bluuebunny/crossref_metadata_2025_split huggingface dataset:
Coarctation of the aorta, hypertension and associated features
Authors: Dubrey Simon W , Mittal Tarun K 
Published: May 2014

A 17-year-old female athlete who had a black belt in Tai-Kwondo was discovered to be hypertensive (blood pressure recorded as 150/90 mmHg in both arms) when she was screened to join a new gym. Although able to perform physical contact sports to a competitive level without apparent symptoms, direct enquiry revealed that she had calf pain on jogging. On examination a grade 4/6 systolic murmur was audible throughout the precordium. Femoral pulses were impalpable bilaterally. Routine blood tests including renal function were all normal as was a renal ultrasound and urine analysis for protein and catecholamines. The electrocardiogram showed sinus rhythm, a normal axis and satisfied voltage criteria for left ventricular hypertrophy. A transthoracic echocardiogram was normal, with no evidence of left ventricular hypertrophy and good biventricular systolic function. However, on examination of flow in the abdominal aorta there was continuous forward flow throughout the cardiac cycle. The chest X-ray (Figure 1) showed rib notching as a result of erosive pressure on the ribs from collateral blood flow in large vessels derived from the subclavian, axillary, internal thoracic, scapular and intercostal arteries. Cardiac magnetic resonance imaging confirmed the diagnosis of coarctation of the aorta (Figure 2), explaining the continuous abdominal aortic blood flow. The murmur was the result of turbulent blood flow through an isolated, typical post-ductus location, coarctation of the thoracic aorta. The diameter at its narrowest was 0.6 cm. The femoral pulses were impalpable as the flow at the femoral arteries was reduced and continuous in character (as demonstrated by the echo study) rather than pulsatile and palpable.
Cerebral venous sinus thrombosis in polycythaemia
Authors: Thomson D , Vyas P , Hammersley MS 
Published: May 2014

A 50-year-old man was admitted as an emergency with severe bilateral headache. For 1 month he had felt unwell with a gradual onset, dull, throbbing headache that kept him awake at night. Admission to hospital was precipitated by an increase in severity of headache, associated with nausea and photophobia. There were no exacerbating factors and the headache was not positional. He denied red eye, lacrimation, blurred vision or visual fortification, dizziness, weakness or change in sensation. He had no other past medical history. He was an ex-smoker with a 10 pack-year history. On examination, he was plethoric. He was afebrile and blood pressure raised at 160/120 mmHg. There was no meningism and fundoscopy was normal. The remainder of the examination was unremarkable. Urine dipstick demonstrated 3+ protein, an electrocardiogram showed T-wave inversion inferiorly, with no evidence of left ventricular hypertrophy by voltage criteria, and a chest radiograph was normal. The initial diagnosis was hypertensive headache, but the patient was found to be significantly polycythaemic. His test results were haemoglobin = 21.2 g/dl (normal range 13.0−17.0 g/dl); haematocrit = 0.656 (normal range 0.4−0.5); red cell count = 7.72×1012/litre (normal range 4.5−5.5×1012/litre); white cell count = 11.0×109/litre (normal range 4.0−11.0×109/litre); platelets = 295×109/litre (normal range 150−400×109/litre); clotting profile was normal; biochemical profile was normal; PaO2 on room air was 10.8 kPa. The diagnosis was amended to headache secondary to hyperviscosity and an urgent computed tomography scan of the brain was arranged to rule out cerebral venous sinus thrombosis. The computed tomography scan of the brain confirmed subacute thromboses of the right transverse and sigmoid sinuses. To manage hyperviscosity, the patient underwent isovolaemic venesection of 450 ml of blood. The venous sinus thrombosis was treated by anticoagulation with low molecular weight heparin and the patient was commenced on warfarin. Subsequent investigations revealed a suppressed erythropoietin (0.88 mU/ml; normal range 5−25 mU/ml) and the presence of the JAK-2 chromosomal mutation, which confirmed a diagnosis of polycythaemia rubra vera. The patient was discharged and returned for day case venesection.
Acute gastrointestinal haemorrhage: a rare presentation of aortic dissection
Authors: Salisbury EM , Ikin N , Bansi DS 
Published: May 2014

