bluuebunny/crossref_metadata_2025_split huggingface dataset:
Chylous ascites: an unusual case
Authors: Manikpure Gaurav , Hamlin Peter J , Tolan Damian , Edward Sara , Prescott Stephen 
Published: May 2014

A 70-year-old man presented with 6 weeks' history of increasing abdominal distension and shortness of breath. He was completely independent before this admission. Relevant past medical history included a recent normal colonoscopy for altered bowel habit. Although abstinent for 1 year, his alcohol consumption had been up to 100 units/week for over 50 years. He was on no medications and had never smoked. Clinical examination revealed massive ascites. Bloods on admission showed a normal platelet count, mild anaemia, haemoglobin 11.4 g/dl and mild renal impairment, urea 10.4 mmol/litre and creatinine 140 umol/litre. Liver function tests and a full liver screen including hepatitis virus B and C, autoantibodies, alfa-fetoprotein and ferritin were normal. Ultrasound of the abdomen showed a nodular liver suggesting cirrhosis with widespread ascites. Chest X-ray was normal. Ascitic fluid aspiration revealed milky white ascitic fluid with a very high triglyceride content of 17.4 mmol/litre (normal <2.2 mmol/litre) in keeping with chylous ascites and negative for microbiology including acid-fast bacilli. The ascites did not respond to diuretic therapy. He suffered a sudden respiratory arrest and was resuscitated and transferred to the high dependency unit. Therapeutic abdominal paracentesis was performed, draining 5 litres of chylous fluid. Urgent computed tomography of the chest, abdomen and pelvis showed a right pulmonary artery embolus and bilateral femoral vein thrombosis. Bony metastases were also identified throughout the axial skeleton, with para-aortic lymphadenopathy and a large nodal mass in the small bowel mesentery (Figure 1). The radiological differential included prostate cancer and lymphoma. Prostate-specific antigen was elevated at 1611 ug/litre (normal < 5 ug/litre) and subsequent computed tomography-guided biopsy of the mesenteric mass revealed fibro-fatty connective tissue infiltrated by tumour cells with immunohistochemistry positive for prostate-specific antigen, consistent with extensive metastatic prostate cancer with nodal and bony metastases (Figure 2). Hormonal treatment with leuprorelin acetate and bicalutamide was started on transfer to urology but unfortunately his clinical condition deteriorated, and he died 2 months later.
Cerebral venous sinus thrombosis: a diagnosis not to be missed
Authors: Imtiaz Komal E , Rajpara Sanjay , Majeed Tahir 
Published: May 2014

A 47-year-old woman was admitted with a severe headache of 5 days' duration, vomiting and collapse with transient loss of consciousness in December 2002. She had been taking black cohosh, a herbal preparation containing plant oestrogen for menopausal symptoms, for 2 years. Her father had a history of pulmonary embolism and her sister had systemic lupus erythematosus. Clinical examination was normal except for slight neck stiffness and photophobia. Brain computed tomography was normal and lumbar puncture revealed normal CSF; CSF pressure was not recorded. Her symptoms improved slowly and she was discharged home with an appointment with the neurologist arranged as an outpatient. Five days post-discharge from the hospital, she was readmitted because of the persisting headache and was found to have papilloedema on neurological examination. Chest X-ray, full blood count, erythrocyte sedimentation rate, clotting screen, urea and electrolytes, liver function tests, serum glucose, immunoglobulins, complement and autoantibody screening were normal or negative. Magnetic resonance imaging and venogram showed deep venous thrombosis in the superior sagittal sinus (Figure 1). She was anticoagulated with heparin followed by warfarin. Her headaches settled and she was discharged home 8 days later. Further investigations confirmed heterozygosity for the prothrombin gene variant (G20210A). She continued to describe ‘pressure headaches’ with tinnitus. Repeat brain magnetic resonance imaging and venogram was normal in 2004. Her headaches recurred and the diagnosis of secondary intracranial hypertension was made and acetazolamide and bendrofluazide were commenced. Further magnetic resonance imaging of the brain with venogram in September 2007 revealed a hypoplastic left transverse sinus and patent superior sagittal sinus. She was referred to the neurosurgeons and had a lumbo-thecal peritoneal shunt insertion in November 2007 with improvement in her symptoms, despite a small frontal subdural collection on brain computed tomography postoperatively, which had resolved on repeat magnetic resonance imaging in March 2008. She is regularly followed up in the neurology and ophthalmology clinics for residual bilateral papilloedema and left amblyopia and continues on ramipril, bendrofluazide and warfarin.
Thyrotoxicosis and abdominal pain: atypical presentation in a middle-aged man
Authors: Bhattacharyya A , Tymms DJ 
Published: May 2014

