Metastatic paraganglioma.

A man in his 70s, with a history of a glomus jugulare paraganglioma diagnosed 18 years ago, presented with an unprovoked deep vein thrombosis (DVT). The paraganglioma had been treated by radiotherapy, and yearly scans had not shown any progression since treatment. A sclerotic focus in L4 vertebral body was reported on a CT scan of the neck and trunk which was done to exclude a neoplastic process being the precipitating factor for the DVT. Nuclear imaging showed multiple areas of bony uptake, suggestive of metastases. A bone biopsy of the left femur resulted positive for metastatic paraganglioma. A monthly intramuscular injection of octreotide 30 mg was prescribed.

Neurosyphilis in a suspected case of giant cell arteritis.

A 67-year-old man had a few month history of deteriorating visual acuity. He had originally presented to ophthalmology with right-sided visual blurring. This subsequently progressed to involve the left eye. At this point, he was empirically treated with high-dose glucocorticoids, both orally and intravenously, with the suspicion that giant cell arteritis was causing acute visual deterioration of his left eye. Unfortunately, his symptoms did not improve. During an admission to hospital for a pneumonia, he underwent further investigations for this bilateral visual loss. He was diagnosed with left neuroretinitis and right vitritis. A thorough workup revealed positive syphilis serology and cerebrospinal fluid was positive on venereal disease research laboratory testing. He was diagnosed and treated for neurosyphilis with intravenous benzylpenicillin 4 million units 4 hourly for 14 days. His left-sided vision improved but he still suffers from severe visual impairment in his right eye.

Adult-onset Still's disease in a 73-year-old Maltese man.

Adult-onset Still's disease (AOSD) is a rare autoinflammatory condition diagnosed by Yamaguchi criteria. We report an atypical presentation of a 73-year-old man, who was admitted with fever, sore throat and pleurisy that were unresponsive to three courses of antibiotics. Fever persisted in a quotidian pattern and the typical salmon-coloured rash consistent with AOSD appeared at 4 weeks from symptoms onset. These features in addition to neutrophilia and hyperferritinaemia in the absence of concurrent infectious and neoplastic causes satisfied Yamaguchi criteria for a diagnosis of AOSD. Epstein-Barr antigen was initially detected at moderate titre levels, but was undetectable after 1 week. Complete resolution of symptoms was reported on initiation of steroid treatment. A relationship between disease onset and viral syndromes has been documented to occur and few similar cases preceded by Epstein-Barr virus detection have been reported.

Lumbosacral spondylodiscitis complicated by sepsis, osteomyelitis, epidural abscess formation and deep vein thrombosis.

A 71-year-old man presented with a 3-month history of low back pain radiating to his right hip and thigh associated with lower limb weakness and constitutional symptoms. Imaging confirmed a lumbosacral spondylodiscitis at L2-3 and L5-S1 as well as a right-side psoas abscess which was treated with urgent CT-guided drainage and intravenous antibiotics. His admission was complicated by a number of issues, including the development of osteomyelitis with vertebral body destruction at multiple sites, epidural abscess formation and deep vein thrombosis. Additionally, the patient developed severe sepsis which necessitated admission to the intensive care unit. The patient's clinical condition improved gradually with intravenous antibiotics until he was well enough for transfer to a rehabilitation centre, where he underwent regular occupational and physical therapy. Repeat imaging showed overall resolution of the aforementioned pathologies and is currently being followed up by the spinal surgeons on an outpatient basis.

Benign cystic mediastinal teratoma presenting as a massive pleural effusion in a 17-year-old boy.

Mediastinal teratomas are a rare, albeit an important differential diagnosis of anterior/middle mediastinal masses in young adults and various atypical presentations have been reported. The authors report a case of a 17-year-old boy who presented with a 2-month history of worsening shortness of breath and pleuritic chest pain. A massive left-sided pleural fluid collection was seen on a chest radiograph (CXR). The pleural fluid was drained and a CT Thorax confirmed the presence of a cystic mass. Following re-accumulation of the fluid, thoracotomy was performed and a benign mediastinal teratoma excised. The patient remained well with no evidence of recurrence on follow-up CXRs a year post operatively.

Coexistence of Takayasu Arteritis and Crohn's Disease in a Maltese Patient.

Takayasu arteritis (TA) and Crohn's disease (CD) are uncommon chronic granulomatous disorders affecting the large arteries and the gastrointestinal tract, respectively. At least 40 occurrences of these two conditions in the same patient have been reported in the literature, raising the possibility of an association between them. We report the coexistence of TA and CD in a young Maltese patient and review the literature to discuss possible aetiological mechanisms that might explain this association.

Intrathoracic schwannoma with Horner syndrome.

Horner syndrome (HS) results from the interruption of the sympathetic pathway to the eye and face, and describes a collection of signs consisting of ipsilateral miosis, partial ptosis, anhidrosis and apparent enophthalmos. It is a clinical observation, and has a plethora of possible causes, ranging from the benign to the malignant. Involvement of the stellate ganglion on the sympathetic chain by malignant tumours of the lung is a well-recognised cause of HS. On the other hand, HS secondary to the excessive growth of a benign intrathoracic neoplasm is a very rare finding, with only a few cases described in the literature. Our patient was found to have such a diagnosis when he presented to medical attention with a 1-month history of cough that was associated with features of HS that he had ignored for the preceding 9 years.