A 72-year-old woman presented with a 24-hour history of severe upper jaw pain and more recent onset central chest pain. She denied difficulty breathing or nausea. Her ast medical history included cluster headaches, mild chronic obstructive airways disease and hypertension. She had been well on review in outpatient clinic the day before. On examination, she was apyrexial, blood pressure 130/60 mmHg, pulse 95 beats per minute and regular, oxygen saturation 96% on room air. Clinical examination was unremarkable. There were no new electrocardiogram changes and a chest X-ray was reported as normal. Blood tests showed haemoglobin 9 g/dl, a 2 g/dl drop from the previous day in clinic. The remaining laboratory tests were normal. With no identified source of bleeding or associated rise in urea, her full blood count was repeated to exclude a spurious result. Over the next 24 hours, her chest and jaw pain eased but she developed diarrhoea and tachycardia. Her blood pressure remained stable at 140/65 mmHg. The haemoglobin drop was confirmed with a repeat value of 8.7 g/dl but still no source of bleeding was identified. Over the course of the day, the patient's diarrhoea continued with increasing abdominal discomfort, until she suddenly passed fresh blood per rectum associated with a blood pressure drop to 70 mmHg systolic. She was resuscitated promptly and a decision made to manage her conservatively with oesophagogastroduodenoscopy and colonoscopy scheduled for 24 hours later, as it was the weekend and endoscopy services were limited. However, she continued to pass fresh blood per rectum and suffer severe generalized abdominal pain, and so an urgent computed tomography scan with contrast was performed (Figure 1). This showed a type A aortic dissection extending from the left coronary artery to involve the carotid arteries and extend down below the renal arteries. The Stanford classification divides dissections into 2 types: A and B. Type A involves the ascending aorta, type B does not. The ascending and transverse colon appeared thickened and oedematous on the scan. The most likely cause of bleeding in this case was ischaemic colitis, secondary to aortic dissection impeding inferior mesenteric artery blood flow. Cardiomegaly raised the probability of pericardial involvement. On the basis of these findings, the patient was immediately reviewed by the on-call vascular surgical team. Given the extent of the dissection, surgery was not felt to be an option. Shortly afterwards she became profoundly hypotensive and died. The most likely cause of death was cardiac tamponade, although an echocardiogram was never performed. The family declined a post mortem.
Recurrent facial nerve palsy caused by a facial cyst
Authors: Michalopoulos Konstantinos , Bajaj Yogesh , Strachan David R 
Published: May 2014

Mr B first presented to the authors' department in 2001 complaining of right-sided facial weakness. He was diagnosed with a grade 2 facial nerve palsy for which no obvious cause was identified. He was actively treated with aciclovir and steroids and his symptoms resolved completely. Over the next 2 years, he suffered two similar episodes that responded well to similar treatment. One year later, he was referred to the clinic with a grade 3 facial nerve palsy. A computed tomography scan showed no abnormality along the course of the right facial nerve. Genetic tests showed no genetic cause for the recurrent facial nerve palsy. His symptoms initially resolved but 6 months later he was readmitted with a grade 4 facial nerve palsy. A magnetic resonance imaging scan showed inflammation of the tympanic and mastoid sections of the facial nerve and facial nerve decompression surgery was planned. Intra-operatively, mild oedema was evident along the intratemporal course of the facial nerve. During decompression of the mastoid (horizontal) segment of the facial nerve (Figure 1), a significant amount of mucoid fluid in keeping with a benign cyst was drained (Figure 2). His facial palsy fully resolved and a magnetic resonance imaging scan performed 1 year after surgery showed no evidence of recurrence or other pathology. At 3-year follow up, there was no recurrence of symptoms.
An unusual complication of an attempt to open the airway in a choking child
Authors: Gjoni D , Mbamalu D , Banerjee A , James KK 
Published: May 2014

