bluuebunny/crossref_metadata_2025_split huggingface dataset:
Bacterial meningitis resulting in visual impairment and panhypopituitarism
Authors: Lynch Ceri , Fish Mark 
Published: May 2014

A 30-year-old man presented to his local district general hospital with a week-long history of headache, cough and coryzal symptoms, followed by 24 hours of fever, neck stiffness, photophobia, confusion and agitation. He had no significant previous medical history. Examination revealed a Glasgow Coma Score of 11 (E4, M5, V2), stiff neck, tachypnoea and tachycardia. There were no localizing neurological signs. Mucus was crusted around the nose. The patient was sedated and ventilated in intensive care and given intravenous benzylpenicillin and cefotaxime. He then underwent a computed tomography (CT) head scan, which suggested fluid in the paranasal sinuses and pus filling the maxillary antrum. CSF was turbid, containing 16 000 white cells/mm3 (97% polymorphs), protein 3.22 g/litre and glucose 0.1 mM although no organisms were seen on Gram stain. At this point the patient was transferred to a tertiary neurology centre, where a repeat CT after 3 days showed further fluid and oedema in the paranasal sinuses. Sinus washout was performed and nasal decongestants prescribed. Initial attempts at extubation led to repeated seizures. Blood tests performed included assessment of pituitary profile, which was unremarkable. Sedation was withdrawn 10 days after admission and the patient extubated; once awake it became clear that he was blind. The patient was pyrexial (38°C), agitated and hallucinating. It was thought that he had Anton's syndrome (cortical blindness and poor awareness of blindness). He was transferred to a neurology ward and a low-dose antipsychotic was started. The patient became more alert and orientated, and able to cooperate with ophthalmological examination, which established healthy optic discs, no intraocular abnormality, no papilloedema and no afferent papillary defect, supporting the diagnosis of cortical blindness. A repeat CT scan to investigate his continuing headache demonstrated loss of radiolucency of all the paranasal sinuses and the patient underwent functional endoscopic sinus surgery; this involved bilateral eithmoidectomy, sphenoidectomy and insertion of stents into both frontal sinuses. An audiogram demonstrated high frequency sensorineural deafness. The patient's condition improved and his eyesight partly recovered (visual acuity 6/60 right eye and 6/24 left eye). Further ophthalmology examination revealed bilateral disc pallor and optic atrophy was diagnosed. It was noticed that this patient's skin had become soft, pale and wrinkled and he was shaving less frequently than usual. On the basis of his skin appearance, a diagnosis of possible hypopituitarism was made, and pituitary hormone profile was assessed. This revealed panhypopituitarism and magnetic resonance imaging confirmed the presence of gross inflammation in the optic chiasm and around the pituitary, although the pituitary gland itself appeared intact (Figure 1). The patient was discharged home on pituitary replacement therapy with planned regular follow-up.
Inversion of Meckel's diverticulum causing gastrointestinal bleeding and small bowel obstruction
Authors: Andrabi SIH , Spence GM , Clements Mr WBD 
Published: May 2014

A 35-year-old man presented with vomiting, mid-gut colic, intermittent passage of fresh blood per rectum and a haemoglobin level of 8.0 g/dl. Clinical examination was unremarkable and initial investigation with abdominal sonography revealed no abnormality. Computed tomography of the abdomen demonstrated a thick-walled loop of small bowel in the region of the terminal ileum (Figure 1). A differential diagnosis of ileo-ileal intussusception, Crohn's disease and Meckel's diverticulitis was considered.The patient proceeded to exploratory laparotomy, which revealed inversion of a Meckel's diverticulum causing incomplete small bowel obstruction. Segmental ileal resection and primary anastomosis was performed without incident. Recovery was uneventful. Histopathological examination showed a 15 mm submucosal nodule with associated ulceration of the overlying mucosa in the base of the diverticulum (Figure 2). Microscopy confirmed that the nodule contained heterotopic pancreas with lobules of ductal and acinar epithelium.
An unusual presentation of globus
Authors: Natt Ravinder S , Karkanevatos Apostolos 
Published: May 2014

