Fluoxetine-induced pill oesophagitis.

Pill-induced oesophagitis is well reported in people of all ages (range 3-98 years), with females outnumbering males by 1.5:1. Antibiotic pills, cardiac pills and non-steroidal anti-inflammatory drugs and alendronate are the most common culprits. We report a case of fluoxetine-induced pill oesophagitis in a young adult without any underlying pathological abnormalities of the oesophagus.

Unusual presentation of mixed germ cell tumour from testis in a 45-year-old man.

Testicular cancer is a common neoplasm in young and middle-aged men. Although, the most common presentation is a palpable testicular mass, it can present with atypical symptoms. There is a lack of awareness among primary-care physicians about the less common presentations of testicular tumours. Early detection is a key prognostic variable. Fever, weight loss, sweating and pain in the abdomen for 4 months in an adult man has multiple differential diagnoses especially if epigastric mass is present. We are presenting an interesting case of fever, weight loss, pain and mass epigastrium and generalised lymphadenopathy which proved to be a testicular germ cell tumour without any testicular symptoms and with normal tumour markers.

Scoping a perforated bleeding peptic ulcer: learning points.

Peptic ulcer perforation and haemorrhage is not unusual as a complication of peptic ulcer disease. In the older patientspresentation can be dramatic and atypical. The authors are presenting a case of duodenal ulcer perforation and haemorrhage which was misdiagnosed as a gastric malignancy and thus failure to have Helicobacter pylori eradication, recurrence with complication and hesitancy in surgical intervention due to initial label of malignancy.

Arnold-Chiari malformation type 1 complicated by sudden onset anterior spinal artery thrombosis, tetraparesis and respiratory arrest.

Chiari in 1891 described a constellation of anomalies at the base of the brain inherited congenitally, the characteristic of which are (1) extension of a tongue of cerebellar tissue posterior to the medulla and cord that extends into the cervical spinal canal; (2) caudal displacement of the medulla and the inferior part of the fourth ventricle into the cervical canal; and (3) a frequent but not invariable association with syringomyelia or a spinal developmental abnormality. Chiari recognized four types of abnormalities. Presently, the term has come to be restricted to Chiari's types I and II, that is, to cerebellomedullary descent without and with a meningomyelocele, respectively. The association of Arnold-Chairi malformation and high cervical cord infarction is unusual. The most common syndrome, anterior spinal artery syndrome (ASAS), is caused by interruption of blood flow to the anterior spinal artery, producing ischaemia in the anterior two-thirds of the cord, with resulting neurologic deficits. Causes of ASAS include aortic disease, postsurgical, sepsis, hypotension and thromboembolic disorders. The authors present an interesting case of cervical cord infarction due to anterior spinal artery thrombosis in a patient of type 1 Arnold-Chiari malformation without any of the above predisposing factors.

Chronic epididymo-orchitis and scrotal ulcers.

Extrapulmonary tuberculosis (TB) still presents a diagnostic and therapeutic challenge. Genitourinary TB constitutes about 20% of the extrapulmonary cases in regions where TB is endemic. Tuberculous infection of epididymis and testis is difficult to differentiate clinically from pyogenic infection, tumour or infarction. High-resolution sonography is currently the best readily available technique for imaging the scrotum and its contents, and accurate differentiation is important for proper diagnosis and treatment. The authors are presenting a unique case of chronic epididymo-orchitis with scrotal ulcers.

Haemoptysis in a patient of achalasia cardia: pulmonary actinomycosis, not tuberculosis.

Actinomycosis is an infectious disease caused by anaerobic gram-positive, non-spore forming bacteria of the genus Actinomyces that affects the oropharynx, digestive tract, and genitalia. Thoracic actinomycosis may affect the respiratory tract and the pleura, even extending to the chest wall. Pulmonary actinomycosis occurs in immunocompetent persons during the fourth and fifth decades of life, with greater prevalence in men, and is generally due to Actinomyces israelii or A meyeri. It is frequently misdiagnosed as primary or metastatic lung cancer or conventional lung infections (eg, tuberculosis). The accepted predisposing factors for bronchopulmonary actinomycosis are poor dental hygiene, alcoholism and various chronic debilitating diseases, hiatus hernia, and gastro-oesophageal reflux. We report an interesting case of pulmonary actinomycosis presenting with haemoptysis, associated with achlasia cardia, and treated as tuberculosis.

Massive haematemesis due to strangulated gangrenous gastric herniation as the delayed presentation of post-traumatic diaphragmatic rupture.

Diaphragmatic injuries are quite uncommon and often result from either blunt or penetrating trauma. Diaphragmatic ruptures are usually associated with abdominal trauma; however, it can occur in isolation. Acute traumatic rupture of the diaphragm may go unnoticed and there is often a delay between the injury and the diagnosis. Patients present with non-specific symptoms and may complain of chest pain, abdominal pain, dyspnoea, tachypnoea and cough, heartburn and symptoms of gastro-oesophageal reflux. Respiratory distress and faeco-pneumothorax have been reported. We present an interesting case of traumatic diaphragmatic hernia presenting 5 years after a road traffic accident as acute abdomen and massive haematemesis due to strangulated gangrenous gastric hernia.

