Twenty-Four Syndrome: An Untold Presentation of Pontine Hemorrhage.

Pontine hemorrhages are relatively uncommon. Various atypical manifestations of pontine stroke like eight-and-a-half syndrome, fifteen-and-a-half syndrome, and sixteen syndrome have been described in the past. We came across a case of pontine bleed that presented with bilateral facial palsy, bilateral horizontal gaze palsy, and contralateral sensorineural hearing loss accounting to the hitherto not described "twenty-four syndrome" with Horner's syndrome and left hemiparesis.

Afebrile scrub typhus infection with cardiac manifestation.

Scrub typhus is an acute febrile disease transmitted via bites from mite larvae (chigger) infected with Orientia tsutsugamushi. Arrhythmias, ischaemic changes and QT prolongation are some of the observed ECG abnormalities. The patient being reported presented with angina and was found to have sinus bradycardia with ST elevation in inferior leads and T wave inversion in lateral leads. His coronary angiography was normal. Further evaluation leads to the diagnosis of scrub typhus infection. Following doxycycline therapy, his ECG became normal. Afebrile scrub typhus infection with cardiac manifestation is an uncommon scenario.

Hashimoto's thyroiditis aggravated by goitrogenic diet presenting as rhabdomyolysis worsened by alcohol intake.

Hashimoto's thyroiditis (HT) is the most common form of primary hypothyroidism. Several muscular manifestations like pain, weakness, stiffness and elevated muscle enzymes have been noticed in hypothyroidism. Alcohol is also known to cause myositis and rhabdomyolysis. Patients with thyroid should avoid certain foods like broccoli, cauliflower and cabbage as they contain goitrogens. This is a case of a young man who presented with severe muscle aches and pain and was found to have rhabdomyolysis. Further evaluation revealed an underlying HT. Moreover, he had been consuming raw broccoli, which is goitrogenic, and alcohol which worsened the rhabdomyolysis. He was managed with levothyroxine and intravenous fluids, following which he improved.

Pituitary microadenoma with hypopituitarism presenting as hyponatremia.

The incidence of pituitary adenoma has been increasing these days. Majority of the cases are incidental findings on imaging; and these patients may be asymptomatic without any laboratory abnormalities. However, a non-functional sellar mass can initially present with hypopituitarism. The patient being described is an elderly female who presented with severe hyponatraemia. She has history of recurrent admissions for hyponatraemia in the past. Her biochemical evaluation revealed hypopituitarism and magnetic resonance imaging of brain showed pituitary microadenoma. Hyponatraemia as a presenting feature of hypopituitarism due to pituitary microadenoma is an uncommon scenario.

Normocomplementemic Urticarial Vasculitis: An Unusual Presentation.

Urticarial vasculitis (UV) is a form of cutaneous vasculitis which lasts for >24 h. Clinically, the patients present with erythema and wheals. The level of complement decides the type of UV. This is a case of a middle-aged lady, who developed vesiculobullous lesion over her leg after trekking. She was diagnosed to have normocomplementemic UV. Bullous presentation of UV is a rare scenario.

Total angiographic regression of coronary atherosclerosis with optimal medical therapy.

Coronary artery disease has shown a dramatic increase worldwide. According to the current guidelines, optimal medical therapy (OMT) is recommended as the first-line treatment for stable angina; with revascularisation being reserved for those with persistent or progressive symptoms despite intensive medical therapy. We report the case of a young man with stable angina, who was advised percutaneous coronary intervention for stenosis of left anterior descending artery. As he was not willing for the same, he was treated with OMT (according to the then relevant Adult Treatment Panel (ATP) III guidelines) and therapeutic lifestyle changes, following which he became asymptomatic along with total regression of the atherosclerotic plaque on coronary angiogram. This case highlights that OMT can be an effective line of management in patients with stable angina; and interventions like angioplasty, stents and surgery may be reserved for those who do not respond adequately.

Superior vena cava syndrome due to mediastinal Gardner fibroma presenting as syncope.

Superior vena cava (SVC) syndrome refers to the clinical manifestation due to an obstruction in the SVC; resulting in decreased venous return from the head, neck and upper extremities. The obstruction can occur either due to tumour invasion of the vessel wall with associated thrombus or due to vessel wall compression by the tumour mass. The patient being reported is a young male who presented with recurrent episodes of syncope and was found to have mediastinal Gardner fibroma causing SVC syndrome. Gardner fibroma is a benign soft tissue lesion; and its occurrence in the mediastinum resulting in SVC syndrome has not been reported yet.

Transient splenial lesion due to non-cirrhotic hyperammonaemia in dengue fever.

Transient splenial lesion(TSL) is seen in a variety of conditions and is detectable only on MRI of the brain. Dengue fever (DF) is a common viral infection encountered in the tropics. The affected patients may face neurological complications like encephalopathy and intracranial haemorrhage, or even ischaemic stroke. Non-cirrhotic hyperammonaemia is a rare scenario; and its occurrence in DF is unknown. The patient being described had DF and developed dysarthria. His MRI brain showed splenial hyperintensity. Further evaluation revealed non-cirrhotic hyperammonaemia. To the best of our knowledge, TSL due to non-cirrhotic hyperammonaemia in DF is an unreported scenario.

Rhabdomyolysis: a rare complication of Hashimoto's thyroiditis precipitated by statin therapy.