A previously fit 49-year-old school teacher presented to the ear, nose and throat department with a 6-week history of globus pharyngeus symptoms ' a clicking sensation in her throat associated with some odynophagia and dysphonia. There was no absolute dysphagia but she described a feeling of a lump of phlegm stuck in her throat which was she was unable to clear and which kept her awake at night. She had recently started taking proton pump inhibitors to treat possible reflux oesophagitis and was a lifetime non-smoker. Fibreoptic laryngoscopy revealed a single large smooth-surfaced polypoidal swelling lateral to the left arytenoid and occluding the ipsilateral piriform fossa, but not obstructing the laryngeal inlet. There was no restriction in movement of her vocal cords. Her ear, nose and throat examination was otherwise unremarkable. Owing to her profound claustrophobia and phobia of intravenous injections, she refused a computed tomography scan and magnetic resonance imaging scan with sedation but consented to a microlaryngoscopy with a view to excising the whole lesion for histological analysis. Subsequently, microlaryngoscopy revealed a large yellow lesion covered by normal mucosa lateral to the left aryepiglottic fold which was occupying but not extending beyond the left piriform fossa (Figure 1). The lesion was fully excised (Figure 2) and sent for histology, which confirmed the diagnosis of lipoma. She made an uneventful recovery with no signs of recurrence after 12 months during surveillance in the outpatient clinic with full restoration of the quality of her voice and swallowing.
Management of HIV:still a long way to go
Authors: Pozniak Anton 
Published: May 2014

In June 1981 the US Center for Disease Control reported the occurrence, without identifiable cause, of an unusual pneumonia caused by Pneumocystis carinii (now jirovecii) in five apparently healthy men in Los Angeles. In that first year over 1600 cases of this new form of severe immunodeficiency were diagnosed with close to 700 deaths. Two years later, after much speculation, the human retrovirus HIV-1 was isolated and found to be the cause of this severe immune deficiency syndrome. Over a decade later effective treatment was discovered, so-called highly active antiretroviral therapy (HAART), consisting of usually three antiviral compounds. Ten years after the widespread introduction of HAART there are still 33.2 million people living with HIV globally and most have no access to antiviral treatment.
Mycetoma of the foot
Authors: Oddy MJ , Blundell CM , Suvarna SK , Greig JM 
Published: May 2014

A 22-year-old Eritrean woman, who had been resident in the UK for 6 years, presented with a 3-year history of a slowly growing mass over the dorsolateral aspect of her right foot. A previous incisional open biopsy performed by the regional bone tumour unit demonstrated fungal hyphae. The mass measured 3 × 4 cm with intact overlying skin and no sinus formation (Figure 1). Plain X-rays were normal and a magnetic resonance image showed the mass to contain discrete rounded opacities of intermediate signal. Bone marrow oedema was seen but no bony infiltration or destruction (Figure 2). She underwent wide excision including the previous biopsy tract (Figure 3). No organism was cultured under routine laboratory conditions. Histological examination showed dense fibrous connective tissue with a granulomatous component, with pigmented brown and black material surrounding central hyphae. The infection was identified as Madurella mycetomatis (Figure 4). Oral voriconazole was given for 3 months and there was no evidence of recurrence 6 months post-operation, either clinically or on magnetic resonance imaging.
Prenatal treatment of fetomaternal thrombocytopenia
Authors: Vatopoulou Theodora , Sorinola Olanrewaju 
Published: May 2014

