bluuebunny/crossref_metadata_2025_split huggingface dataset:
Systemic granulomatous disease and syndrome of inappropriate antidiuretic hormone
Authors: Nazir T , Talab SK , Kadir S 
Published: May 2014

A 71-year-old man was admitted with generalized tiredness, mild confusion and low-grade pyrexia following the fourth cycle of intravesical bacillus Calmette–Guérin instillation for the treatment of superficial bladder carcinoma. These symptoms were accompanied by some weight loss which was difficult to quantify. His past medical history included type 1 diabetes mellitus, chronic obstructive pulmonary disease and prostatic hyperplasia. He was a smoker and consumed a moderate amount of alcohol. Physical examination was unremarkable with the exception of confusion (abbreviated mental test score 7/10). Initial investigations showed low serum sodium of 122 mmol/litre with normal potassium, renal and thyroid functions. His liver functions were abnormal with aspartate transferase of 76 IU/litre and alkaline phosphatase 286 U/litre. Chest X-ray showed bilateral non-specific reticular changes suggestive of infection. Two sets of blood cultures showed no growth after 72 hours. Urine tests for legionella and pneumococcal antigen were negative. Computed tomography of the brain revealed deep white matter changes suggestive of small vessel disease. On further investigations urine osmolality was 546 mOsm/kg, serum osmolality 256 mOsm/kg, urine sodium 61 mmol/litre and the short Synacthen test was normal, confirming the diagnosis of syndrome of inappropriate antidiuretic hormone. After fluid restriction to 1 litre per day his sodium level started to improve slowly, but the patient's condition continued to deteriorate with ongoing low-grade pyrexia, confusion and lethargy. A repeat chest X-ray 5 days later (Figure 1) showed multiple small non-calcified nodules in both lungs raising the possibility of miliary tuberculosis. This was confirmed on high resolution computed tomography scan of the chest (Figure 2) as presence of bilateral diffuse miliary shadowing in keeping with a diagnosis of miliary tuberculosis. In view of his confusion, CSF examination was done to rule out CNS involvement, but this was normal. No endobronchial lesions were identified on bronchoscopy and bronchial washings were sent for analysis and cultures. The patient was started on anti-tuberculous treatment (isoniazid, rifampicin and ethambutol) as well as steroids and pyridoxine. Unfortunately, the patient suffered a cardiac arrest and died a week after starting the treatment. Cultures of bronchial lavage and CSF did not grow any mycobacterium. On post-mortem examination he was found to have multiple small whitish nodules in both lungs, with caseating granulomata, central areas of necrosis and multinucleated giant cells microscopically.
Nocturia, enuresis and snoring: an unusual combination in an adult?
Authors: Dushianthan A , Ebden P 
Published: May 2014

A 41-year-old man was seen in a respiratory clinic with symptoms of snoring, sleepiness during the day, enuresis and nocturia. He was waking up a minimum of 6–7 times to micturate every night. He had a past medical history of hypertension. His medication included lisinopril, omeprazole and simvastatin. He denied significant alcohol intake. On examination he was obese with a body mass index of 32 kg/m2, his blood pressure was raised at 170/120 mmHg. Chest examination revealed clear lung fields and otherwise unremarkable general examination. His collar size was 45 cm. His blood tests suggested normal renal, thyroid, calcium and blood sugar profiles. The mid-stream urine did not show any evidence of urinary tract infection. He had an elevated score of 15/24 on the Epworth Sleepiness scale (a questionnaire tool to assess daytime sleepiness). He subsequently had an overnight oximetry, which showed 4% oxygenation desaturation index of 80.6 per hour (Figure 1). This is consistent with severe obstructive sleep apnoea hypopnoea syndrome. He was commenced on continuous positive airway pressure with substantial improvement in his sleep apnoea symptoms, including nocturic frequency, and his enuresis is completely resolved.
Primary adrenal B cell lymphoma
Authors: Fearon Paul , Rahilly Maeve 
Published: May 2014