A 3-year-old boy was brought to the emergency department with bleeding from the throat. Earlier that day he had been given a boiled sweet by an older cousin. This was followed by an episode of choking and apnoea. His mother intervened, placing her finger into his mouth and attempting to extract the offending sweet. The sweet was delivered along with some fleshy tissue, followed by bleeding from the throat. On arrival in the emergency department, the child was alert, with no evidence of respiratory distress at rest. Vital signs were: heart rate 120 bpm, blood pressure 108/70 mmHg, respiratory rate 20/minute, and oxygen saturation on 15 litres of oxygen (Fi02 85%) 100%. Bloody secretions were noted at the mouth. Airway patency was maintained. Examination of the throat showed loss of the upper third of the right tonsil. There was no active bleeding, there being clotted blood in the tonsillar fossa. Respiratory and cardiovascular examinations was normal. The sweet and the missing part of the tonsil were available for inspection (Figure 1). Initial management included intravenous access, venous blood testing, including blood grouping, and the provision of analgesia (rectal paracetamol). The child was taken to the operating theatre where loss of the upper third of the right tonsil was confirmed (Figure 2). The remainder of the tonsil was nearly completely detached from the tonsillar fossa, being attached only by a small mucosal pedicle. Bilateral tonsillectomy was performed, and the right-sided palatal laceration sutured. An uneventful recovery was followed by discharge the following day.
Cutaneous Listeria infection
Authors: Gilchrist Mark 
Published: May 2014

A 38-year-old farmer presented with a 3-day history of a pustular rash, originally affecting his hands and wrists (Figure 1), before ascending up his forearms. This was accompanied by progressively worsening systemic upset. Three days before presentation the patient had delivered a stillborn calf as an emergency because of maternal distress. He had not had time to retrieve birthing gloves from the distant farmhouse. The delivery was physically difficult and the patient observed some minor soft tissue trauma to his hands at the time. Approximately 6 hours later he became aware of the rash on his wrists. This was accompanied by flu-like symptoms with myalgia, and followed by intermittent rigors and pyrexia. The rash began to ascend up both arms with the evolution of multiple large pustules (Figure 2). On the third day he sought attention from his GP who commenced oral amoxicillin. Despite this the patient felt his symptoms becoming more pronounced and presented to the emergency department. On admission he was pyrexial with a temperature of 40.8°C. His heart rate was 123 beats per minute with a blood pressure of 103/58 mmHg. Respiratory rate was 24 breaths per minute. His chest was clear to auscultation, heart sounds were normal and the abdomen was soft and non-tender. Inspection of his arms revealed a symmetrical erythematous rash with multiple well-demarcated, now ruptured, pustules, some of which had coalesced. Some smaller pustules remained intact. There was a 5 cm linear area of erythema consistent with ascending lymphangitis. There was no axillary lymphadenopathy, although both axillae were exquisitely tender on palpation. Two sets of blood cultures were taken. One of the few remaining pustules was aspirated and sent for culture. He was fluid resuscitated and commenced on high dose intravenous benzyl penicillin and gentamicin. Within 12 hours he was symptomatically tremendously improved. He was apyrexial and his haemodynamic status had significantly improved. The rash had also begun to diminish dramatically. Two days later he was fit for discharge and went home with a 10-day course of oral co-amoxiclav. The blood cultures taken on the night of admission plus two further sets taken the following day remained sterile. The sample from the pustules grew Listeria monocytogenes.
Ovarian pregnancy: report of three cases and review of the literature
Authors: Yang Jing , Yin Tailang , Xu Wangming 
Published: May 2014