A 34-year old Caucasian woman (gravida 2, para 1) with a history of fetomaternal alloimmune thrombocytopenia presented for antenatal care in her second pregnancy at 12 weeks' gestation. Her first baby was severely affected by fetomaternal alloimmune thrombocytopenia (platelet count < 3×109/litre) and presented with neonatal purpura and fits caused by intracranial haemorrhage. Fetomaternal platelet incompatibility and presence of maternal anti-HPA-1b antibodies was demonstrated (Table 1) and the baby treated successfully, with platelet transfusions (HPA-1 negative). During her second pregnancy, the mother's booking platelet count was 250 × 109/litre. Fetal platelet typing via amniocentesis at 16 weeks showed fetal platelet genotype HPA 1a1b. The modified direct monoclonal antibody-specific immobilization of platelet antigens (MAIPA) test showed that the mother was still positive for anti-HPA-1b antibodies (Table 1), indicating a high risk of fetomaternal alloimmune thrombocytopenia in this pregnancy. Starting at 16 weeks, she received weekly intravenous immunoglobulin 1 g/kg. The anomaly scan at 20 weeks was unremarkable. Further monitoring included weekly cranial scans to detect intracranial haemorrhage, and monthly growth scans. These were all normal. The mother declined fetal blood sampling to assess the fetal platelet count. Steroids were given at 33 weeks and baby delivered by planned caesarean section at 34 weeks. The boy weighed 2.75 kg and had no signs of bleeding. His platelet count was 100 × 109/litre and he has been well since.
Cocaine-induced myocardial infarction: not your average acute coronary syndrome
Authors: Behar Jonathan M , Lindsay Alistair C , McEwan Jean R 
Published: May 2014

A 31-year-old woman presented to accident and emergency at 03.20 hrs complaining of central chest pain since the preceding evening. She denied any significant medical history or family history and initially denied taking any medication or drugs of abuse. On examination her pulse was 110 beats per minute and her blood pressure 126/82 mmHg but there were no other abnormal physical findings. Her initial electrocardiogram showed multiple ventricular ectopics with periods of idioventricular rhythm but no acute ST segment elevation that met thrombolysis criteria (Figure 1). She was initially treated with aspirin, low molecular weight heparin and intravenous nitrates. Although her symptoms of pain resolved overnight, the electrocardiogram evolved Q waves suggesting a significant anterior myocardial infarction (Figure 2). This was confirmed by a raised cardiac troponin T level at 12 hours. It was not until some 15 hours after admission, and only after direct questioning, that she admitted to being a regular cocaine user, often using up to 3 g per week. She had smoked a pipe containing crack cocaine the preceding evening, and then immediately afterwards injected cocaine into a femoral vein. She described a euphoric rush followed by a non-resolving severe chest pain. She underwent coronary angiography 36 hours after presentation which revealed a thrombus in the proximal left anterior descending artery (Figure 3). The coronary arteries were angiographically normal, with no evidence of angiographic atheromatous disease. She was treated with intravenous heparin and abciximab, and thereafter remained pain free and haemodynamically stable. An echocardiogram showed severe left ventricular impairment (ejection fraction 30%) with gross apical dyskinesis. She was discharged on aspirin and an angiotensin-converting enzyme inhibitor and given strong advice to cease using cocaine. She failed to return for pre-arranged follow up, was not registered with the GP she indicated and could not be traced through the NHS database.
HIV-related psychosis
Authors: Honey Helen , Bolton Jim , Attard Doreen 
Published: May 2014

A 35-year-old Ugandan man was escorted to the emergency department by his family following 2 days of uncharacteristic behaviour. He had presented himself to a police station believing that he was guilty of terrorist acts. He had no psychiatric history and no history of illicit drug use. The patient was responding to auditory hallucinations and lacked insight into his symptoms. Preliminary blood investigations and a computed tomography brain scan were normal. The patient was able to give informed consent for an HIV test, which was positive. He was admitted to a psychiatric ward and was successfully treated with antipsychotic medication.
When headaches are not neurological: an unusual presentation of Ebstein's anomaly
Authors: Cook C , Carpenter JP , Longcroft-Wheaton G , Wong Y-K 
Published: May 2014