A 57-year-old man presented with a 12-hour history of abdominal pain of sudden onset. The pain was localized to the right upper quadrant, and there were no relieving or aggravating factors. There was also no associated nausea or vomiting. Clinical examination revealed tenderness and voluntary guarding in the right upper quadrant, but no signs of rebound or peritonism. His only other symptom was night sweats which had been occurring for 2 years. There was no relevant past medical or family history. An ultrasound scan of the abdomen demonstrated a 7.5×6.6×4 cm mass, superior to and separate from the right kidney and separate from the right lobe of liver. The mass contained multiple internal echoes and had appearances consistent with an adrenal mass. The other abdominal organs including the contralateral adrenal gland appeared within normal limits. The ultrasound findings were confirmed on abdominal computed tomography (CT) scan and followed up by urine biochemistry, chest X-ray and routine blood tests, which were all normal. Protein electrophoresis showed a diffuse increase in γ-globulins (15 g/litre; range 4–7 g/litre). A CT-guided adrenal biopsy was performed which yielded a core of mostly necrotic tissue on which the differential diagnosis of malignant lymphoma or tuberculosis was raised. The patient proceeded to right adrenalectomy, which was uncomplicated. A spherical tumour mass 85×80×75 mm (weight 230 g), with a smooth capsule and some normal adrenal gland attached to one pole, was resected. Opening the tumour revealed mostly necrotic yellowish material containing flecks of calcification. Histological examination showed some viable tumour at the periphery of the mass destructively infiltrating residual normal adrenal gland. The neoplastic cells were arranged in solid sheets and possessed large vesicular nuclei and 1–2 nucleoli. There was a high mitotic and apoptotic rate. The neoplastic cells were immunoreactive for leucocyte common antigen and the B cell marker L26, and the appearances were thus of a diffuse high grade B cell lymphoma (Figures 1 and 2). Staging procedures including bone marrow trephine biopsy and CT scanning of the chest, abdomen and pelvis did not demonstrate any evidence of disease elsewhere. The patient received chemotherapy (cyclophosphamide, mitozantrone, vincristine and prednisolone) and has maintained a complete remission for 12 months.
Blue and breathless
Authors: Seaton RA , Nathwani D , Kirk J , France AJ 
Published: May 2014

A25-year-old HIV-antibody positive female had been admitted to hospital on 12 occasions with respiratory infections over a 3-year period. Pneumocystis carinii pneumonia (PCP) had been suspected twice but never proven and sputum culture for tuberculosis was repeatedly negative. Her CD4 count was 6/mm3. Treatment had been problematic. Antiretroviral therapy was not tolerated, she reported a rash with cotrimoxazole and nebulized pentamidine provoked severe bronchospasm. During her twelfth hospital admission PCP was suspected despite negative induced sputa. She completed treatment with intravenous pentamidine and corticosteroids followed by oral clindamycin with primaquine. Following discharge dapsone 100 mg thrice weekly was started as secondary prophylaxis. Twelve days later she was readmitted with worsening dyspnoea, fever and vomiting. Inadvertently she had taken 300 mg dapsone daily for 4 days. Physical examination revealed a deeply cyanosed patient. Respiratory rate was 50/minute, heart rate 130/minute, temperature 37.6°C and blood pressure 120/70 mmHg. Chest radiograph showed a diffuse bilateral pneumonia and arterial blood gases breathing air revealed a PaO2 of 8.37 kPa, PCO2 of 3.92 kPa and a calculated oxygen saturation of 93.3%. Haemoglobin concentration was 9.7 g/dl, blood film demonstrated 6% reticulocytes with Heinz body inclusions and the methaemoglobin level was 30%. Activated charcoal, high flow oxygen and 2 mg/kg intravenous methylene blue was commenced. Piperacillin-tazobactam and gentamicin were added for presumptive severe hospitalacquired pneumonia and she was transfused one unit of blood. PaO2 improved to 31.8 kPa on 100% oxygen but she remained deeply cyanosed. The methaemoglobin level 12 hours later was 34% so a further bolus of methylene blue followed by an infusion (0.1 mg/kg/hour) was administered. During the administration of methylene blue pulse oximetry showed a dramatic fall in oxygen ‘saturation’. Twenty-four hours later methaemoglobin level was 1.7% and by day three <1% with an oxygen saturation of 88% measured by pulse oximetry. Following discontinuation of methylene blue on day five an arterial blood sample showed PaO2 was 11 kPa on air with a calculated oxygen saturation of 96%. Repeat chest X-ray showed a right middle-lobe bulla with partial clearing of the infiltrates. She was discharged on day 12 at her own request but died 3 weeks later in hospital following admission with a pneumothorax and severe pneumonia. Autopsy was refused.
Retained gall-stone as a differential diagnosis of acute appendicitis
Authors: Salih Ali K , Insall Robert L 
Published: May 2014

