Pneumothorax during shoulder surgery. / Pneumothorax under skulderkirurgi.

Background: Pneumothorax following shoulder arthroscopy, although rare, is documented in over 30 PubMed case reports as occurring during or within 10 hours post-procedure. Case Presentation: A fit septuagenarian underwent a two-hour arthroscopic rotator cuff repair with IV anaesthesia and laryngeal mask airway, without a nerve block. With one hour remaining of the operation, the patient had desaturation and hypotension. Lung sliding was absent on ultrasound and x-ray confirmed left-sided tension pneumothorax. Successful thoracic drain insertion and lung re-expansion facilitated his recovery, allowing discharge after 24 hours and symptom-free status at 6 months. Interpretation: This case highlights pneumothorax as an uncommon yet possible post-arthroscopic event. The speculated aetiology is the surgical procedure, where pump-induced pressure fluctuations may displace air into surrounding tissue. Instances of pneumomediastinum and subcutaneous emphysema without pneumothorax suggest arthroscopic origin of air. Prompt perioperative ultrasound can aid in detecting such critical complications.

[Acute visual loss in an eight-year-old girl]. / Akutt synstap hos åtte år gammel jente.

BACKGROUND: There are many causes of acute visual loss in childhood. Inflammation of the optic nerve, optic neuritis, is rare. While mostly unilateral in adults, the disease often presents bilaterally in childhood. Furthermore, progression to demyelinating disease is unusual and optic neuritis has a better prognosis in childhood than in adulthood. MATERIAL AND METHODS: We describe an 8-year-old girl who over a few days developed painful eyes and profound visual loss. She had afferent pupil defect; ophthalmoscopy showed bilateral papilloedema, characteristic of bilateral optic neuritis. Current literature and guidelines are reviewed with regards to diagnosis and treatment of optic neuritis in childhood. RESULTS: Steroids seem to be beneficial in the treatment of optic neuritis in childhood. Following five days intravenous administration of methylprednisolone and an oral taper over five weeks, visual acuity was almost normalised in both eyes. INTERPRETATION: After studying the literature, we started a treatment with good outcome. Although the prognosis is usually good in children even without treatment, it is important to be aware that there are cases in which treatment with steroids is recommended.

Brain magnetic resonance imaging white-matter lesions and cerebrospinal fluid findings in patients with acute intermittent porphyria.

BACKGROUND: Case reports display similarities between multiple sclerosis and acute intermittent porphyria (AIP). This study examines whether patients with AIP in general demonstrate white-matter lesions on brain magnetic resonance imaging (MRI) and/or abnormalities in plasma and/or cerebrospinal fluid (CSF) when examined outside attacks. We looked particularly for the presence of oligoclonal bands (OB) of immunoglobulin (Ig) in liquor. METHODS: Eight AIP gene carriers without previous episodes of porphyria, mean age 42.8 years (range 30-60), and 8 AIP gene carriers with previous episodes of porphyria, mean age 42.8 years (range 33-62), were examined with brain MRI, venous blood samples and lumbar punctures. RESULTS: Two male AIP gene carriers with previous episodes of porphyria, 58 and 35 years of age, had multiple white-matter, high-signal lesions on T(2)- weighted MRI sequences. Two AIP gene carriers without previous episodes of porphyria, 1 male and 1 female, had less than 5 such lesions. No OB were seen in the CSF in any patient, but 1 carrier had an increased level of protein in the CSF. Seven of 16 subjects (44%) had increased levels of HbA1c (>6.0), suggesting protracted hyperglycemia, and 3 further subjects had borderline levels (5.9). CONCLUSION: T(2)-weighted MRI sequences demonstrated multiple white-matter, high-signal lesions in 4 out of 16 AIP gene carriers (25%). No carrier demonstrated OB of Ig in CSF, making it unlikely that demyelinating lesions play a pivotal role in the pathogenesis of CNS symptoms in AIP. Only 1 AIP gene carrier had an increased level of protein in CSF; this contrasts with studies during acute attacks of porphyria. Seven subjects (44%) had abnormally high levels of HbA1c, in spite of the fact that no patient had a previous diagnosis of diabetes mellitus.