Hashimoto's thyroiditis (HT) or chronic lymphocytic thyroiditis is the most common form of primary hypothyroidism. Muscular manifestations like weakness, pain, stiffness and elevated muscle enzymes have been noticed in hypothyroidism. Statins are also known to cause myositis and rhabdomyolysis. This is a case of a middle-aged man, on statin therapy, who presented with severe muscle aches and pain and was found to have rhabdomyolysis. Further evaluation revealed an underlying HT as the culprit for his condition. He was managed with intravenous fluids and levothyroxine along with cessation of statins, following which he improved.

Solid pseudopapillary neoplasm of pancreas: an unusual aetiology for haematochezia.

Solid pseudopapillary neoplasm of the pancreas is a rare condition. It is mostly seen among young women, with abdominal pain as the presenting complaint. This is a case of a young woman who presented with haematochezia, and was found to have splenic vein thrombosis and left-sided portal hypertension as a result of mass lesion at the tail of the pancreas which was diagnosed as solid pseudopapillary neoplasm.

Pontine haemorrhage disguised as Bell's palsy.

Isolated facial nerve palsy is a common presentation of Bell's palsy, but rarely seen in pontine lesions. The patient being reported is a middle-aged man who developed isolated facial nerve palsy and was initially treated as Bell's palsy. However, on MRI of the brain, he was found to have pontine haemorrhage. He was managed conservatively and improved. Pontine haemorrhage as an aetiology for isolated facial nerve palsy is a rare scenario, which often goes misdiagnosed and treated as Bell's palsy.

Multiple renal calculi due to hypercalcaemia induced by over-the-counter vitamin D intoxication.

Renal stone disease is a common and painful condition. Even though it is rarely fatal, patients describe it as the worst pain in their life. While dietary calcium may decrease the risk of stone formation, patients on supplemental calcium are at higher risk. Moreover, patients with diabetes are more prone to develop renal calculi. Hypervitaminosis D is a rare cause of hypercalcaemia. This is a case of an elderly diabetic man who developed multiple calcium oxalate renal stones due to hypercalcaemia following calcium-vitamin D supplementation.

Severe bone marrow suppression due to methotrexate toxicity following aceclofenac-induced acute kidney injury.

Methotrexate is one of the most commonly used drugs in autoimmune disorders like rheumatoid arthritis. Gastrointestinal symptoms like nausea and stomatitis, skin rashes, alopecia, central nervous system symptoms like headache and confusion, hepatotoxicity and myelosuppression are some of the adverse effects. However, low oral doses on a weekly basis seldom show any signs of toxicity. Leucovorin or folinic acid is given along with methotrexate as rescue to reduce the toxic effects like bone marrow suppression. Non-steroidal anti-inflammatory drugs, like aceclofenac, are also used in chronic inflammatory conditions like rheumatoid arthritis and osteoarthritis. Nephrotoxicity is one of the adverse effects of both methotrexate and non-steroidal anti-inflammatory drugs; and its combined administration should be done with caution. This is a case of an elderly woman, a known case of rheumatoid arthritis, who presented in severe bone marrow suppression due to methotrexate toxicity following aceclofenac-induced acute kidney injury.

Pyopericardium progressing to tamponade in a patient with immune thrombocytopenia.

Pericardial effusion can develop during any stage of pericarditis, and small effusions that appear rapidly can cause cardiac tamponade. Pyopericardium is a rare aetiology for tamponade. This is a case of an elderly diabetic lady, on steroid therapy for immune thrombocytopenia, who presented with fever and acute dyspnoea. She developed cardiac tamponade due to pyopericardium with Staphylococcus as the causative organism. Staphylococcus pyopericardium, in the absence of a primary focus of infection, progressing to tamponade is an uncommon scenario.

Blue Finger Syndrome: An Unusual Presentation of Rheumatoid Arthritis.

Blue Finger Syndrome (BFS) is a benign and rare condition with an idiopathic aetiology. It is characterised by an acute bluish discoloration of fingers which may be accompanied by pain. This is a case of a middle aged female who presented with painless bluish discoloration of right hand and was diagnosed to have BFS. Though BFS is idiopathic, our patient on evaluation was found to have an underlying Rheumatoid Arthritis (RA). Patients with RA are subject to Raynaud's phenomenon; but BFS presenting in a patient with RA is a rare scenario.

A Case of Macrophage Activation Syndrome with Acute Respiratory Distress Syndrome.

Macrophage Activation Syndrome (MAS) is a rare form of Haemophagocytic Lymphohistiocytosis (HLH) associated with rheumatologic conditions. It is characterised by haemophagocytosis and cytokine overproduction, resulting from the activation and uncontrolled proliferation of T lymphocytes and macrophages. The patient being reported is an elderly female with Rheumatoid Arthritis (RA), who presented with fever and was found to have MAS. She later developed Acute Respiratory Distress Syndrome (ARDS) and died. Such a scenario has rarely been reported.

Delirium in Parkinson's Disease: A Cocktail Diagnosis.

Mental disturbances have been described in patients with Parkinson's Disease (PD). Of these, the common conditions are delirium and psychosis. Delirium has been attributed to change of environment, especially hospital stay and infections; while psychosis is due to drugs like dopamine agonists. This is a case of a 75-year-old male, on levodopa therapy for PD, who presented with delirium and ended up with a cocktail diagnosis: Cryptococcal meningitis, Hashimoto's Encephalopathy (HE), Urinary tract infection with acute renal failure, Uremic encephalopathy and Levodopa induced psychosis. This case report, therefore, highlights the need to look for other causes of delirium in a patient with PD who is on levodopa therapy.