A52-year-old female suffering repeated attacks of cholecystitis underwent an otherwise straightforward laparoscopic cholecystectomy. At completion the gall bladder was seen through the laparoscope to rupture during its removal via the umbilical incision. A single stone was noted to fall from the gall bladder into the peritoneal cavity and this was easily retrieved. No other spilled stones were seen at completion laparoscopy. The immediate postoperative recovery was uneventful and the patient was allowed home on the following day. Eight weeks later the patient presented as an emergency with central abdominal pain which radiated to the right iliac fossa. There was associated nausea and vomiting and a tachycardia but no fever or bowel upset. Clinical findings included tenderness and guarding in the right iliac fossa but normal bowel sounds and rectal examination. Chest and abdominal radiographs were normal, as were blood count, glucose, amylase, renal and liver function tests. A clinical diagnosis of acute appendicitis was suspected and the right iliac fossa was explored through a muscle-splitting incision. A normal appendix was found and was removed but there were fibrinous adhesions and inflammation around a gallstone surrounded by the mesentery of the terminal ileum. The adhesions were divided and the gallstone removed, followed by peritoneal lavage. The patient again made an uneventful recovery and was allowed home, free of symptoms, 72 hours later.
An unusual cause of third nerve palsy
Authors: Morris GC , Gupta A 
Published: May 2014

A74-year-old Caucasian, non-hypertensive, non-diabetic, otherwise fit male presented to the outpatient department with a 1-week history of painless left ptosis and diplopia of gradual onset. There were no other neurological symptoms. Examination revealed partial left third nerve palsy (i.e. ptosis, eyeball fixed down and outward but with normal reacting pupil). There was no other neurological deficit and systemic examination was normal. Investigations revealed normal full blood counts, erythrocyte sedimentation rate, glucose, electrolytes, thyroid function test, serum immunoglobulins, chest X-ray and negative antinuclear and rheumatoid factor. Computed tomography brain scan with contrast enhancement was normal. The third nerve palsy improved spontaneously to normal over a period of 3–4 weeks. The patient re-presented 2 months later, this time with features of gradual painless partial right third nerve palsy (ptosis, eyeball fixed down and out with normally reacting pupil). Again there was no further neurological deficit and systemic examination was normal. Following this assessment, the anatomy of the third cranial nerve was considered in detail leading to a positive Tensilon test to confirm the diagnosis of ocular myasthenia gravis. Computed chest scan did not reveal any evidence of thymoma. Anti-acetylcholine receptor antibodies were absent. He has remained well on a small dose of pyridostigmine.
Parapharyngeal abscess: a diagnosis not to miss
Authors: Hobbs CGL , Pinder DK 
Published: May 2014

A15-year-old girl presented with a 3-week history of sore throat, which had been unresponsive to penicillin. She had also recently developed a painful swelling in the left side of the neck. On examination she had tonsillitis and a large tender mass in the jugulodigastric region on the left side. This was hard and non-fluctuant with no overlying cellulitis or erythema. Ultrasound confirmed cervical lymphadenitis and she was commenced on intravenous antibiotics. Despite an initial improvement in her symptoms, on the third day after admission she remained pyrexial and developed a left spastic torticollis. A computed tomography (CT) scan was performed which showed a large parapharyngeal abscess (Figure 1). This was incised and drained immediately and she was discharged home 4 days later having made an excellent recovery. A week later, however, she was reviewed in clinic and was found to have an ipsilateral Horner's syndrome. After 6 months, this has yet to recover (Figure 2).
An unusual case of nephrocutaneous fistula
Authors: Tan YK , Valerio D 
Published: May 2014