A45-year-old man was referred to the surgical assessment unit by his GP with a 1-week history of vomiting and severe abdominal pain. Marked tenderness was noted in the epigastrium and umbilical region. He was dehydrated with blood pressure 100/70 mmHg and pulse of 110/min. The rest of the initial examination was normal. Abdominal and chest X-ray, electrocardiogram, routine blood tests, including full blood count, liver and kidney functions, cardiac enzymes and serum amylase were normal as were the ultrasound scan of the abdomen and endoscopy of stomach and duodenum. Serum calcium was very high at 3.11 mmol/litre (normal 2.10–2.60) with a normal serum phosphate level. Treatment with normal saline, frusemide and pamidronate (three daily doses of 30 mg each) reduced the serum calcium to 2.94 mmol/litre with little symptomatic improvement. He also had tremor and a small goitre when thyrotoxicosis was suspected and confirmed (free thyroxine 57.5, normal 9–24 pmol/litre; triiodothyronine 8.9, normal 0.8–2.7 nmol/litre; and undetectable thyroid- stimulating hormone, normal 0.4–4 mu/litre). Serum parathyroid hormone subsequently was reported as low (<5, normal 12–81pg/ml). He was treated with carbimazole 40 mg daily with remarkable improvement. Subsequently alternative causes of hypercalcaemia were excluded by a normal serum and urine electrophoresis, and bone scan. Serum calcium returned to normal in 3 weeks time. He received radioactive iodine, and became hypothyroid 5 months later. He had done well on follow-up with 75 μg thyroxine daily and serum calcium remained normal.
An unusual cause of iron deficiency anaemia in an intravenous drug user
Authors: Younis N , Casson IF 
Published: May 2014

A40-year-old intravenous drug user was admitted to the department of medicine with a painful swollen left leg. He freely admitted to injecting heroin (diamorphine) intravenously and had recently injected into his left leg. He had a 10-year history of illicit drug use and had previously attempted to stop with the use of methadone. There was no history of hepatitis, human immunodeficiency virus (HIV) infection or the sharing of syringes used for injection. Clinical examination revealed a thin, unkempt, middle-aged gentleman, who had pallor of the skin and the mucous membranes. He had evidence of drug ‘tramline’ marks, venous thrombophlebitis in his groins and both upper and lower limbs (Figure 1). There was no evidence of lymphadenopathy or signs of endocarditis. Chest and abdominal examination revealed no abnormalities. He had evidence of swelling, erythema and tenderness in the anterior lower left leg and there was no calf tenderness. The signs in his leg were consistent with cellulitis. Initial investigations revealed a severe hypochromic microcytic anaemia, a haemoglobin level of 4.3 g/dl with low serum iron, low ferritin and raised iron binding capacity consistent with iron deficiency anaemia. Electrolytes, liver function tests and clotting were normal. He was transfused four units of red packed cells and treated with intravenous antibiotics. He denied any history of maleana, haematemesis, rectal bleeding or haematuria. He denied usage of non-steroidal inflammatory drugs or aspirin. A Doppler ultrasound of his leg revealed no evidence of thrombus. A chest X-ray revealed no abnormalities. A transoesophageal echocardiogram showed no evidence of endocarditis. Tests for HIV, hepatitis B or C revealed no abnormalities. A gastroscopy revealed no abnormality and duodenal biopsies revealed no evidence of coeliac disease. Colonoscopy revealed no abnormality. Red cell isotope scanning using 51-chromium-labelled red cells and mesenteric angiography revealed no cause for blood loss. Repeated samples of urine revealed no red blood cells. He eventually admitted to injection with syringes into his groin, often hitting his femoral artery rather than the femoral vein, with concomitant loss of arterial blood on multiple occasions. We assumed that this was the most likely cause of his iron deficiency anaemia.
Quadruple primary neoplasms in a 27-year-old woman
Authors: Wai HPS , Yau TK , Sze WM , Yeung MW , Lee AWM 
Published: May 2014

