We report a case of a young female patient with American Society of Anaesthesiologists Physical Status Class I who underwent functional endoscopic sinus surgery under routine general anaesthesia. After patient positionin...We report a case of a young female patient with American Society of Anaesthesiologists Physical Status Class I who underwent functional endoscopic sinus surgery under routine general anaesthesia. After patient positioning, a sudden increase in peak airway pressures was noted, and kinking of the endotracheal tube (ETT) was observed. Bougie-assisted ETT exchange was performed. After an otherwise uneventful surgery, the patient was extubated and transferred to the post-anaesthesia care unit before being discharged to the ward. Several hours later she developed tachypnoea and tachycardia with a drop in oxygen saturation and decreased air entry on the right side of her chest. Radiological imaging confirmed a right pneumothorax. An intercostal chest drain was placed, which allowed for gradual re-expansion of the lung and clinical improvement. She was subsequently discharged from the hospital. Pneumothorax was presumed to be secondary to airway trauma during bougie-guided tube exchange.
Hypothyroidism is a common endocrine disorder with potential multi-system involvement. While pericardial effusion may occur in up to 30% of patients with hypothyroidism, cardiac tamponade is rare.We present a case of a w...Hypothyroidism is a common endocrine disorder with potential multi-system involvement. While pericardial effusion may occur in up to 30% of patients with hypothyroidism, cardiac tamponade is rare.We present a case of a woman in her mid 60s who came with complaints of progressive dyspnoea on exertion, apathy, cold intolerance and weight gain. Clinically, she was hypotensive, tachypnoeic and hypoxic but had a normal pulse rate. Echocardiography revealed massive pericardial effusion with cardiac tamponade. She was managed with urgent pericardiocentesis and oral thyroxine replacement.Cardiac tamponade is a medical emergency that necessitates immediate intervention. Our case underscores the need to suspect hypothyroidism as the underlying cause in a patient presenting with cardiac tamponade with a normal heart rate or bradycardia.
A woman with multiple comorbidities developed acute respiratory distress within minutes of intravenous iohexol administration for abdominal imaging. She presented with severe hypoxaemia, bilateral pulmonary crackles and...A woman with multiple comorbidities developed acute respiratory distress within minutes of intravenous iohexol administration for abdominal imaging. She presented with severe hypoxaemia, bilateral pulmonary crackles and diffuse opacities on chest imaging without evidence of cardiac dysfunction. Bedside echocardiography and brain natriuretic peptide levels excluded cardiogenic pulmonary oedema. A diagnosis of contrast-induced non-cardiogenic pulmonary oedema was made. She required non-invasive ventilation and supportive therapy with complete resolution over 1 week. This case highlights a rare, life-threatening but reversible reaction to iodinated contrast and underscores the importance of early recognition, prompt respiratory support and readiness with resuscitation equipment during contrast administration.
Extraintestinal () infection rarely involves bone and can mimic malignancy. A man in his 70s with chronic kidney disease presented with a longstanding, painless, fluctuant anterior lower leg mass without systemic or gas...Extraintestinal () infection rarely involves bone and can mimic malignancy. A man in his 70s with chronic kidney disease presented with a longstanding, painless, fluctuant anterior lower leg mass without systemic or gastrointestinal symptoms. Imaging showed a proximal tibial lytic lesion and aspiration of a superficial collection grew Symptoms persisted despite 4 weeks of oral amoxicillin-clavulanate (875-125 mg every 12 hours) plus oral metronidazole (500 mg every 8 hours). MRI demonstrated chronic tibial osteomyelitis with cortical disruption and a contiguous intramedullary and soft tissue abscess consistent with a Brodie's abscess. He underwent excisional debridement with dead-space management and local vancomycin, followed by prolonged pathogen-directed antimicrobials. Two deep intraoperative cultures again yielded rare with negative aerobic and blood cultures. He improved without amputation and remained stable at 9-month follow-up.
Organising pneumonia (OP) is a lung inflammation-repair pattern characterised by rapid and complete resolution. In rare instances, it may progress to respiratory failure with poor outcomes due to steroid unresponsiveness...Organising pneumonia (OP) is a lung inflammation-repair pattern characterised by rapid and complete resolution. In rare instances, it may progress to respiratory failure with poor outcomes due to steroid unresponsiveness and limited treatment options. A man in his 70s presented with shortness of breath, without accompanying symptoms, signs or laboratory markers of infection. Broad-spectrum antibiotics and corticosteroids were administered. An extensive infectious and immunological workup yielded negative results. Despite these interventions, the patient's oxygen requirements increased, necessitating invasive mechanical ventilation. OP was confirmed on biopsy. The patient's respiratory status did not improve and he was unable to be weaned from mechanical ventilation, ultimately resulting in death. This case prompted a review of the literature on rapidly progressive OP, a rare subset of steroid-refractory cases and treatments trialled by other authors. Alternative immunosuppressive treatments include mycophenolate, cyclosporine, rituximab and intravenous immunoglobulin but their use is limited to case reports and series.
