Para-spinal abscess presenting with abdominal pain-a case report of 'red herring' symptoms.

INTRODUCTION: Paraspinal abscesses are rare infections affecting the paraspinal muscles and soft tissues. An evolving abscess may pose a threat to the spinal cord via the compressive effect which can manifest as impaired motor or sensory function at the corresponding vertebral level. Paraspinal abscess is often a late diagnosis due to non-specific symptoms at presentation. This results in high morbidity and mortality. CASE PRESENTATION: We describe the case of a 59-year-old female with a paraspinal abscess presenting with epigastric pain who was initially worked up for a suspected intra-abdominal pathology, however computerised tomography of the chest, abdomen, and pelvis (CTCAP) revealed no abnormality. Later, rising inflammatory markers, accompanied by worsening cervicalgia, prompted a CT of the head, neck and thorax which revealed a soft tissue abscess compressing the thecal sac at cervical levels 1 to 3 (C1-3). This was successfully managed with radiologically guided drainage and long-term intravenous antibiotics. Our patient made a full recovery and a repeat MRI demonstrated resolution of the abscess. CONCLUSION: We demonstrate that spinal abscess can present with a misleading combination of symptoms and highlight the importance of considering rarer differentials in the face of an evolving clinical picture. Our case also demonstrates that once the correct diagnosis is reached, patients can make an excellent recovery from uncomplicated spinal abscesses.

Spondylodiscitis-a cohort analysis of its identification and management.

PURPOSE: Discitis represents infection of the intervertebral disc and osteomyelitis of the adjacent end plates. Classically, patients present with fever and back pain. Varied presentations and lack of adherence to guidelines lead to great variation in its identification and management. The primary objective of this study was to conduct a cohort analysis, assessing the identification and management of discitis, in a busy secondary orthopaedic centre. METHODS: A retrospective study was conducted, of cases diagnosed and treated for discitis, in a secondary orthopaedic department, within the UK from January 2017 to October 2019. During this time period, all patients who underwent magnetic resonance imaging (MRI) spine were identified. Patients with MRI-proven discitis were then added into the study. RESULTS: A total of 152 MRIs showed radiographic features of discitis. Of these, only 38 had a clear clinical correlation. Back pain was the most common presenting complaint followed by fever. The commonest site of involvement was vertebral levels L5 and S1. All patients had baseline bloods, and most, but not all, had blood cultures taken. Staphylococcus aureus was the most frequently isolated, causative organism. The mainstay of treatment was intravenous flucloxacillin, with most patients requiring a minimum of six weeks. CONCLUSION: Our study has helped define the population of patients presenting with discitis, in a busy secondary orthopedic center. Analyzing over two years of data has provided us with valuable insight into the most appropriate diagnostics and management for discitis.

Case-report: A rare cause of intestinal obstruction in late pregnancy.

INTRODUCTION: Caecal volvulus represents a rare and often life-threatening cause of intestinal obstruction. Diagnosis and management of caecal volvulus remains a clinical challenge, since those presenting with symptoms can have vague nonspecific presentations. Symptoms eventually occur, usually secondary to obstruction or ischaemia. This case report will discuss the presentation, investigation and management options available. PRESENTATION: A 31-year-old multigravida, at 38 weeks and 6 days gestation; presented to hospital with a 2-day history of diffuse abdominal pain and distension. Initial examination was unremarkable aside from mild epigastric tenderness. Raised inflammatory markers and concerns for foetal health resulted in an emergency caesarean section. Symptoms however worsened and the patient underwent colonoscopy and computerised tomography (CT) of the abdomen and pelvis with contrast; showing caecal volvulus. The patient was taken to the operating theatres for an emergency right hemicolectomy with formation of end ileostomy. Intra-operatively, areas of necrosis were noted within the caecum suggestive of impending perforation. The patient recovered well post reversal of end ileostomy, with no complications to date. DISCUSSION: Caecal volvulus represents a rare, but potentially fatal cause of intestinal obstruction and ischaemia. High mortality rates are attributed to delayed diagnosis and treatment. Patients may initially present with vague symptoms, which rapidly progress with the development of ischaemia. Multiple management modalities exist. Central to prognosis is early diagnosis. CONCLUSION: Early diagnosis and intervention are paramount. Imaging via abdominal x-rays and CT are of particular importance. Surgical management is widely reported as the mainstay of treatment. We advise clinicians to remember this rare diagnosis, as a potential cause of abdominal pain and intestinal obstruction; especially in those with predisposing risk factors.

Inotropic Agents and Vasopressors in the Treatment of Cardiogenic Shock.

