Spontaneous Subdural Haemorrhage: A Rare Association with Plasmodium Vivax Malaria.

Malaria is an endemic disease in tropical countries and disease of universal importance. Central Nervous System (CNS) complications of malaria are severe and associated with significant mortality. Thrombocytopaenia in malaria causing haemorrhagic CNS complications is rare. We report a case of 35-year-old male patient presented with headache, vomiting and was diagnosed to have subdural haemorrhage (SDH). On examination patient was found to be febrile with peripheral smear showing evidence of Plasmodium vivax (P.vivax) infection with severe thrombocytopaenia. In endemic regions with malaria, SDH being rare presentation of malaria should be considered as a differential diagnosis in febrile patients with neurological manifestations. Rarity of spontaneous SDH in malaria and raising awareness amongst treating physicians about the same is the driving factor for reporting this case.

Community-acquired multidrug-resistant Gram-negative bacterial infective endocarditis.

We describe two cases of bacterial endocarditis secondary to multidrug-resistant Gram-negative organisms. In both cases, the diagnosis was made in accordance with the modified Duke's criteria and confirmed by histopathological analysis. Furthermore, in both instances there were no identifiable sources of bacteraemia and no history of contact with hospital or other medical services prior to the onset of symptoms. The patients were managed in similar fashion with prolonged broad-spectrum antibiotic therapy and surgical intervention and made complete recoveries. These cases highlight Gram-negative organisms as potential agents for endocarditis, as well as expose the dissemination of such multidrug-resistant bacteria into the community. The application of an integrated medical and surgical approach and therapeutic dilemmas encountered in managing these cases are described.

Primary presentation of chronic calcific pancreatitis with massive unilateral pleural effusion.

We described a 45-year-old previously healthy man presenting with progressively worsening breathlessness for 10 days. Physical examination was suggestive of a left-sided pleural effusion. A chest X-ray was confirmatory. Analysis of aspirated fluid showed a lymphocytic exudate with grossly elevated amylase and lipase levels. CT revealed chronic calcific pancreatitis as the underlying cause of effusion. Retrospective questioning failed to identify classical symptoms of chronic pancreatitis including abdominal pain and steatorrhoea. The patient was managed with intercostal drainage and supportive care. Although unusual, chronic pancreatitis should be kept as a differential diagnosis in patients with unilateral exudative pleural effusion. Elevated fluid levels of amylase and lipase are useful clues to this uncommon diagnosis.

Severe unconjugated hyperbilirubinaemia: one and one makes three?

A 38-year-old housewife presented with a 3-month history of gradually progressive fatigue and deepening jaundice as well as a history of mild fluctuating jaundice since childhood. General examination revealed an obvious icterus. Systemic examination was normal. Laboratory tests confirmed unconjugated hyperbilirubinaemia. Further evaluation yielded a diagnosis of vitamin B12 deficiency on a background of Gilbert's syndrome.

Primary presentation with acute flaccid quadriparesis in Sjogren's syndrome sans sicca.

We report the case of a 40-year-old housewife, who presented with vomiting since past 5 days and weakness of all four limbs since 1 day. Clinical examination confirmed the presence of flaccid quadriparesis with preserved tendon reflexes. Routine laboratory parameters showed severe hypokalaemia. On further evaluation she was diagnosed to have type 1 renal tubular acidosis secondary to Sjogren's syndrome. Sicca symptoms were conspicuous by their absence.