Opsoclonus is a poorly understood abnormality of saccades, possibly associated with autoantibodies precipitated by infections or neoplasms. It is essential to identify infection-associated opsoclonus to ensure proper man...Opsoclonus is a poorly understood abnormality of saccades, possibly associated with autoantibodies precipitated by infections or neoplasms. It is essential to identify infection-associated opsoclonus to ensure proper management and prognostication. Timely treatment may help complete recovery in select cases.
Management of large corneal perforations in patients with rheumatoid arthritis is often challenging. It is further challenging when associated with advanced cataracts. We describe a case of corneal perforation in a patie...Management of large corneal perforations in patients with rheumatoid arthritis is often challenging. It is further challenging when associated with advanced cataracts. We describe a case of corneal perforation in a patient with secondary Sjogren's syndrome, which was initially managed with cyanoacrylate glue and amniotic membrane as temporising measure. However, during the follow-up at 8 weeks, he developed advanced cataract in the same eye. He was successfully managed with a tectonic posterior corneal lamellar graft with phacoemulsification and intraocular lens (IOL) implantation. Phacoemulsification was performed with glue in situ, as trypan blue dye leakage was observed at the beginning of the procedure. Successful capsulorrhexis and low flow settings during phacoemulsification with anterior chamber maintainer during lenticule insertion lead to a successful end result with a clear cornea and in the bag IOL placement. The patient's vision improved to 6/9 with a scleral contact lens. All along this period, systemic immunosuppression was maintained.
This case presents a progression from benign focal nodular hyperplasia (FNH) to hepatocellular carcinoma (HCC) in a middle-aged patient undergoing private testosterone therapy for andropause. The patient presented to the...This case presents a progression from benign focal nodular hyperplasia (FNH) to hepatocellular carcinoma (HCC) in a middle-aged patient undergoing private testosterone therapy for andropause. The patient presented to their general practitioner with fatigue and pruritus; routine blood tests showed deranged liver function tests. Historical records indicated a large FNH lesion that was stable for decades and required no intervention.Subsequent imaging demonstrated a mass within the right lobe suggestive of malignant transformation. Multidisciplinary discussion concluded the lesion likely represented HCC or hepatic adenoma. The patient underwent a successful robotic right hemihepatectomy. Histopathology confirmed well-differentiated HCC with macroscopic vascular invasion (pT2N0M0). Postoperative imaging showed no evidence of recurrence or metastasis, and liver function returned to normal.This case underscores the potential for malignant transformation in large FNH-like lesions despite prolonged radiological stability. It emphasises the role of imaging surveillance and robotic surgery as effective curative strategies.
Intestinal tuberculosis (TB) most commonly involves the ileo-caecal region. Isolated involvement of the jejunum without concomitant ileo-caecal or colonic disease is exceptionally rare. We report the case of a woman in h...Intestinal tuberculosis (TB) most commonly involves the ileo-caecal region. Isolated involvement of the jejunum without concomitant ileo-caecal or colonic disease is exceptionally rare. We report the case of a woman in her early 60s who presented with a 2-year history of postprandial abdominal pain, intermittent constipation, anorexia and weight loss, followed by acute-onset vomiting suggestive of small bowel obstruction. Contrast-enhanced CT demonstrated a short-segment jejunal stricture with proximal dilatation. Enteroscopy confirmed luminal narrowing. Ileo-colonoscopy showed no ileo-caecal involvement. The patient underwent laparoscopy-assisted segmental jejunal resection. Histopathology revealed necrotising epithelioid granulomatous inflammation consistent with TB. Cartridge-based nucleic acid amplification test (GeneXpert MTB/RIF assay system, Cepheid, Sunnyvale, California, USA) was negative. She was commenced on standard antitubercular therapy with a good clinical response. This case highlights the importance of considering TB in isolated small bowel strictures in endemic regions, even in the absence of ileo-caecal disease or systemic features.