A 16-year-old male was admitted following a loss of vision. Baseline observations demonstrated SpO2 80% on air, tachycardia of 180 beats per minute (bpm) and hypotension of 90/50 mmHg. He reported bilateral visual disturbance while sitting in bed together with breathlessness, chest discomfort and dizziness but had not had palpitation or syncope. He had been prescribed propranolol for recurrent migraines of increasing frequency with similar visual disturbances, nausea and vomiting but with no perceived benefit. He was otherwise well, a non-smoker who drank minimally and denied recreational drug use. On examination, the jugular venous pressure was elevated but there were no other cardiorespiratory findings of note. Arterial blood gas analysis revealed profound hypoxia and a compensated metabolic acidosis. A 12-lead electrocardiogram demonstrated a supraventricular tachycardia with broad QRS (Figure 1). Carotid sinus massage and intravenous adenosine had no effect. Electrolyte levels were abnormal (potassium 2.7 mmol/litre, magnesium 0.45 mmol/litre, corrected calcium 1.60 mmol/litre) and a central venous line was inserted to allow electrolyte replacement. During this procedure, he spontaneously reverted to sinus rhythm at a rate of 70 bpm. A repeat electrocardiogram showed sinus rhythm with normal axis but T wave inversion in the inferior leads and evidence of pre-excitation with a short PR interval and classical delta waves (Figure 2). As a result, Wolff–Parkinson–White syndrome was diagnosed. The chest radiograph showed an abnormal, globular cardiac silhouette (Figure 3). Following return to sinus rhythm, the blood pressure and acid–base status normalized. Routine transthoracic echocardiography demonstrated Ebstein's anomaly with an associated atrial septal defect and small membranous ventricular septal defect.
Parotid incidentaloma detected during thoracic PET imaging: how should these lesions be managed?
Authors: Thomas Robert , Sharma Neel , Burke Chris , Maxwell David , Howlett David C 
Published: May 2014

Three patients (two female, one male) were aged between 60 and 78 years with no significant previous medical history. In all three cases the patients had histopathological and radiological diagnosis of non-small cell lung cancer and the staging computed tomography scans showed no evidence of metastatic disease. These patients were considered to be potential surgical candidates in view of their spirometry and general health, and therefore proceeded to positron emission tomography as part of the preoperative work-up. In each patient unilateral intense focal uptake was reported in the parotid gland (with no evidence of other metastases) and this was deemed to be of uncertain significance (Figures 1 and 2). There was diagnostic uncertainty as to whether the uptake represented another malignancy, metastasis or benign parotid disease. In each case high-resolution ultrasound was undertaken for further evaluation of the parotid gland combined with ultrasound-guided core biopsy (18G needle) of the focal lesion demonstrated. Ultrasound confirmed focal hypoechoic lesions in the parotid gland in each case, corresponding with the location on positron emission tomography imaging. Sonographic differences between patients were noted, as demonstrated in Figures 3 and 4. Histology from the core biopsy confirmed a diagnosis of Warthin's tumour in two patients and pleomorphic adenoma in the third. The patients were referred to ear, nose and throat surgery for further management of these lesions. All patients were deemed to have resectable lung cancer and were referred on for thoracic surgical assessment.
The acute prescription of oxygen in orthopaedic trauma patients
Authors: Young AF , Kostalas M 
Published: May 2014

Background: In trauma and orthopaedic surgery high flow oxygen can save lives by preventing severe hypoxaemia. Conversely, excessive oxygen can cause harm, and inadequate monitoring of its use has been reported in both pre-hospital and hospital audits. In 2008 the British Thoracic Society published guidelines on the use of emergency oxygen in adults. Method: Data were collected before, 3 months after and 12 months after the introduction of an oxygen prescription chart and education of junior doctors and ward staff. Results: A total of 84 patients were recorded in the first study, 76 in the second and 72 in the third. After education and introduction of an oxygen prescription section on the drug charts the number of oxygen treatments correctly prescribed increased from 10/84 (12%) to 56/76 patients (74%, P<0.001) at 3 months. Twelve months after education and introduction of an oxygen prescription section on the drug charts the number of oxygen treatments prescribed decreased to 37/72 (51%, P<0.001). Conclusions: Education and the use of oxygen prescribing charts significantly improved the prescription of oxygen. The effect of the intervention fell at 12 months, suggesting poor sustainability. Continued education and feedback to ward staff is vital to maintain change and improve sustainability.
Beware of groin pain in the elderly athlete
Authors: Williams EV , Hughes JL , Foster ME , Pemberton D 
Published: May 2014

