Lesson of the month 2: A choroid plexus papilloma manifesting as anorexia nervosa in an adult.

A Caucasian female previously diagnosed with anorexia nervosa was referred by psychiatric services to the general medical team. She presented with dehydration, vomiting, weakness, a body mass index of 13 kg/m2 and was treated with intravenous and enteral supplementation. During admission her vomiting worsened and she developed visual hallucinations and confabulation. Neurological examination demonstrated cerebellar signs and bilateral papilloedema on fundoscopy. Subsequent magnetic resonance imaging of the brain revealed a large fourth ventricular tumour causing obstructive hydrocephalus. The tumour was excised and histologically confirmed to be a choroid plexus papilloma. Postoperatively her neurological symptoms and negative feelings towards eating resolved.

Obscure upper gastrointestinal haemorrhage: haemosuccus pancreaticus.

A Caucasian man aged 28 years with a history of pancreatitis presented with fatigue, intermittent melaena and severe anaemia. Symptomatic treatment for anaemia was coupled with thorough investigation to localise the source of gastrointestinal haemorrhage. Two oesophagogastroduodenoscopies and colonoscopies failed to identify a cause. CT abdomen revealed splenomegaly secondary to splenic vein thrombosis with evidence of portal hypertension and small collateral vessels. A CT mesenteric angiogram revealed a splenic artery pseudoaneurysm as the likely source of bleeding. This was embolised successfully via interventional radiology and the patient's haemoglobin levels stabilised. During admission, the patient also developed severe epigastric pain radiating to the back secondary to acute-on-chronic pancreatitis, as evidenced by MRCP. The acute pancreatitis resolved with medical management, but the pain from his chronic condition was extremely difficult to control, even with opioids. He consequently underwent a successful splenic nerve radiofrequency ablation.