A27-year-old woman was referred to our department on 3 February 1998 with a diagnosis of malignant melanoma associated with cystic teratoma of ovary. She had had a laparotomy and bilateral salphingo-oophorectomy on 5 January 1998. Pathology revealed tumour involvement of left ovary, left parametrium and malignant ascites, the right ovary showed polycystic disease, the uterus showed simple hyperplasia of endothelium, the omentum had no tumour and subdiaphragmatic scrapping was negative. On histological examination of the tumour, the cystic portion was basically a cystic teratoma with presence of skin, glial and bony tissue, the solid portion consisted of sheets of undifferentiated tumour cells, which on immunohistochemical staining shown strong positivity to HMB 45 and S-100. Ultrastructual examination confirmed melanocytic differentiation. Her chest X-ray was clear. Computed tomography of abdomen and pelvis suggested bilobar liver metastasis and significant para-aortic lymphadenopathy. The alpha-fetoprotein (αFP) and beta-human chorionic gonadotrophin (β-hCG) were within normal limits. The diagnosis was a malignant melanoma arising in cystic teratoma of ovary, stage IV disease. Her past medical history included multiple primary neoplasms. She had right thigh cutaneous histiocytoma at the age of 20 years, with complete excision performed. She developed poorly differentiated invasive ductal carcinoma of left breast (stage pT2N0M0) at the age of 21 years and had a left mastectomy and left axillary clearance; no postoperative adjuvant treatment was given. She also recently had multiple thyroid nodules which shown atypical cells, suggestive of a follicular neoplasm, and total thyroidectomy was contemplated. Evaluation of her family revealed a strong family history of malignancy. Her twin sister died of a primary brain tumour at the age of 8 years. Her father died of lung cancer at the age of 45 years. Her paternal grandfather died of lung cancer in his 60s. Her paternal grandmother died of primary liver cancer in her 60s. One of her paternal half-uncles (mutual grandfather, different grandmothers) died of a primary brain tumour in his 50s while another died of lung cancer in his 70s. There was no positive family history of malignancy on her maternal side (Figure 1). She was treated with combination chemotherapy using cisplatin (75 mg/m2) and cyclophosphamide (750 mg/m2). However, she deteriorated rapidly after the first cycle of chemotherapy and died on 16 March 1998.
A pain in the neck: dissection of the vertebral artery
Authors: Scott Glyn , Jack Catherine 
Published: May 2014

A49-year-old male model developed an acute severe occipital headache and neck stiffness following a day spent striking dynamic poses for a modelling assignment, during which he had been required to hold his head in several awkward positions for protracted periods of time. In the subsequent 24 hours he developed slurred speech, poor balance and a persistent pain in the neck. On presentation to hospital he was dysarthric and ataxic of gait, and had upper limb weakness, finger nose ataxia, an upper motor neurone facial nerve palsy and an extensor plantar response. Magnetic resonance imaging of the brain showed a 2 cm × 1 cm infarction in the left pons extending to the midbrain (Figure 1). The patient was commenced on aspirin and by 8 weeks his neurological symptoms had completely resolved.
Pseudoangiomatous hyperplasia of mammary stroma: an unusual entity
Authors: Lawrentschuk Nathan , Scott Alan R , Archer Richard , Clark Don 
Published: May 2014

A74-year-old woman was noted to have a lesion in her right breast. It was painless and had been present for an unknown period. There were no other associated symptoms. A clinically large, firm, non-tender mass (3×4 cm) was felt in the upper outer quadrant of the right breast. There was minimal adherence to overlying tissue. On further examination, no evidence of metastatic disease was found. There was no past history of breast disease. Mammography demonstrated a well-circumscribed soft tissue mass (40 mm) without associated microcalcification or conspicuous regions of fat density (Figure 1). Ultrasound demonstrated an ellipsoid, lobular, solid mass of variable parenchymal reflectivity (Figure 1). No cystic component was identified. The mass was predominantly hyperreflective compared with adjacent parenchyma, with a few regions casting acoustic shadowing. Colour Doppler energy imaging demonstrated prominent abnormal vessels within the mass. Based on the clinical findings a provisional diagnosis of a carcinoma was made. In view of the hyperreflectivity, vascularity, and relatively small amount of acoustic shadowing, a differential diagnosis of hamartoma, phylloides tumour or sarcoma was offered. Under ultrasound guidance, core biopsy was undertaken. A diagnosis of pseudoangiomatous hyperplasia of mammary stroma (PASH) was made, although angiocarcinoma could not be excluded. The mass was then surgically excised. The tumour was of a rubbery texture and was shelled out from the surrounding stroma with ease. It had a capsule and was solid throughout (Figure 2). Further histology confirmed the core biopsy diagnosis of PASH (Figure 3). This was supported by immunohistochemistry. The patient recovered without incident.
Squamous cell carcinoma of the nasal vestibule presenting as chronic vestibulitis
Authors: Badran Khaled , Rapado Fernando , Simo Ricard , Carpentier John de 
Published: May 2014