A 29-year-old woman presented 77 days after she had undergone in-vitro fertilization and embryo transplantation with a 15-day history of vague pain in the hypogastrium which had increased over the last 8 days. Her pulse rate was 75 bpm and blood pressure was 100/70 mmHg. Abdominal examination revealed tenderness of the hypogastrium and rebound in the left lower quadrant. A routine blood test showed her haemoglobin levels were 79 g/litre. Transvaginal sonography revealed an enlarged uterus with evidence of intrauterine pregnancy and a complex 10.4×5.5 cm mass in the left adnexal region (Figure 1). After admission, the patient was prescribed antibiotic (penicillin) and antihaemorrhagic (aminomethylbenzoic acid and Dicynone) medication, but her symptoms did not improve. On the 85th day of pregnancy, the patient complained of severe and persistent hypogastric pain. Ultrasound showed that the complex structure was now 12.6×10.5 cm. Immediate laparotomy revealed 700 ml haemoperitoneum, 300 ml of sludgy blood in the rectouterine pouch, a normal pregnant uterus, a dark smooth left ovary with a crevice on the back and the left fallopian tube adherent to the abdominal membrane. Pathology showed ovarian pregnancy with bleeding. After ovary wedge resection the patient felt better and the intrauterine pregnancy continued. To the authors' knowledge, this is the first reported case of ovarian pregnancy along with intrauterine pregnancy after in-vitro fertilization and embryo transplantation. In this case, the transferred embryo moved from the uterus into the ovary.
The role of embolization in the management of tumour recurrence after radical nephrectomy
Authors: Akhtar Kashif , Lee George , Khan Masood , Mitchell Adam , Livni Naomi , Christmas Timothy 
Published: May 2014

A 56-year-old Caucasian female underwent left thoraco-abdominal radical nephrectomy with excision of the regional lymph nodes for a 10 × 11 cm mass in the upper pole of the left kidney. Histology confirmed a Fuhrman grade 4 clear cell renal carcinoma, pT2 NoMx, with microscopic venous invasion. All 11 lymph nodes were negative for metastatic disease as were the staging scans. A follow up computed tomography scan at 3 months revealed bilateral small pulmonary metastases with no evidence of renal bed recurrence. Bone scan was also negative. However, a further computed tomography scan 6 months after the nephrectomy demonstrated a 3.8 × 2.6 cm mass in the left renal bed with enlargement of the left gastric lymph nodes. In addition, there was a mass in the fundus of the stomach and the size of the pulmonary lesions had increased. The patient therefore started three cycles of chemotherapy (interferon-alpha, interleukin-2 and 5-fluorouracil, experimental arm of the MRC RE04 protocol) with an excellent response seen on subsequent imaging with complete resolution of the renal bed mass. A repeat computed tomography scan 16 months after surgery showed significant disease progression with a 6 × 7 cm mass in the left renal bed. The patient was admitted to hospital soon after this with a haemoglobin of 6.0 g/dl following several episodes of fresh rectal bleeding, requiring a 7-unit blood transfusion. Colonoscopy revealed a polypoid tumour in the proximal descending colon which was felt to be extrinsic in origin. Angiography revealed a number of sources of blood supply to the retroperitoneal mass, the largest from the T11 and T12 intercostal vessels (Figure 1). These were embolized satisfactorily with no further bleeding (Figure 2). The patient subsequently underwent a resection of the renal bed mass and a left hemicolectomy (Figure 3).
Boerhaave's syndrome complicating status epilepticus
Authors: Bailey Cheron , Burke Siun 
Published: May 2014

A 40-year-old woman with a history of absence seizures presented to the accident and emergency department in status epilepticus following generalized tonic clonic seizures. The patient was drowsy (Glasgow Coma Scale 10/15) and had vomited several times during the preceding 24 hours. The seizures were controlled with lorazepam and phenytoin. She was sedated and intubated uneventfully and transferred to the radiology department for a computed tomography brain scan. The computed tomography scan of the brain was normal; she had no further seizures and was extubated, with a Glasgow Coma Scale of 12/15 post extubation. She had two further episodes of vomiting following extubation. Two hours later she developed respiratory distress associated with a high-pitched voice, stridor, and massive facial and upper body swelling. She was intubated once again, this time there was a limited view of the airway secondary to soft tissue swelling. Chest X-ray and computed tomography of the thorax revealed massive subcutaneous emphysema and bilateral pneumothoraces (Figures 1 and 2), which were decompressed. The computed tomography scan also revealed a focus of air within the mid-third of the oesophagus representing an oesophageal perforation (Figure 2). The patient was managed conservatively with intravenous antibiotics and nasojejunal feeding. Ten days later she was weaned from mechanical ventilation and transferred to the ward. She was discharged home 1 month after admission.
Extensive pneumocephalus after nose blowing: an unusual cause of severe headache
Authors: Rial Carlos Lojo , Oldfield Matthew 
Published: May 2014