We present a middle childhood boy with type 1b diabetes mellitus (defined as insulin-dependent diabetes mellitus without evidence of autoimmunity) diagnosed at the age of 4 years who was on a basal bolus insulin regimen....We present a middle childhood boy with type 1b diabetes mellitus (defined as insulin-dependent diabetes mellitus without evidence of autoimmunity) diagnosed at the age of 4 years who was on a basal bolus insulin regimen. Identifying the presence of bilateral optic atrophy in him during an ophthalmological evaluation led to a closer clinical assessment for Wolfram syndrome. Although there was no hearing loss on the audiogram and no evidence presently of arginine vasopressin (AVP) deficiency, we proceeded with genetic testing by next-generation sequencing. This confirmed the diagnosis of Wolfram syndrome with significant prognostic implications. Wolfram syndrome, also known as DIDMOAD (Diabetes Insipidus, Diabetes Mellitus, Optic Atrophy and Deafness), is a rare autosomal recessive neurodegenerative disorder primarily caused by mutations in the and genes. It is characterised by early-onset insulin-dependent diabetes mellitus, progressive bilateral optic atrophy, hearing loss and AVP deficiency. Other complications include neurological degeneration, urinary tract dysfunction, psychiatric disturbances and eventually respiratory failure. This case emphasises the importance of early diagnosis, genetic confirmation and a multidisciplinary approach in clinical management.
A woman in her early 20s underwent bilateral photorefractive keratectomy (PRK) for correction of myopia. She developed bilateral central corneal melt 3 weeks post-operatively. There was no response to oral antivirals (fo...A woman in her early 20s underwent bilateral photorefractive keratectomy (PRK) for correction of myopia. She developed bilateral central corneal melt 3 weeks post-operatively. There was no response to oral antivirals (for presumed necrotising stromal keratitis) and oral steroids (for presumed immune-mediated melt). She gradually developed pigmented corneal infiltrates and microbiology revealed a fungal infection. Despite intensive antifungal therapy, she developed corneal perforations. After applying tissue adhesive as a temporary measure, she was referred for further management. Bilateral Tenon's patch grafts (TPG) were performed and the infection resolved with antifungal therapy. Three months later, her vision improved to 20/40, which was maintained even at the 1-year follow-up.Bilateral corneal melt following PRK is uncommon. A high index of suspicion is required to identify microbial keratitis as a potential cause, especially since sterile infiltrates are also known post-PRK. TPG serves as an effective option in such a situation.
Cerebral oedema is a rare and potentially lethal complication of diabetic ketoacidosis (DKA). While more commonly reported in the paediatric population, adult cerebral oedema in the setting of DKA remains poorly understo...Cerebral oedema is a rare and potentially lethal complication of diabetic ketoacidosis (DKA). While more commonly reported in the paediatric population, adult cerebral oedema in the setting of DKA remains poorly understood and under-recognised. We present the case of a woman in her late 20s who was brought to the emergency department with severe DKA and altered mental status. Her imaging demonstrated diffuse cerebral oedema with effacement of sulci and basal cisterns. Notably, the oedema was identified before significant metabolic correction had occurred, suggesting that cerebral oedema may have been a direct consequence of DKA rather than a complication of its treatment. The patient received fluid resuscitation, insulin infusion and hyperosmolar therapy, and recovered fully without neurosurgical intervention. This case highlights the importance of early recognition and intervention for cerebral oedema in adult DKA, especially in patients presenting with severe acidosis and neurologic changes.
A girl with very early-onset inflammatory bowel disease due to a loss-of-function mutation (c.611G>A p.Trp204*) presented in infancy with severe Crohn's disease-like colitis requiring colectomy. Two matched-sibling allo...A girl with very early-onset inflammatory bowel disease due to a loss-of-function mutation (c.611G>A p.Trp204*) presented in infancy with severe Crohn's disease-like colitis requiring colectomy. Two matched-sibling allogeneic haematopoietic stem cell transplantations using treosulfan-based conditioning engrafted transiently but ultimately failed with autologous recovery and immune cytopenias. A third transplant from the same donor with busulfan/fludarabine/melphalan plus serotherapy and peripheral blood stem cells achieved durable engraftment. Acute skin and gut graft-versus-host disease responded to corticosteroids and etanercept. On long-term follow-up, the patient remained off immunosuppression with stable donor chimerism, normal immunoglobulins, nutritional catch-up (weight), preserved puberty and regular menses though short stature persisted.
Fungal keratitis is a serious ocular infection that can result in permanent vision loss if not promptly diagnosed and treated. A healthy woman in her early 20s developed keratitis nearly 2 weeks after an ocular trauma wi...Fungal keratitis is a serious ocular infection that can result in permanent vision loss if not promptly diagnosed and treated. A healthy woman in her early 20s developed keratitis nearly 2 weeks after an ocular trauma with an organic material, a cardboard paper, on her left eye. Ocular examination revealed a mid-stromal corneal infiltrate with brush-like borders and hypopyon. The Giemsa stain of the corneal scraping demonstrated branching septated hyphae, and fungal culture grew resistant to amphotericin B. She was successfully treated with topical natamycin 5% drops for 2 weeks, leading to complete eradication of the corneal infection with a residual stromal scar. This case documented a rare fungal aetiology in post-traumatic keratitis in a tropical country, successfully treated with natamycin 5%. Despite the virulence of , the infection was promptly treated, resulting in a good functional vision.