A 62-year-old male smoker was referred to the department of otorhinolaryngology in January 1998. He described a 6-year history of intermittent soreness and scabbing of the right nostril, which was treated with topical antibiotics on three occasions in the same department. Previous medical history included several dermatology visits in 1994, during which the diagnosis of psoriasis and recurrent nasal furunculosis had been made. No history of irradiation to the face was present. Examination revealed a 1 × 1 cm area of ulceration on the lateral aspect of the right nasal vestibule (Figure 1) in a superimposed picture of chronic rhinitis. Examination of the throat, ear, larynx and neck revealed no other abnormality. Haematological, biochemical and chest radiology assessments were all normal. Microbiology studies of the area did not grow any organisms. Biopsy and frozen section analysis revealed a superficially invasive squamous cell carcinoma arising in an area of carcinoma in situ. Subsequent excision biopsy of the affected area with wide margins (Figure 2) revealed no evidence of residual carcinoma. The patient remains well and disease free 5 years later.
Leiomyoma of the nasal cavity: case report and literature review
Authors: Kumar S , Taylor W , Swift AC 
Published: May 2014

A 73-year-old man presented with a history of left nasal obstruction and mucosal discharge from the nose for several years. Nasal endoscopy showed a smooth red polyp in the left nasal cavity (Figure 1). A computed tomography scan showed the lesion was present in the left nasal cavity and the paranasal sinuses were clear (Figure 2). The polyp arose from the left sphenoethmoidal recess and was removed endoscopically. The patient has been followed up for 6 months with no evidence of recurrence. Macroscopically the tumour consisted of a polypoid mucosal-covered mass measuring 4 × 2.5 × 1.5 cm. The consistency was firm and the cut surface was homogeneous grey-white. Microscopically the lesion comprised interweaving bundles of spindle-shaped cells with ovoid nuclei, mild nuclear pleomorphism and eosinophilic cytoplasm (Figures 3 and 4). There was a variable amount of oedematous and fibrous stroma. There was no mitosis or necrosis. Immunocytochemical labelling showed patchy smooth muscle actin, mainly towards the periphery of the tumour and patchy central labelling for S-100 protein, but was negative for caldesmin, CD34, desmin, epithelioid membrane antigen and cytokeratin. The differential diagnosis included benign leiomyoma, benign nerve sheath tumour, solitary fibrous tumour and haemangiopericytoma. The lesion was considered to be a leiomyoma.
Ocular symptoms and signs as presenting features of endocarditis caused by Streptococcus bovis II
Authors: Menezo Victor , Lightman Susan , Yeo Tun Kuan , Liyanage Sidath , Lynn William A 
Published: May 2014