An 86-year-old Caucasian woman presented with a 2-day history of a painful swelling in the left upper thigh anteriorly. She also gave a recent history of recurrent urinary tract infection associated with macroscopic haematuria, against a background of a long-term indwelling catheter for complete urinary incontinence. She denied any change in bowel habit and her weight had also been stable. Her past history included a hysterectomy, dynamic hip screw insertion for fractured right neck of femur and coronary artery disease. On examination she was apyrexial with no signs of anaemia, jaundice or lymphadenopathy. The left thigh swelling was confirmed to be an abscess. Abdominal and rectal examinations were unremarkable. The abscess was subsequently incised and drained. A substantial amount of pus was released. Culture of the pus yielded Proteus and Escherichia coli. Unfortunately the left thigh wound failed to heal up completely resulting in a constantly discharging sinus (Figure 1). A sonogram was then performed which revealed a fistulous track passing closely to the left greater trochanter and then superiorly projected over the left iliac wing. It then tracked medially towards the spine and particularly towards a small staghorn-like calculus on the left side. At no time was contrast seen to spill intra-abdominally (Figure 2). A subsequent computed tomography scan demonstrated that the fistulous track lay anterior to the neck of femur and passed superiorly in front of the hip joint before entering the iliacus muscle compartment retroperitoneally. The contrast then tracked superiorly until it reached the iliac crest. It continued superomedially and retroperitoneally towards the lower pole of the left kidney which contained a staghorn-like calculus. Contrast was also seen in the bladder (Figure 3). The patient did not have intravenous pyelography. A diethylene triamine pentaacetic acid (DTPA) renogram was carried out which confirmed that the patient had a non-functioning left kidney but good function of the right kidney. This woman subsequently underwent a left nephrectomy through a midline incision. The left kidney was shrunken and tethered retroperitoneally, and was associated with a well-defined fistulous track. The track was opened and curetted and an associated abscess cavity involving iliacus muscle drained. Histology of the kidney confirmed chronic pyelonephritis with scarring and presence of calculus in the dilated pelvicalyceal system. The patient made a straightforward postoperative recovery. At follow-up 3 months postoperatively, the thigh sinus had healed completely and the patient was asymptomatic.
Dancing eyes
Authors: Storey Imogen , Denniston Alastair , Denniston Sarah 
Published: May 2014

A7-month-old girl was referred by her GP with a 6-hour history of ‘jittery eyes’. During the preceding day she had been ‘grizzly’ and non-specifically unwell. Her mother reported that on the day of admission she had had rigors and abnormal eye movements. The child had no significant past medical history. There was a family history of epilepsy. Paediatric review noted a miserable child with an inflamed right tympanic membrane and sudden eye movements up and to the right. An electroencephalogram was performed which was normal and a provisional diagnosis was made of right-sided otitis media with associated nystagmus resulting from putative labyrinthine involvement. The child was started on a course of amoxycillin and admitted. After 24 hours her condition had improved and she was discharged, pending an ophthalmology review 4 days later. At the ophthalmology review it was noted that although the child appeared generally well, she was distressed by recurrent sudden conjugate dextro-elevatory eye movements associated with simultaneous backward jerks of the head. She was ataxic but the examination was otherwise normal. The opinion of a paediatric ophthalmologist was sought, the diagnosis of opsoclonus was made and further investigation arranged. Chest radiography revealed bilateral paravertebral mass in the lower thoracic region (Figure 1). Magnetic resonance imaging confirmed this and showed anterior extension encircling the aorta and displacing the inferior vena cava (Figure 2). Considerable enhancement with gadolinium was noted. No involvement of liver, spleen or cranium was seen. A bone scan and marrow trephine was normal. An MIBG (metaiodobenzyl guanidine) scan showed increased uptake in the lower thoracic right paraspinal area. Tumour biopsy revealed rosettes of small round cells consistent with neuroblastoma. The diagnosis was therefore of thoraco-abdominal neuroblastoma stage 3. This was not resectable and chemotherapy was started as per the European Infant Neuroblastoma Protocol. She made rapid improvement with radiographic reduction in tumour size and dramatic improvement in her neurological features.
A vascular left atrial myxoma causing obstructive symptoms
Authors: Butler Rob , Webster Mark , Greaves Sally 
Published: May 2014

