bluuebunny/crossref_metadata_2025_split huggingface dataset:
Thyroid storm treated with intravenous methimazole in patients with gastrointestinal dysfunction
Authors: Thomas DJB , Hardy J , Sarwar R , Banner NR , Mumani S , Lemon K , Hillson RM 
Published: May 2014

A 27-year-old man, who had type 1 diabetes, presented with agitation, confusion, vomiting and faecal incontinence. There was an abscess on his right upper arm at an insulin injection site (temperature 38.5°C, pulse 140 per minute, and blood pressure 125/85 mmHg). Investigations included neutrophil count 13.6 ×109/litre, glucose 26 mmol/litre, pH 7.4, free thyroxine (T4)>77 pmol/litre (normal range (NR) 9–22.7), thyroid-stimulating hormone (TSH) <0.01 mu/litre (NR 0.35–5). After sedation with haloperidol 15 mg intramuscularly, he was rehydrated with physiological saline and treated with intravenous (IV) cefotaxime 3 g three times daily, IV dexamethazone 2 mg twice daily, IV methimazole 15 mg two doses 8 hours apart (Favistan injection solution, Temmler Pharma, Marburg, Germany), labetolol 120 mg (infused over 1 hour twice daily), and an insulin infusion using up to 4 u/hour. After 24 hours there was a marked clinical improvement with resolution of his agitation and confusion and his pulse rate was normal (T4 22 pmol/litre, TSH <0.05 mU/litre after 72 hours). He was discharged on carbimazole 60 mg daily and propranolol 20 mg four times daily, and had radio-iodine treatment (339 MBq) 6 months later. He is well on thyroxine 50 μg daily 2 years later.
‘Just a sharp scratch’: permanent radial, median and ulnar neuropathy following diagnostic venepuncture
Authors: Dawson Joe , Christie Martin 
Published: May 2014

An 82-year-old woman was admitted to hospital with acute left ventricular failure following a recent myocardial infarction for which she had been commenced on clopidogrel. An uneventful venepuncture in her left antecubital fossa yielded a normal full blood count and coagulation profile. Diuretics were commenced to which she responded well. Five days later she described pain, swelling and bruising of her left forearm with numbness over her thumb, index and middle fingers. Prophylactic low molecular weight heparin was discontinued and the arm elevated. Nine days later she was unable to move her left hand. Bruising extended from the shoulder to the hand with swelling distal to the antecubital fossa (Figures 1 and 2). Woody subcutaneous oedema was present around the antecubital fossa with forearm tenderness. The radial pulse was present with good capillary circulation in all fingers. Neurological examination revealed complete wrist drop, minimal finger flexion and no small muscle function of the hand. The dorsal aspect of the forearm and hand were hypersensitive, with numbness over the volar aspect of the thumb, index and middle fingers. These findings were consistent with an ischaemic neuropathy of the median, radial and ulnar nerves as a result of compartment syndrome, secondary to a compressive haematoma at the antecubital fossa following venepuncture. Surgery to relieve compartment pressures at this stage was thought to provide little chance of recovery, with the additional risk of supervening infection. Initial treatment was therefore conservative consisting of physiotherapy, vitamin B and gabapentine. An ultrasound scan confirmed the presence of a haematoma occupying the entire flexor compartment of the forearm. Nerve conduction studies revealed completely absent sensory potentials, with motor potentials 1%, 30% and 60% of normal in the radial, median and ulnar nerves respectively. This confirmed a severe subtotal axonotmesis of the radial nerve with partial axonal injury to the median and ulnar nerves. The prognosis was one of permanent major neurological deficit and despite intensive hand physiotherapy there was little functional recovery 1 year later.
Unusually positioned abscesses of the head and neck following suppurative otitis media
Authors: Onyon Clare , Goodyear Helen M 
Published: May 2014