We report a case of three bezoars identified on computed tomography (CT) in a paediatric patient presenting with acute small bowel obstruction. The bezoars were surgically removed via laparotomy with gastrotomy and enter...We report a case of three bezoars identified on computed tomography (CT) in a paediatric patient presenting with acute small bowel obstruction. The bezoars were surgically removed via laparotomy with gastrotomy and enterotomy, confirming their classification as trichobezoars. A trichobezoar is a mass of undigested hair in the gastrointestinal tract (GIT). This case report demonstrates the use of CT in the diagnosis of this extremely rare case.
We report a rare and potentially life-threatening case of a young male with Behçet's disease complicated by Hughes-Stovin syndrome who presented with massive haemoptysis secondary to multiple pulmonary artery aneurysms w...We report a rare and potentially life-threatening case of a young male with Behçet's disease complicated by Hughes-Stovin syndrome who presented with massive haemoptysis secondary to multiple pulmonary artery aneurysms with associated thrombosis. The patient presented to the emergency department with a 20-day history of cough and fever, followed by acute worsening haemoptysis over 2 days, accompanied by haemodynamic instability. Initial CT pulmonary angiography demonstrated multiple bilateral saccular pulmonary artery aneurysms involving the descending and segmental branches, with partial and complete thrombosis. Transthoracic echocardiography revealed an associated right ventricular thrombus.The patient required emergency airway protection, blood transfusion and vasopressor support. A multidisciplinary team involving pulmonology, rheumatology, cardiothoracic surgery and interventional radiology was engaged. High-dose systemic corticosteroids and immunosuppressive therapy were initiated for underlying vasculitis. Given the inaccessibility of the aneurysms for surgical repair, endovascular embolisation was recommended as definitive management. Despite transient relapses of haemoptysis during subsequent admissions, the patient was stabilised with aggressive immunosuppression and successfully underwent vascular intervention.This case highlights the importance of early recognition of vascular Behçet's disease and Hughes-Stovin syndrome as rare but critical causes of massive haemoptysis in young patients. Hughes-Stovin syndrome is a rare vasculitic disorder characterised by pulmonary artery aneurysms and thrombosis and is considered a cardiovascular variant of Behçet's disease. Rupture of pulmonary artery aneurysms frequently presents with massive haemoptysis and is associated with high mortality. Prompt multidisciplinary management combining immunosuppressive therapy and endovascular intervention is essential to prevent fatal complications.
Methaemoglobinaemia is a rare disorder due to an increase in the amount of a variant of haemoglobin known as methaemoglobin (MetHb), which decreases the oxygen-carrying capacity of blood. It is usually caused by enzyme d...Methaemoglobinaemia is a rare disorder due to an increase in the amount of a variant of haemoglobin known as methaemoglobin (MetHb), which decreases the oxygen-carrying capacity of blood. It is usually caused by enzyme deficiency. Hb Q India is another rare alpha-chain variant haemoglobinopathy. A young primigravida was referred due to low oxygen saturation. She was otherwise asymptomatic. Patient was received with peripheral cyanosis and in a tachypneic state due to advanced labour. On the pulse oximeter, oxygen saturation was found to be 40%; hence, the patient was immediately intubated, and instrumental delivery was conducted. A detailed workup showed high MetHb levels, and the Hb Q India variant was detected on HPLC. We present this case report of dual haemoglobinopathy, which can pose a great diagnostic dilemma.Methaemoglobinaemia is usually an asymptomatic disease and is managed conservatively, but if symptomatic, it requires intensive management to avoid fatality.
Ocular amyloidosis is rare, and lacrimal gland involvement is even more uncommon. We present a case of bilateral lacrimal gland enlargement, diagnosed as amyloidosis through histopathological examination. Further evaluat...Ocular amyloidosis is rare, and lacrimal gland involvement is even more uncommon. We present a case of bilateral lacrimal gland enlargement, diagnosed as amyloidosis through histopathological examination. Further evaluation revealed elevated serum free light chains with a positive difference between involved and uninvolved free light chains in electrophoresis, whereas all other investigations showed no evidence of systemic involvement. Although systemic amyloidosis was not identified, the presence of abnormal free light chains necessitates careful longitudinal surveillance. To the best of our knowledge, this represents only the third reported case of bilateral lacrimal gland amyloidosis in English literature.