Presacral schwannoma treated as irritable bowel syndrome.

Presacral tumours represent a heterogeneous group of predominantly benign and occasionally malignant neoplasms. These tumours, though rare, frequently present either incidentally or with vague symptoms. Schwannomas of the presacral region are one variant described as benign tumours of neurogenic origin. The case of a large presacral schwannoma in a 26-year-old man, who was treated for irritable bowel syndrome for 4 years, is presented. The patient presented with intermittent constipation, a feeling of incomplete evacuation of the bowel and vague abdominal discomfort relieved by defecation. The symptomatology worsened and constipation became frequent, and the patient experienced increased urinary frequency. Baseline investigations were normal and ultrasonography of the abdomen revealed a pelvic mass, which on CT scanning was revealed to be a large retrorectal mass. The tumour was resected and histology revealed it to be a schwannoma. This unique case is presented to emphasise that irritable bowel syndrome must be a diagnosis of exclusion, especially if atypical symptoms are present.

Gastric antral vascular ectasia (GAVE) in a non-cirrhotic patients with diabetes: case report and possible pathophysiological mechanism.

Gastric antral vascular ectasia (GAVE) syndrome is an uncommon but well-described cause of recurrent upper gastrointestinal bleeding or iron deficiency anaemia. Atiology is unknown but several associated diseases have been reported like connective tissue or autoimmune disorders or cirrhosis. Cases have been reported in systemic sclerosis, achlorhydia, atrophic gastritis and chronic renal failure. The most common cause is portal hypertension and portal hypertensive gastropathy. This is especially so after eradication of oesophageal varices by sclerotherapy or banding. Diabetic complications are characterised by microvascular diseases especially in the retina, glomerulus and vasa nervorum. It involves apoptosis and remodelling of endothelial cells. Hyperglycaemia is an essential cause of reactive oxygen species (ROS)-mediated oxidative stress in this complication. Angiopathy of gastric mucosa in diabetes mellitus has not been reported so far in the literature. We are presenting an interesting case of diabetes mellitus with gastric vascular ectasia without evidence of any other systemic illness.

Practice of symptomatic treatment in the era of evidence-based medicine: report of 2 cases of diagnosis of Sheehan's syndrome delayed till eighth decade.

Sheehan's syndrome, first described in 1937, is characterised by postpartum haemorrhage, pituitary necrosis, lactational failure and hypopitutarism. Presentation is variable and late presentations are not unusual due to partial ischaemic injury of the pituitary and gradual loss of endocrine function. A history of postpartum haemorrhage is usual but in some cases it is not elicited. Presentations such as malaise, fatigue, hypoglycaemia, decline in cognition, hyponatraemia, pancytopoenia, osteoporosis, secondary infertility, confusion and coma have all been reported. Two interesting cases of Sheehan's syndrome are presented that were diagnosed in the eighth decade; one due to atypical presentation of recurrent hyponatraemia and confusion, another from hypoglycaemic coma and symptoms of malaise and lethargy.

Catastrophic cerebral antiphospholipid syndrome presenting as cerebral infarction with haemorrhagic transformation after sudden withdrawal of warfarin in a patient with primary antiphospholipid syndrome.

Catastrophic antiphospholipid syndrome (APS) is caused by thrombotic vascular occlusions that affect both small and large vessels, producing ischaemia in the affected organs. The "catastrophic" variant of the antiphospholipid syndrome (cAPS) develops over a short period of time. Although patients with cAPS represent <1% of all patients with APS, they are usually life threatening with a 50% mortality rate. A strong association with concomitant infection is thought to act as the main trigger of microthromboses in cAPS. Several theories have been proposed to explain these physiopathological features. Some of them suggest the possibility of molecular mimicry between components of infectious microorganisms and natural anticoagulants, which might be involved in the production of cross-reacting antiphospholipid antibodies. We present a case of catastrophic cerebral APS characterised by massive temporal lobe infarction and subsequent haemorrhagic transformation after sudden withdrawal of warfarin.

Skin rash, headache and abnormal behaviour: unusual presentation of intracranial haemorrhage in dengue fever.

Dengue viral infections are one of the most important mosquito borne diseases in the world. The dengue virus is a single stranded RNA virus belonging to the Flaviviridae family. There are four serotypes (DEN 1-4) classified according to biological and immunological criteria. Patients may be asymptomatic or their condition may give rise to undifferentiated fever, dengue fever, dengue haemorrhagic fever (DHF), or dengue shock syndrome. Annually, 100 million cases of dengue fever and half a million cases of DHF occur worldwide and 2.5 billion people are at risk. At present, dengue is endemic in 112 countries. Early recognition and prompt initiation of appropriate treatment are vital if disease related morbidity and mortality are to be limited. We present an interesting case of dengue fever with headache, skin rash and abnormal behaviour who had a massive intracranial haemorrhage with fatal outcome.

Lupus mastitis - peculiar radiological and pathological features.