A 5-year-old boy presented to the authors' paediatric admissions unit with a sudden onset of swelling of his left temple. He had a 4-day history of fever and otalgia. He had been prescribed cefalexin by his GP the previous day for suspected acute otitis media. His mother described him waking from his afternoon nap when she noticed, for the first time, a swelling over his left temple. He had a history of two previously treated episodes of acute otitis media in the preceding year. On examination he was febrile with a temperature of 37.9°C. A tender, firm, non-erythematous swelling was present over his left temple and several left cervical lymph nodes were palpable. Otoscopy revealed bilaterally scarred tympanic membranes. Initial investigations revealed a white cell count of 31.2 × 109/litre with a neutrophilia of 27.5 × 109/litre and a C-reactive protein of 261 mg/litre. Intravenous cefuroxime was started to cover a suspected soft tissue infection. Skull radiographs showed no areas of osteolysis. Ultrasonography of the lump was reported as showing a small fluid collection beneath a soft tissue swelling overlying the left temple, separate to the skull vault. Inflammatory markers returned to normal levels after a few days of antibiotic treatment. However, the temporal swelling was slow to resolve and he developed difficulty in opening his jaw fully. The original diagnosis was reconsidered and the opinion of a paediatric otolaryngologist was sought. A diagnosis of an abscess deep to the temporalis muscle (Luc's abscess) secondary to chronic suppurative otitis media was made and intravenous metronidazole was commenced in addition to cefuroxime. Computed tomography scanning, performed under sedation, revealed an ipsilateral mastoiditis ith opacification of the mastoid air cells (Figure 1) and confirmed soft tissue thickening and a fluid collection overlying the left squamous temporal bone (Figure 2). Mastoid exploration and drainage were considered. However, as the swelling resolved completely and his clinical condition quickly improved, he was managed conservatively with a total of 2 weeks intravenous antibiotics.
Life-threatening fungal meningitis-ventriculitis secondary to vaginal candidiasis
Authors: Choudhari Yashashri K , Choudhari Kishor A 
Published: May 2014

A 39-year-old woman presented with headache and drowsiness. Computed tomography scan confirmed aneurysmal subarachnoid haemorrhage with acute hydrocephalus, necessitating insertion of an external ventricular drain. This improved her consciousness level but she remained restless and confused. Cerebral angiography revealed an aneurysm arising at the origin of the posterior communicating artery. On the third day following haemorrhage the aneurysm was successfully treated by endovascular coiling. During this time she was often noticed to be scratching her vulval area as well as the scalp at the site of insertion of the drain. On vaginal speculum examination copious curdy white discharge was seen. A vaginal swab confirmed this to be caused by Candida albicans. On the eighth day, her condition deteriorated again. She became drowsy with high grade fever, pyrexia, neck stiffness, vomiting and left hemiparesis. On the tenth day she became very ill and toxic with fulminant signs of meningitis-ventriculitis requiring a transfer to the intensive care unit. The CSF showed a high white cell count of 9500/mm3 with 90% neutrophils. No bacterial organisms were detected on direct microscopy but the culture grew Candida albicans. With aggressive antimicrobial therapy using vaginal clotrimazole pessaries, intravenous fluconazole and intraventricular vancomycin, her neurological condition gradually improved over the next 4 weeks. Clinical improvement also correlated with normalization of CSF picture and eradication of Candida on subsequent cultures. Vaginal discharge also gradually diminished and vulval redness subsided. Six weeks later, she was discharged with mild residual left hemiparesis. She did not have any itching or vaginal discharge.
Inhaled heroin causing a life-threatening asthma exacerbation and marked peripheral eosinophilia
Authors: Whale Christopher I , Molyneux Andrew W , Ward Michael J 
Published: May 2014

Miss H was born in 1982 and diagnosed with asthma at the age of 7 years. In 2004 she presented with cough and wheeze, a peak flow of 55% predicted, an eosinophil count of 3.75 × 109/litre (normal range 0−0.4 × 109/litre) and a normal chest radiograph. In the preceding year, she attended the accident and emergency department twice and required six courses of prednisolone, despite taking low-dose inhaled steroids on a regular basis. A smoker, she lived in a rented room and was not registered with a doctor. Following standard treatment, she was prescribed an inhaled corticosteroid and long-acting β2-agonist. She took discharge against medical advice and failed to attend follow-up clinic. Two months later she was admitted with increasing wheeze and breathlessness, but refused investigations. During this admission, but only after direct questioning, she admitted to smoking heroin. She was discharged with community drug liaison service follow-up and abstained from heroin until she attended clinic 6 weeks later. At this point she had no symptoms and a supranormal peak flow. In February 2005, she become wheezy after inhaling heroin and was admitted overnight. She took her own discharge before seeing the hospital drug liaison team and again refused investigation. Admissions followed in June, July and August 2005, with life-threatening features on the last occasion, when she narrowly avoided ventilation. During this admission she recognized that exacerbations always followed heroin inhalation and she was referred to a direct access clinic to commence oral buprenorphine (Subutex, Schering-Plough, NJ, USA), a partial opioid antagonist.
Methaemoglobinaemia: a case of mistaken identity
Authors: Washington Stephen J , P Meadows Diana , McCluskey Anthony 
Published: May 2014

