arterial blood gas analysis. Specific treatment with intravenous methylene blue is the treatment of choice. Full resolution can be expected with treatment but severe cases can be associated with shock and mortality.     

Carcinosarcoma of the penis

Background  Carcinosarcoma of the penis is extremely rare and little is known about its biological behaviour. Aims  We report the second such case and discuss its histological categorisation and biological behaviour. Methods  A total penectomy with perineal urethrostomy was performed without lymphadenectomy in an 83-year old presenting with a fungating penile mass. Results  Microscopy of the gross specimen showed a biphasic tumour with both squamous and spindle cell elements. Immunohistochemical staining for epithelial markers showed positivity in the squamous cell elements but was uniformly negative in the spindle component. Immunohistochemistry of the spindle cell element demonstrated mesenchymal markers. The patient refused further treatment and follow up but presented at 26 months with inguinal lymphadenopathy. Biopsy confirmed squamous cell carcinoma metastasis consistent with penile origin. The patient refused further surgery and received pelvic irradiation. He died 6 months later. Conclusions  This case illustrates the biological behaviour of this rare tumour.     

Superior orbital fissure syndrome in herpes zoster ophthalmicus

Aim  To report a case of superior orbital fissure syndrome (SOFS) in a patient with herpes zoster ophthalmicus (HZO). Materials and methods  A case report. Results  A 71-year-old male with HZO presented acutely to accident and emergency complaining of right vision loss, double vision and drowsiness. The right visual acuity was counting fingers. There was no relative afferent pupillary defect. He had interstitial keratitis, ptosis, proptosis and total ophthalmoplaegia. The signs indicated HZO complicated by SOFS. Brain imaging and lumbar puncture confirmed the diagnosis of varicella zoster encephalitis. Systemic acyclovir and prednisolone led to recovery of visual acuity and ocular motility in addition to resolution of his proptosis and ptosis. Conclusion  SOFS is a rare complication of herpes zoster infection. With the appropriate treatment and follow-up, patients may be reassured that recovery of their visual acuity and ocular motility will occur.     

Hepatic lymphangioma: a rare cause of abdominal pain in a 30-year-old female

Background  Lymphangiomas are rare tumours usually found in the paediatric population in extra abdominal sites. Aim  To report on a patient with a hepatic lymphangioma. Result  A 30-year-old woman presented with a 4-year history of right upper quadrant pain. Ultrasound and CT imaging demonstrated a cystic mass adjacent to the gallbladder. Histology of the resected specimen conferred a diagnosis of hepatic lymphangioma. Conclusion  We present a case of hepatic lymphangioma together with a review of diagnostic and therapeutic strategies currently available.     

ACTH-secreting bronchial carcinoid: a diagnostic and therapeutic challenge

Objective  We describe a case of Cushing’s syndrome due to ectopic ACTH secretion, where the only potential source on conventional imaging was a tiny benign-appearing lung nodule, which failed to take up radiolabelled octreotide. Design and methods  To determine whether the patient might respond to therapeutic administration of octreotide, a test dose was given. Results  Compared to ACTH and cortisol levels on a control day, the levels following the test dose of octreotide were lower. Subsequent therapeutic administration of subcutaneous octreotide normalised urine free cortisol, with symptomatic improvement, pending evaluation for surgery. Eventual resection of the lung nodule resulted in cure of hypercortisolism. Histological examination of the resected specimen confirmed bronchial carcinoid staining positive for ACTH. Conclusions  This is one of the few cases described where ectopic ACTH secretion secondary to bronchial carcinoid responded to somatostatin analogue therapy. The case was also unusual in that the tumour responded despite not taking up radiolabelled octreotide.