Lupus mastitis is a form of lupus profundus that is seen in patients with systemic lupus erythematosus. It usually presents as a swelling (or swellings) in the breasts, with or without pain. The condition is recurrent and progresses along with the underlying disease, with fat necrosis, calcification, fibrosis, scarring, and breast atrophy. Lupus mastitis is often confused with malignancy and lymphoma and, in our part of the world, with tuberculosis. Confusion is especially likely when it occurs in an unusual clinical setting. In this article, we present a case that presented with unique radiological, pathological, and clinical features. Awareness of the various manifestations of lupus mastitis is essential if unnecessary interventions such as biopsies and surgeries, and their consequences, are to be avoided.

Analgesics are not always the culprits: isolated gastric fundal varices as the cause of recurrent upper GI bleed in a patient with SLE, rheumatoid arthritis and polymyositis overlap syndrome.

The most common cause of upper gastrointestinal bleeding in patients with systemic rheumatic diseases is non-steroidal drug use; this is the case with COX-2 inhibitors, especially when used concomitantly with corticosteroids. Bleeding from varices is unusual in the absence of liver disease. We present an interesting case of a patient with systemic lupus erythematosus, rheumatoid arthritis and polymyositis overlap syndrome with recurrent upper gastrointestinal bleeds from isolated fundal gastric varices and a normal liver.

Congenital cataract and congenital chloride diarrhoea-a unique combination and antenatal diagnosis.

Congenital chloride diarrhoea (CCD) is a serious inherited defect of intestinal electrolyte absorption transmitted in an autosomal recessive way. The molecular pathology involves an epithelial Cl(-)/HCO(3)(-) exchanger protein, encoded by the solute carrier family 26 member 3 gene (SLC26A3) and known DRA (down regulated in adenomas) in the distal ileum and colon. Polyhydramnios, premature birth, ileus without meconium passage, hypochloremia, and hyponatremia are typical features of CCD in the neonate followed by chronic metabolic alkalosis, hypokalemia, hypochloremia, retarded growth and renal impairment in older children and adults if the disease is not adequately treated. Antenatal diagnosis if made on the basis of findings on ultrasonography-a non-invasive diagnostic test-can help in early management of the disorder immediately after birth and, thus, prevent the sequelae. We present an interesting case of CCD diagnosed antenatally and found to have congenital cataract, which is a unique occurrence not reported in literature so far.

Delirium in a 74-year-old man: correct imaging revealed the truth.

Delirium is a cognitive disorder. DSM-IV criteria for delirium must include both acute onset and fluctuating symptoms; disturbance of consciousness (including inattention); at least one of the following: disorganised thinking, disorientation, memory impairment or perceptual disturbance; and evidence of a putative causal medical condition. Traditionally, the course has been described as transient in which recovery is likely to be complete if the underlying aetiological factor is promptly corrected or is self-limited. The most common precipitating causes in elderly include sepsis, dehydration and drugs. Work-up for delirium is limited to septic screening, baseline investigations and imaging. Patients with delirium without focal signs and with either evidence for a medical aetiology of delirium or pre-diagnosed dementia are at a very low risk of having focal lesions in their contrast-enhanced CT or MRI. We are presenting an interesting case of delirium with urosepsis whose imaging revealed milliary brain tuberculomas on contrast-enhanced MRI.

Lower cranial nerve palsy, aseptic meningitis and hydrocephalus: unusual presentation of primary antiphospholipid syndrome.

Presentation of primary antiphospholipid syndrome (APS) is usually untrustworthy and unusual presentations are difficult to diagnose on the basis of clinical features alone. This is true especially in young and elderly patients. Cerebral venous thrombosis (CVT) is less frequent than arterial thrombosis in APS. CVT has a wide spectrum of signs and symptoms, which may evolve suddenly or over weeks. It mimics many neurological conditions such as meningitis, encephalopathy, benign intracranial hypertension and stroke. Headache is the most frequent symptom in patients with CVT, and is present in about 80% of cases. The most common pattern of presentation is with a benign intracranial hypertension-like syndrome. Sixth cranial nerve palsy usually manifests as a false localising sign. Patients may have recurrent seizures. Cranial nerve syndromes are seen with venous sinus thrombosis. We present a case of APS with lower cranial nerve palsy, aseptic meningitis and hydrocephalus initially treated as tuberculous meningitis.

Chest wall swelling: unusual presentation of an aggressive mediastinal tumour.

The majority of patients with primary mediastinal lymphoma are symptomatic at the time of diagnosis and commonly have fever, weight loss and/or night sweats. Symptoms due to compression of adjacent mediastinal structures are infrequent, but may include pain, dyspnoea, stridor, or superior vena cava syndrome. Local infiltration into the chest wall, pleura and pericardium is not uncommon.In the present report, two interesting cases of chest wall swellings that in fact were extensions of primary mediastinal lymphoma are given. Histopathology of the tumour was large B cell lymphoma (CD20+). The first case was in a 23-year-old woman, with dramatic onset but a good outcome. The second was in a 34-year-old Pakistani woman, with insidious onset and poor outcome due to extent and invasion by the tumour. Interesting CT images are presented showing chest wall and left supraclavicular swelling.