A 54-year-old Afro-Caribbean woman presented to the emergency department with a 1-day history of severe headache and general malaise. The pain started suddenly after blowing her nose, was frontal in location and became rapidly severe and throbbing in nature. There were no symptoms that would suggest orthostatic headache, no dizziness or vertigo, no visual or auditory disturbance and no neurological weakness. The pain was worse on movement, coughing and bending and was associated with photophobia, nausea and the development of a clear nasal discharge. Previous medical history was unremarkable; there was no history of sinus or nasal problems, no recent headaches or migraines, no visual abnormalities and no life history of head injury or nasal trauma. Examination was largely unremarkable; on arrival her Glasgow Coma Scale was 15 and she was apyrexial with no meningism or photophobia. No evidence of intracranial hypertension was found. There was slight skull tenderness on palpation over the frontal sinus, but the remainder of her neurological (including cranial nerve) examination and general examination was unremarkable. Biochemical (electrolytes, liver function, glucose, calcium) and haematological tests revealed a mild neutrophilia (12.5×109cells/litre) but were otherwise normal. Over the course of the admission, she became increasingly unwell with increasing nausea, further vomiting and fluctuant levels of consciousness. A computed tomography scan of the head showed an extensive pneumocephalus extending to the foramen magnum with marked sulcal and basal cistern effacement (Figure 1 and 2). Bone windows revealed a hole in the roof of the right sphenoid sinus. The clear discharge was found to be CSF and sent for microbiology analysis. Prophylactic cefotaxime and metronidazole antibiotics were commenced and she underwent endoscopic endonasal exploration. The bony defect in the roof of the right sphenoid and the CSF leak were identified. The dural defect was closed with a fascia lata graft and fat harvested from the thigh. Four days after the operation, she became increasingly confused and a repeat computed tomography scan showed new hydrocephalus. A lumbar puncture was performed and showed an opening pressure of 43 cm (5–20 cm). Two days later she underwent ventricular-peritoneal shunting. She eventually made a full recovery. It is still uncertain whether the hydrocephalus was secondary to a disruption of the sinus by the air pressure in the skull or whether there was hydrocephalus before the events leaking through the ethmoidal bone, suggesting the possibility of spontaneous CSF leak syndrome complicated with pneumocephalus (Schievink, 2000).
A rare cause of acute abdominal distension presenting as a surgical emergency
Authors: Alkhalil Mohammad , Brough William A , Hadjiloucas Ioannis 
Published: May 2014

A 16-year-old man, who was previously fit and well, presented as an emergency with a 2-day history of abdominal distension. Clinical examination showed a diffusely distended non-tender abdomen dull to percussion. Plain abdominal X-ray (Figure 1) showed no gas shadows on the right side of the abdomen, suggesting displacement of the intestine to the left side. Abdominal computed tomography scan (Figure 2) showed an enormous, multilocular fluid-filled mass lesion occupying most of the peritoneal cavity and measuring about 152 × 259 × 384 mm with no evidence of a solid component. The intestine was shifted to the left of the abdomen. There was evidence of compression of the retroperitoneal structures, in particular the renal vessels. Laparotomy and resection of this lesion was undertaken following mobilization of the lesion and division of the feeding vessels. Following excision of the lesion, a large defect in the mesentery of the ascending colon was found on the right side of the superior mesenteric vessels. The lesion contained haemoserous fluid (Figures 3 and 4). Histological examination of the lesion showed that the multicystic mass was partly lined by a single layer of flattened attenuated cells, fibrous tissue and histiocytes with foreign body-type giant cell reaction associated with cholesterol-like clefts. The fluid in the cyst lumen contained inflammatory cells, red blood cells, proteinaceous fluid and fibrin. The overall histological appearance, supported by immunohistochemistry, favoured the diagnosis of multilocular cystic lymphangioma. The patient made a good postoperative recovery and was discharged. He underwent surveillance computed tomography scan 6 months following surgery and a surveillance ultrasound scan 12 months following surgery and no evidence of recurrence was found. Further surveillance was planned with clinical review and abdominal ultrasound scans every 6 months for the next 2 years and annually thereafter.