Ambulatory management of pulmonary embolism.

The diagnosis of pulmonary embolism can be very difficult and elusive. It depends greatly on the use of diagnostic tests, which are in turn interpreted according to a pre-test clinical probability. These include non-specific tests such as the chest X-ray and electrocardiograph, which help exclude other conditions such as pneumonia or myocardial infarction. On the other hand, more specific tests such as computed tomography or ventilation/perfusion scanning are used to confirm or exclude the diagnosis of pulmonary embolism. The condition is potentially fatal, and in the past patients with suspected pulmonary embolism constituted a significant number of hospital admissions. Despite this, the majority were found not to have pulmonary embolism. More recently, studies have suggested that most patients with suspected pulmonary embolism who are haemodynamically stable can be safely managed on an ambulatory pathway. Therefore, there is a paradigm shift towards investigating and treating pulmonary embolism in the outpatient setting. This article discusses the ambulatory pathway of the diagnosis and treatment of pulmonary embolism.

Rifampicin-induced adrenal crisis in a patient with tuberculosis: a therapeutic challenge.

A 55-year-old Indian man presented with productive cough and a large left pleural effusion. Pleural fluid culture grew Mycobacterium tuberculosis, and he was started on antituberculosis therapy. One week later, the patient presented to hospital with drowsiness, dehydration and hypotension. He was transferred to critical care and only improved after starting hydrocortisone and stopping rifampicin. His short synACTHen test subsequently confirmed primary adrenal insufficiency, and a CT of the abdomen showed bilateral adrenal enlargement. Rifampicin is known to accelerate cortisol metabolism. We report the rare case of a rifampicin-induced adrenal crisis as a first presentation of Addison's disease in a patient with tuberculous infiltration of the adrenal glands.

Case report: Sudden cardiac death in a young man.

A 35-year-old man presented to the accident and emergency department with history of productive cough, breathlessness and some weight loss over several weeks. He had a past medical history of asthma and eczema. He mentioned that, at times, he had been expectorating sputum with some haemoptysis over the past few months. He was of Bangladeshi origin, but had been resident in the UK since 1986 and last visited Bangladesh a year ago. He was a smoker of 10-15 cigarettes per day. He also admitted to smoking heroin. In addition to his respiratory symptoms he also complained of vomiting, which was precipitated by eating. He denied bowel or urinary symptoms.

Recurrent embolotherapy in Dieulafoy's disease of the bronchus.

Dieulafoy's disease is a vascular anomaly characterized by the presence of a dysplastic artery that is related to an epithelial ulcer. The French surgeon Georges Dieulafoy first described it in 1898. Most frequently, it is a gastrointestinal condition, but occurrence in the bronchus has been reported in a few cases. The case of a 52-year-old man with massive hemoptysis, for which he underwent successful embolotherapy 10 years previously, is described. Over the next 10 years, he had several hospital admissions due to hemoptysis, and he underwent successful embolotherapy on each occasion. This case report underlines the importance of bronchial arteriography as the investigation of choice for massive hemoptysis.

Sleep-disordered breathing and heart failure.

Sleep-disordered breathing is a spectrum of disorders. As our knowledge of sleep medicine is improving, the strong association of sleep-disordered breathing with cardiac disorders is being recognized. This article discusses the association of sleep-disordered breathing and heart failure.