A 63-year-old Chinese lady presented with acute dyspnoea, palpitations and a short history of intermittent presyncope. Her dyspnoea was worse on lying flat, improved on standing, and had an effort-related component. She had had a similar episode of positional dyspnoea 3 months earlier, while visiting relatives in China. There was no history of constitutional symptoms or signs consistent with systemic embolization. On admission, her cardiac rhythm was an atrial tachycardia, which terminated with intravenous adenosine. A mid diastolic murmur was then heard on examination, and investigated by echocardiography (Figure 1). This demonstrated a left-sided intra-cardiac mass (5.8 cm x 4.2 cm) attached to the atrial septum, consistent with an atrial myxoma. There was obvious prolapse through the mitral valve, associated with a functional mitral inflow gradient of 9 mmHg. A coronary angiogram (Figure 2), performed before surgical removal of the tumour the next day, demonstrated a single feeding vessel arising from the right coronary artery, supplying a large vascular mass. The left coronary system was normal. At operation, a large, smooth, gelatinous mass was excised, including its broad-based attachment to the intra-atrial septum. The atrial septum was repaired with a pericardial patch. Histology demonstrated features typical of a cardiac myxoma. Postoperatively she has remained well.
A delayed diagnosis of stiff person syndrome
Authors: Yeow Toh Peng , Tomkin Gerald H 
Published: May 2014

A 37-year-old industrial designer presented in February 2002 with a 6-week history of thirst, polydipsia and polyuria. Urine dipstick showed glucose and 3+ ketones. Diabetes was diagnosed following fasting glucose of 13 mmol/litre and glycosylated haemoglobin (Hba1c) of 10.3%. He was commenced on insulin therapy. He had been healthy until 1995 when he described the onset of muscle spasm and pain in upper back and shoulders. There was no obvious precipitating injury. He described the muscle over his left shoulder tightening up like a knot. It subsequently spread to his neck, upper and, later, lower back, giving significant rigidity and pain. Exertion and sporting activities cause his whole back to seize up with extreme pain afterwards. The spasms spread to his legs twice in the last 7 years, but the rigidity was fortunately only short lasting. He sought advice from a chiropractor and various medical specialists including an orthopaedic surgeon, rheumatologist and pain consultant. He had many investigations including isotope bone scan and magnetic resonance imaging (MRI) scan of cervical and thoracic spine which were all normal. There was no explanation for his symptoms and no diagnosis was given. He was prescribed baclofen, which brought some relief. Clinical examination was normal except for markedly increased tone of muscles over his left shoulder. There was no obvious truncal rigidity or exaggerated lumbar lordosis and no pyramidal or extrapyramidal signs. He was clinically euthyroid. Antiglutamic acid decarboxylase (GAD) 65 antibody was highly elevated at 220 U/ml (normal range (NR) <1 U/ml; >100 U/ml associated with neurological disease). Thyroid function test showed normal free thyroxine of 16.3 pmol/litre (NR 10–25.0 pmol/litre) with elevated thyroid-stimulating hormone of 8.43 mU/litre (NR 0.4–4 mU/litre) and positive thyroid peroxidase (TPO) antibody at 82 IU/ml (NR <37.0 IU/ml). Nerve conduction studies showed no evidence of neuropathy. Electromyograph studies were not done because of the difficulty of excluding voluntary movement from this quite painful test. Full blood count, renal, liver and bone profile were normal. CSF was not examined. The typical history of painful muscle spasm and strongly positive anti-GAD 65 antibody suggested the diagnosis of stiff person syndrome. The association with an autoimmune condition, in this case type 1 diabetes, and elevated TPO antibody levels further supports the diagnosis.