A previously healthy 76-year-old man was referred to the uveitis clinic at Moorfields Eye Hospital with a 2-month history of bilateral painless blurred vision and floaters. He had undergone intraocular surgery on his left eye a long time ago after trauma to remove a cataract. He also complained of generalized arthralgia, night sweats and headache. On examination, both eyes had a visual acuity of 6/6 and normal pupillary reactions. Slitlamp biomicroscopy showed no evidence of anterior uveitis. Funduscopy revealed few inflammatory cells in the vitreous and multifocal yellow subretinal lesions in both eyes, with a retinal haemorrhage in the right eye but no cotton wool spots or exudates and normal retinal vasculature (Figure 1). Uveitis masquerade syndrome was considered and investigations to detect lymphoma were initiated. Full blood cell count revealed normocytic anaemia with mild neutrophilia and an erythrocyte sedimentation rate of 105 mm/h. The blood film showed mild toxic granulation in some neutrophils. Renal and liver function and chest X-ray (CXR) were normal. Computed tomography (CT) scan of the brain and orbits showed no abnormality. Shortly after, his vision decreased to 1/60 in the left eye with associated increased vitritis, retinal exudates and peripheral retinal haemorrhages. The patient was systemically well, admitting no further constitutional symptoms. On examination no lymphadenopathy or abdominal masses were detected. CXR and further blood investigations including immunoglobulin screen and tumour markers were normal. A left vitreous biopsy showed predominantly chronic inflammation with a lymphohistiocytic infiltrate but no specific features of intraocular lymphoma. Since it was not possible to completely exclude lymphoma, further systemic work up was suggested. Three months after the initial presentation the patient developed lassitude, anorexia, breathlessness on exertion and progressive peripheral oedema. A repeat CXR and abdominal ultrasound showed bilateral pleural effusions and splenomegaly respectively. A new diastolic murmur was detected and infective endocarditis was considered. Echocardiography showed severe aortic regurgitation resulting from a large vegetation with depressed left ventricular function (Figure 2). Blood cultures isolated Streptococcus bovis type II sensitive to penicillin and glycopeptides. He became haemodynamically unstable despite intravenous antibiotic therapy and an urgent aortic valve replacement was undertaken. Following a 1-month course of antibiotic therapy his constitutional symptoms resolved, blood tests returned to normal and his vision improved to 6/6. Fundoscopy revealed few left vitreous debris but no signs of active inflammation or subretinal lesions. A colonoscopy to rule out associated gastrointestinal malignancy was performed and showed no abnormality.
Chest wall tuberculosis involving the second rib in a young Ethiopian woman
Authors: Ansari Aneel , Smith Michael A 
Published: May 2014

A 20-year-old Ethiopian woman presented to the orthopaedic clinic with a 6-week history of a painful mass on the anterior aspect of her chest wall above the left breast. It appeared suddenly and increased in size. There was a history of anorexia and weight loss but no cough, haemoptysis, night sweats nor fever. There was no past medical history or family history. She had been resident in the UK for 2 years. On examination the patient appeared well. She was apyrexial with a normal pulse rate and blood pressure. There was a 6 cm × 4 cm swelling on the anterior chest wall at the level of the first and second ribs. It was firm, warm and tender. It was fixed deeply; the overlying skin was normal although it was hot. There was no associated lymphadenopathy. She had a mild hypochromic microcytic anaemia, normal white cell count and differential but the erythrocyte sedimentation rate was elevated to 54 mm/hr and C-reactive protein was 27 mg/litre. Her chest X-ray was reported as normal. Ultrasound showed an echo-poor septated area within which there were echogenic areas. In addition, there was destruction of the anterior quarter of the first rib with erosion of the superior border of the second rib. A computed tomography scan revealed a soft tissue mass with associated rib involvement (Figure 1). In addition, there was a subcarinal calcified lymph node but there was no parenchymal pathology. In view of the rapid progression, she was admitted for urgent biopsy. Following incisional biopsy, tissue was taken for histopathology and microbiology. Histology confirmed the diagnosis of tuberculosis. Culture grew a light growth of Mycobacterium tuberculosis that was sensitive. She was commenced on quadruple therapy. At 6-month follow up, symptoms had settled, the swelling had subsided and her inflammatory markers were all normal.
Perimetry and imaging in glaucoma diagnosis: a pilot study
Authors: Landstedt Gunilla 
Published: May 2014

Aim: To compare the findings from Humphrey Matrix and Rarebit (RB) perimetry in relation to the results from Heidelberg confocal laser scanning retina tomography (HRT II). Material: Data from 22 eyes (12 subjects, age 51–75 years) with known or suspected glaucoma were analyzed. Methods: The central 30° visual field was examined with two perimetric techniques; Humphrey Matrix, using frequency doubling technology, and the RB test, relying on the detection of very small bright dots on a dark background. In addition, all subjects underwent laser scanning tomography of the optic nerve head. Results: There was no significant difference regarding the number of normal/abnormal findings between Humphrey Matrix and RB perimetry (9/22 and 8/22, respectively). Abnormal glaucoma index from the HRT II was observed in 5/22 eyes. In four of these, both Humphrey Matrix and RB perimetry were abnormal. In one eye both with abnormal HRTII, both perimetric tests were normal. Conclusion: This pilot study indicates that the studied perimetric methods appear to give equivalent results in glaucoma, despite the considerable difference in test principles.