A 69-year-old man was admitted under the care of the orthopaedic surgeons after fracturing his femur. He had been diagnosed with polyarteritis nodosa 10 years previously and was asthmatic. A recent echocardiogram had revealed moderate aortic stenosis. His medications were dapsone 250 mg daily, prednisolone 5 mg daily, salbutamol and beclomethasone inhalers. The planned orthopaedic management was open reduction and internal fixation. He had no complaints apart from the pain associated with his injury. He did not complain of breathlessness or chest pain. He was alert and orientated; heart rate 80/minute and regular; arterial pressure 132/74 mmHg; respiratory rate 16/minute; his chest was clinically clear. However, his lips were blue and pulse oximetry was 79% with a good waveform. A differential diagnosis of pulmonary or fat embolism was made and high flow oxygen was given. Further investigations were ordered and a medical opinion sought from a chest physician. Laboratory haemoglobin was 105 g/litre; a chest X-ray showed chronic pleural thickening but no acute lung changes; an electrocardiogram confirmed normal sinus rhythm. Arterial blood analysis (breathing oxygen 15 litres/min from a face mask with attached reservoir bag) showed PaO2 23 kPa, PaCO2 4.5 kPa, pH 7.42, bicarbonate 24 mmol/litre, base excess zero. The chest physician agreed with the diagnosis of acute thrombotic pulmonary embolism and the patient was heparinised pending further investigation by computed tomography pulmonary angiography. This showed minor atelectasis, bronchiectasis and chronic pleural thickening consistent with previous asbestos exposure but no evidence of pulmonary embolism or parenchymal lung disease. The patient was referred for an anaesthetic opinion before the proposed surgery, and the raised PaO2 was noted. As the patient was clinically well and all investigations were negative, he was deemed fit for urgent surgery under general anaesthesia. In the anaesthetic room routine monitoring was attached. Again, a low peripheral oxygen saturation (approximately 86%) was observed on pulse oximetry breathing air. After routine induction of general anaesthesia, the low saturation persisted despite ventilation of the patient's lungs with 100% oxygen. At this point, a diagnosis of acquired methaemoglobinaemia – secondary to dapsone therapy – was considered. Methylene blue 20 mg was injected intravenously slowly and the pulse oximetry reading increased from 86 to 96% within a few minutes. The rest of the anaesthetic was uneventful. Postoperatively he was transferred to the high dependency unit for observation and started on ascorbic acid. He had a methaemoglobin concentration of 4.8% (normal range 0–2%) even after the methylene blue and return to normal peripheral oxygen saturation. His dapsone was not restarted. Further investigation confirmed normal red cell methaemoglobin reductase concentration and a diagnosis of acquired methaemoglobinaemia secondary to dapsone therapy.
Explosive proctitis: potential treatments and pitfalls in the treatment of chronic radiation proctitis
Authors: Farmer AD , Zanetto U , Lewis MJV 
Published: May 2014