BACKGROUND: Worldwide, cardiogenic shock (CS) is the leading cause of death in patients admitted with an acute myocardial infarction (AMI). CS is characterised by reduced cardiac output secondary to systolic dysfunction which can lead to multi-organ failure. The mainstay of medical treatment in CS are inotropes and vasopressors to improve cardiac output. However, current clinical guidelines do not direct clinicians as to which agents to use and in what combinations. This article aims to review the current evidence on the management of CS with a major focus on the use of inotropes and vasopressors. METHOD: A literature review was conducted analysing published literature from the following databases: PubMed, MedLine, Cochrane Library and Embase, as well as a manual search of articles that were deemed relevant. Relevant articles were identified by using keywords such as "cardiogenic shock". RESULTS: Literature was assessed to review the use of inotropes and vasopressors in CS. Dopamine and adrenaline were associated with increased mortality and arrhythmias. Dobutamine was associated with an improvement in cardiac output, at the determinant of causing arrhythmias. Conversely, noradrenaline was associated with a lower likelihood of arrhythmias and most importantly decreased mortality in CS. Compared to other inotropes, levosimendan appears to have a better safety profile and is associated with decreased mortality in CS, particularly when combined with a vasopressor. Our literature review suggests that treatment combination of the inotrope levosimendan with the vasopressor noradrenaline may be the most effective management option in CS.

Case-report: A rare cause of an intra-abdominal mass.

INTRODUCTION: Mesenteric cysts are a rare and often asymptomatic incidental finding on imaging. The diagnosis and management of mesenteric cysts remains a clinical challenge since those presenting with symptoms, often have vague and nonspecific symptoms, owing to variability in cyst location and size. This case report will aim to discuss the presentation, investigation and management options available. PRESENTATION: A 73-year-old female presented with abdominal swelling and a palpable right sided mass. Examination revealed a right sided mass and abdominal distention with vital signs within normal limits. Ultrasound scan (USS) revealed a right-sided 12 cm × 11 cm × 8 cm thin walled cyst. DISCUSSION: Mesenteric cysts are mostly asymptomatic but can cause nonspecific symptoms of abdominal pain, abdominal distension, altered bowel habit, nausea, vomiting and an abdominal mass. Complete surgical excision, either laparoscopically, or through a laparotomy is typically considered first line treatment. If size or location of the cyst precludes complete surgical excision, partial excision with marsupialisation of the opening of the cyst into the abdominal peritoneal cavity is a second option. CONCLUSION: Mesenteric cysts represent a rare cause of intra-abdominal mass. Owing to low prevalence, literature is limited as is guidance on management. Careful pre-operative planning is essential so as to avoid operative complications. Imaging such as USS is of great importance; however Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) may be of more benefit, owing to the complex anatomical relations within which mesenteric cysts can present. Surgical excision is widely reported as the surgical treatment of choice for symptomatic cysts.

Gone in the blink of an eye - A Tolosa-Hunt syndrome variant.

Tolosa-Hunt syndrome is a rare disorder characterized by severe peri-orbital headache and ophthalmoplegia resulting from pseudotumour in the cavernous sinus compressing structures within it, namely cranial nerves III, IV, and VI and the superior divisions of cranial nerve V. We report the case of a 47 year old female who presented with painless left unilateral ptosis and complete external ophthalmoplegia. Magnetic Resonance Imaging (MRI) identified an enhancing heterogeneous mass filling the left cavernous sinus, following the course of the oculomotor nerve. After 2 weeks symptoms and signs resolved and there was a parallel resolution of the MRI findings, without the administration of corticosteroids. As far as we are aware this is one of the first reports of Tolosa-Hunt syndrome variant, with painless neurological involvement confined solely to the oculomotor nerve, and with complete resolution without pharmacological intervention.

Case-report: A rare cause of an intra-abdominal mass.

INTRODUCTION: Mesenteric cysts are a rare and often asymptomatic incidental finding on imaging. The diagnosis and management of mesenteric cysts remains a clinical challenge since those presenting with symptoms, often have vague and nonspecific symptoms, owing to variability in cyst location and size. This case report will aim to discuss the presentation, investigation and management options available. PRESENTATION: A 73-year-old female presented with abdominal swelling and a palpable right sided mass. Examination revealed a right sided mass and abdominal distention with vital signs within normal limits. Ultrasound scan (USS) revealed a right-sided 12 cm × 11 × cm × 8 cm thin walled cyst. DISCUSSION: Mesenteric cysts are mostly asymptomatic but can cause nonspecific symptoms of abdominal pain, abdominal distension, altered bowel habit, nausea, vomiting and an abdominal mass. Complete surgical excision, either laparoscopically, or through a laparotomy is typically considered first line treatment. If size or location of the cyst precludes complete surgical excision, partial excision with marsupialisation of the opening of the cyst into the abdominal peritoneal cavity is a second option. CONCLUSION: Mesenteric cysts represent a rare cause of intra-abdominal mass. Owing to low prevalence, literature is limited as is guidance on management. Careful pre-operative planning is essential so as to avoid operative complications. Imaging such as USS is of great importance; however Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) may be of more benefit, owing to the complex anatomical relations within which mesenteric cysts can present. Surgical excision is widely reported as the surgical treatment of choice for symptomatic cysts.