A62-year-old man, who was a keen amateur swimmer, presented to the orthopaedic department in June 1996 with a 4-month history of lower back pain, which had developed after he had been swimming. Mild tenderness was noted over his left sacroiliac joint, straight leg raising was normal, and resisted movements failed to reproduce his pain. He was advised to alter activity and discharged. His pain persisted, however, and 10 months later had become localized to his right groin. Further review in the orthopaedic clinic revealed a full range of movement of his hips, but extreme abduction was painful. Plain radiographs of the lumbar spine showed degenerative changes. His pain was attributed to lumbar root irritation, and so he was referred for physiotherapy. By October 1997, 16 months after initial presentation, there was no real improvement. A soft tissue magnetic resonance imaging scan confirmed spondylosis and degenerate discs, but no actual disc prolapse. As he was still troubled with pain, specifically in the right groin, a general surgical opinion was requested. Localized tenderness was demonstrated at the deep ring, but no herniation noted. ‘Gilmore's groin’ was suspected, but his advancing age aroused suspicion, therefore other causes needed to be excluded. There was nothing else to find on clinical examination of his abdomen, but rectal examination revealed a hard nodular prostate. A prostate-specific antigen (PSA) test was performed, and this was significantly elevated at 168 ng/ml (normal Ã4 ng/ml). Plain pelvic X-rays were obtained, and reported as sclerotic lesions involving left ischium, right superior pubic ramus and adjacent pubic bone (Figure 1). An isotope bone scan later revealed multiple areas of increased activity consistent with metastatic disease (Figure 2). A subsequent tru-cut biopsy confirmed carcinoma of the prostate.
Cerebral venous thrombosis presenting as unilateral headache and visual blurring in a man with nephrotic syndrome
Authors: Chan KH , Mak W , Cheung RTF , Ho SL , Au-Yeung KM 
Published: May 2014

A 44-year-old man presented with persistent left-sided headache for 2 weeks. His ankylosing spondylitis was in remission following a course of sulphasalazine and methotrexate in the past. Six months before admission, he developed nephrotic syndrome as a result of minimal change glomerulopathy. Prednisolone was started at 60 mg daily and later tailed down to 15 mg daily plus azathioprine 50 mg daily. His 24-hour urinary protein decreased from 5.89 to 1.08 g/day. He ran out of prednisolone for 1 week before he developed persistent throbbing headache over his left temporal and occipital regions together with mild neck pain and stiffness. The headache was worse in the morning and aggravated by straining and sneezing. He also noticed more than 20 episodes of transient visual blurring without diplopia, each episode lasting up to 30 seconds. There was no visual aura, photophobia or phonophobia. He did not have any fever, nausea, vomiting or temporal tenderness. He was afebrile. Neck stiffness and loss of physiological cervical lordosis could be attributed to his ankylosing spondylitis. Mild facial puffiness and ankle oedema were caused by his nephrotic syndrome. Apart from bilateral papilloedema, his neurological examination was normal. Complete blood count, erythrocyte sedimentation rate, liver and renal function tests, autoantibodies, serum complement levels and serum immunoglobulins were normal except for the serum albumin of 36 g/litre. Computed tomography brain scan was normal. X-ray of the cervical spine revealed spondylitic changes. Magnetic resonance imaging brain scan was normal, but magnetic resonance venography (MRV) revealed a loss of venous flow over the right transverse and sigmoid sinuses, indicating cerebral venous thrombosis (Figure 1). Anticoagulation was commenced initially with subcutaneous low-molecular weight heparin and followed later with warfarin. His headache gradually subsided after 2 days of anticoagulation. Warfarin was continued for 6 months with the international normalized ratio kept between 2 and 2.5. Repeated MRV after completion of anticoagulation showed recanalization of the thrombosed cerebral venous sinuses. Subsequent screening was negative for deficiency in protein C, protein S or antithrombin III, resistance to activated protein C, and anti-cardiolipin antibodies. In the past 4.5 years, the patient remained well with no evidence of malignancy or relapse of nephrotic syndrome.