A 73-year-old man presented to the authors' clinic with profuse rectal bleeding, defaecatory urgency and symptomatic anaemia. He had been treated for prostatic adenocarcinoma 12 months previously, with neoadjuvant hormones and radiotherapy (total dose of 60 Gy). Chronic radiation proctitis was confirmed endoscopically and histologically in the absence of any other left-sided colonic pathology. His initial medical management with sucralfate enemas and oral metronidazole failed. However, he withheld consent for further topical or endoscopic treatment despite continued symptomatic deterioration and transfusion dependency, presenting a therapeutic impasse. Oral thalidomide (75 mg/day) was started and he made an excellent symptomatic response and became transfusion independent. However, 23 days after starting thalidomide peripheral neuropathy ensued, a well documented side effect (Mileshkin and Prince, 2006), which resolved rapidly following its discontinuation. His symptoms and anaemia rapidly re-emerged and at this point he consented to endoscopic therapy with argon plasma coagulation. An unprepared flexible sigmoidoscopy, to the rectosigmoid junction, demonstrated features of chronic radiation proctitis and argon plasma coagulation was applied exclusively to the rectum. However, the patient developed sudden onset abdominal pain necessitating abandonment of the procedure. A chest radiograph showed free air under the right hemidiaphragm. An emergency laparotomy revealed multiple perforations and lacerations in the proximal descending colon without abdominal contamination. A Hartmann's procedure was performed. A direct perforation as a sequelae of the procedure is unlikely as multiple perforations and lacerations were evident proximal to the upper limit of the examination. Furthermore, no perforation was observed in the rectum or sigmoid where the argon plasma coagulation was applied. As bowel preparation was not administered before the flexible sigmoidoscopy and given the aforementioned findings at laparotomy, the likely cause of the perforation was an intracolonic gas explosion, a rare iatrogenic complication of using thermocoagulative endoscopic techniques within the colon. The patient died 16 days postoperatively of multiorgan failure.
Lambert–Eaton myasthenic syndrome
Authors: Chiang Yi Zhen , Tan Kian Tjon , Hart Ian K 
Published: May 2014

A 64-year-old man presented with proximal lower limb muscle weakness that had ascended over 3 months to involve the upper limb, bulbar and periocular muscles. In addition, he had muscle aches, dry eyes and mouth, with 10 kg of weight loss. He was an ex-smoker of 50 pack-years. On examination, he had mild dysarthria, bilateral ptosis and proximal muscle weakness (MRC power 4/5) in all limbs that improved transiently after muscle use. All limb tendon reflexes were absent at rest but returned after sustained muscle contraction for 10 seconds. The serum voltage-gated calcium-channel antibody titre was 237 pmol/litre (normal <45 pmol/litre). High frequency repetitive nerve stimulation (Figure 1) produced a successive increase in compound muscle action potential amplitude, confirming the diagnosis of Lambert–Eaton myasthenic syndrome. On spiral computed tomography there was a pretracheal mass extending into the right paratracheal region (Figure 2). Tissue biopsy confirmed small cell lung carcinoma.
Two contrasting presentations of Peutz-Jeghers syndrome
Authors: Cathcart Paul , Aziz Omer , Desai Anil , Ziprin Paul 
Published: May 2014

A 17-year-old girl of Chinese origin was referred as a case of suspected acute appendicitis with a 3-day history of a colicky abdominal pain which had started off in her peri-umbilical region. She had presented to another hospital 2 days before, but was discharged home after an overnight stay because her symptoms had improved. The pain had now become more severe and was associated with bilious vomiting, absolute constipation for 3 days, and increasing abdominal distension. On further questioning she had experienced a self-resolving peri-umbilical pain intermittently over the past 3 years, but had never had this investigated. Her last period was 3 months ago, and she was being investigated for irregular menstruation in China. There was no family history of any gastrointestinal problems. On examination, she was markedly dehydrated and noted to have ‘freckle-like’ lesions around her mouth and on her lips (Figure 1). She had a pyrexia of 38.1 °C, a tachycardia of 130 beats per minute, and was normotensive. The abdomen was visibly distended, tender (mostly in her epigastrium and left upper quadrant) and absent of bowel sounds. There was no evidence of previous surgery and scars, and digital rectal examination was unremarkable with an empty rectum. Blood tests showed marginally raised white cell count (13.8×109/litre) and C-reactive protein (51 mg/litre), and urine tests were unremarkable with a negative β-human chorionic gonadotrophin level. A plain abdominal radiograph showed an isolated loop of small bowel in the left upper quadrant (Figure 2), and a computed tomography scan of her abdomen was performed showing a long intussusception of the proximal jejunum with free pelvic fluid (Figure 3). This segment of bowel was grossly dilated and a diagnosis of small bowel obstruction secondary to intussusception was made. Exploratory laparotomy was performed and revealed a 45 cm-long segment of intussuscepted jejunum which was ischaemic and non-viable, thereby requiring small bowel resection and primary anastomosis. On opening of the resected specimen a small polyp was identified at the lead point of the intussusceptions (Figure 4). The remainder of the small bowel did not contain any palpable or visible polyps, but a Meckel's diverticulum was found and resected. Histology of the intussuscepted small bowel segment revealed three pedunculated polyps (the largest 45×25×25 cm) with branching muscle pattern and relatively bland nuclei, consistent with a diagnosis of Peutz–Jeghers syndrome. The patient made a complete uncomplicated recovery and was discharged at postoperative day five.
Papulonecrotic tuberculide: a forgotten cutaneous manifestation of tuberculosis
Authors: Tay E , Chinegwundoh J , Sahota A , Cerio R 
Published: May 2014

