Primary Sjogren's syndrome presenting as an isolated severe autonomic dysfunction treated with steroids.

Primary Sjogren's syndrome (pSS) is an autoimmune connective tissue disorder with multisystem manifestations. We here report a previously healthy woman who presented with autonomic dysfunction in the form of severe dizziness without any apparent sensory neuropathy. Detailed history and examination revealed the signs and symptoms of Sjogren's syndrome such as constipation and dry eyes and mouth, following which anti-SSA and SSB antibodies were found to be positive. Finally, a diagnosis of pSS was established after ruling out all the other causes of autonomic dysfunction in addition to the clinical and laboratory evidence. The patient was treated with the maximum doses of midodrine and fludrocortisone, yet no progress was noticed. Hence, a trial of steroids was started and she showed a significant clinical improvement. Our patient presented with pure autonomic failure associated with Sjogren's syndrome, making it an extremely rare entity.

A Case of Massive Gastrointestinal Bleeding Due to Abdominal Tuberculosis.

This case is about a complication of abdominal tuberculosis in the form of a massive lower gastrointestinal (GI) bleed, which was timely intervened by angioembolization. A young man in his mid-20s on empirical anti-tubercular therapy (ATT) for abdominal tuberculosis, presented with severe abdominal pain. The patient then developed frank per rectal bleeding, leading to a significant drop in hemoglobin level, requiring multiple blood transfusions. Upper GI endoscopy and colonoscopy findings were inconclusive. Contrast-enhanced computed tomography (CECT) of the abdomen was performed, which revealed a contrast extravasation into the jejunum due to a leak in the jejunal branch of the superior mesenteric artery (SMA), followed by selective SMA angiography (digital subtraction angiography), which was arrested by angioembolization. The patient had multiple abdominal lymphadenopathies with omental nodules. Histopathological examination of the omental nodules revealed epithelioid granuloma with Langerhans-type cells. The patient is currently receiving ATT and is doing well.

Spontaneous muscle haematoma in a patient with cirrhosis.

Decompensated liver disease is associated with alterated haemostasis that can either lead to spontaneous bleeding or development of thrombosis. Alcohol consumption coupled with advanced liver disease favours spontaneous bleeding. There have been only few documented cases of spontaneous muscle haematoma (SMH) in patients with cirrhosis. The pathogenesis of SMH is hypothesised to be multifactorial and it has been seen in patients on anticoagulation or with haemostatic disorders. We report a case of alcohol-related cirrhosis presenting with an expanding, voluminous haematoma in the intermuscular plane between the trapezius and the teres major muscles. This patient also had a retroperitoneal haemorrhage, clinically evidenced by the Grey Turner's and Cullen's signs. Haemorrhage was confirmed radiologically by CT. The patient was managed in an intensive care facility and treated with multiple blood products, including packed red blood cells, fresh frozen plasma and cryoprecipitates. However, as his clinical condition deteriorated, he required surgical intervention by incision and drainage, followed by evacuation. Early identification of coagulopathy and aggressive treatment are essential in these cases of cirrhosis to avoid unfavourable outcomes.