A 30-year-old Chinese man presented with a 2-month history of enlarging neck masses and a widespread rash. He had first noticed the swellings 10 years ago when a diagnosis of tuberculosis was made. The lymphadenopathy improved after anti-tuberculous therapy but never completely regressed. Seven years later, a skin eruption developed over his limbs and trunk. He described recurring crops of asymptomatic reddish papules which discharged a yellowish fluid and subsequently healed with scarring and hyperpigmentation. There was no pruritus or tenderness and no pulmonary symptoms. Clinical examination revealed a non-tender, 10 cm, firm and ovoid mass with overlying erythema in the right anterior triangle of his neck (Figure 1) with several smaller lumps on the other side. There was a widespread eruption on his trunk and limbs, sparing the face, palms, sole and scalp (Figure 2). Recent lesions consisted of 1cm erythematous papules with a scaly collarette (Figure 3). Older lesions had left atrophic scarring and hyperpigmentation. A clinical diagnosis of papulonecrotic tuberculide was made. An X-ray of the chest was normal. Serum immunoglobulins (IgG, A and M) were moderately elevated. Erythrocyte sedimentation rate and C-reactive protein level were normal. Syphilis serology was negative. A Heaf test was strongly positive (Figure 4). Fine needle aspirations of the neck mass were negative for microscopic identification of acid-fast bacilli and for malignancy. On the other hand, a lymph node biopsy on the left side revealed fragments of connective tissue showing granulomatous inflammation and non-caseating necrosis. Occasional acid-fast bacilli were seen with a Ziehl-Neelsen stain. Skin biopsies were taken of recent, established and old lesions. The histological features of the established lesion were diagnostic, showing a florid, acute on chronic, perivascular and periappendiceal inflammmatory infiltrate involving both the superficial and deep dermis. There was also evidence of lobular panniculitis with fibrinoid necrosis of medium-sized arterial vessels, venulitis and extensive endothelial cell swelling. Histological features of the other two skin specimens were non-specific. No organisms were identified with special stains. Anti-tuberculous therapy with rifampicin, isoniazid and pyrazinamide was started and 2 weeks after treatment, the patient reported a complete cessation in the development of new skin lesions. His skin remains in remission after 6 weeks of treatment.
Extrapancreatic tumour hypoglycaemia
Authors: Ratoff JC , Gossage AAR 
Published: May 2014

A64-year-old woman presented with drowsiness and a history of worsening abdominal pain associated with abdominal bloating. Before admission her GP had arranged an ultrasound scan to investigate the abdominal symptoms and the finding of hepatomegaly. However, the development of drowsiness with slurred speech and dizziness prompted her admission. There was no other history of ill health. She was a non-smoker and took alcohol only occasionally. On examination she was drowsy, restless and had recently vomited. Her Glasgow coma score was 9/15 and her speech was slurred. She was moving all four limbs, plantar reflexes were flexor, pupils equally reactive and fundi appeared normal. She was afebrile, her pulse was 80 beats/minute and regular. Her blood pressure was 170/100 mmHg, and auscultation of heart and lungs was normal. Abdominal examination revealed a football-sized irregular mass in the right upper quadrant.