A boy with attention deficit and hyperactivity disorder (ADHD) presented with a fetish for and the subsequent stealing of female undergarments. He was predominantly inattentive and had been a slow learner. Psychological tests showed that he had significant cognitive and inattention problems without significant hyperactivity, and was at risk of dyslexia as well as conduct disorder.
Acute bacterial meningitis is not an uncommon central nervous system infection. In severe cases, it can be associated with various neurological or systemic complications. However, acute spinal cord dysfunction rarely occurs. We report a case of bacterial meningitis complicated with spinal cord infarction despite adequate treatment with antibiotics and corticosteroid therapy. He had residual paraplegia and was fully dependent in the activity of daily living.
An adolescent with autism spectrum disorder and improperly treated attention deficit hyperactivity disorder presented with recurrent hair pulling. Treatment with selective serotonin reuptake inhibitor and stimulant improved these conditions.
We report a case of a 70-year-old farmer admitted for viper bite who presented with bilateral hyphema and angle closure attack. He was managed conservatively with topical steroids and cycloplegics. He responded well and was discharged after 2 weeks.
An 18-year-old male adolescent presented with prolonged high spiking temperature, photosensitive rash, oral ulcers and reduced hearing bilaterally of recent onset. Examination revealed malar rash, vasculitis rash over bilateral palms and soles, oral and buccal ulcers, palpable posterior auricular and inguinal lymph nodes, and reduced hearing bilaterally. His further investigations noted pancytopaenia, elevated transaminases, hyperferritinaemia, low C3 and C4 levels, positive antinuclear antibody, double-stranded DNA and direct Coombs test, while bone marrow aspiration revealed active phagocytic activity suggestive of hemophagocytic syndrome. We made a diagnosis of systemic lupus erythematosus with macrophage activation syndrome. We treated him with pulse intravenous methylprednisolone and his condition improved drastically. Temperature resolved on the next day after intravenous methylprednisolone; bilateral sensorineural hearing loss improved to near-normal hearing after treatment. He remained well during follow-up with a tapering dose of prednisolone.
Leprosy and tuberculosis (TB) are endemic to India, however, their coinfection is not frequently encountered in clinical practice. Here, we report a 32-year-old female patient who presented with a history of high-grade intermittent fever, cough and painless skin lesions since a month, along with bilateral claw hand (on examination). The haematological profile was suggestive of anaemia of chronic disease, chest radiograph showed consolidation, sputum smears were positive for Mycobacterium tuberculosis, and skin slit smear confirmed leprosy. The patient was prescribed WHO recommended multidrug therapy for multibacillary leprosy with three drugs. Additionally, prednisolone was added to her regimen for 2 weeks to treat the type 2 lepra reaction. For treatment of TB, she was placed on the standard 6-month short course chemotherapy. She was lost to follow-up, and attempts were made to contact her. Later, it came to our notice that she had discontinued medications and passed away 3 months after diagnosis.
A 19-year-old girl presented to the rheumatology clinic for left knee monoarthritis for the past 4 months. She also had constitutional symptoms with significant weight loss. On physical examination, she appeared cachexic, her left knee was swollen and tender. MRI of the left knee showed a soft tissue swelling extending into the knee joint. Left knee synovial fluid showed small round cells. Histopathology results were compatible with Ewing's sarcoma. Due to the delay in seeking medical advice, she succumbed to the disease 1 week after the diagnosis was made. Soft tissue/bone tumour causes monoarthritis is not common. A careful history taking, physical examination and investigations should be done in order to identify a sinister cause of monoarthritis such as Ewing's sarcoma. Early treatment should be initiated to ensure a better outcome.
Vitamin B12 deficiency in vegans is a known cause of megaloblastic anaemia. We report an adolescent girl who presented with jaundice and weight loss for 6 months secondary to vitamin B12 deficiency, leading to megaloblastic anaemia. Replacement with vitamin B12 reversed her symptoms, resulting in weight gain, and normalised her haemoglobin, red blood cell morphology, bilirubin levels and serum vitamin B12 levels.
We report a case of a 46-year-old woman who has presented to a peripheral hospital with progressive exertional dyspnoea and chest discomfort. The resting ECG showed features of left-sided ventricular hypertrophy. The initial chest radiograph was reported as cardiomegaly. Initial echocardiography revealed left atrial dilatation and 'left ventricular' hypertrophy with normal ejection fraction. She was treated as possible coronary artery disease and was subsequently referred to our centre for CT coronary angiography. Findings from the CT scan were consistent with congenitally corrected transposition of the great arteries (ccTGA). This report describes the radiological features of ccTGA, its associated cardiovascular anomalies, pathophysiology and potential complications.
Children with Down syndrome have a higher risk of stroke. Similarly, intravenous immunoglobulin (IV Ig) is also known to cause a stroke. We reported a 3-year-old boy with Down syndrome who presented with severe pneumonia and received IV Ig. He developed right hemiparesis 60 hours after the infusion. Blood investigations, echocardiography and carotid Doppler did not suggest vasculitis, thrombophilia or extracranial dissection. Brain computerised tomography (CT) showed acute left frontal and parietal infarcts. Initial magnetic resonance angiography (MRA) of cerebral vessels showed short segment attenuations of both proximal middle cerebral arteries and reduction in the calibre of bilateral supraclinoid internal carotid arteries. The boy was treated with enoxaparin and aspirin. He only had partial recovery of the hemiparesis on follow-up. A repeat MRA 13 months later showed parenchymal collateral vessels suggestive of moyamoya disease. We recommend imaging the cerebral vessels in children with a high risk of moyamoya before giving IV Ig.
A 50-year-old Indian woman presented with acute dysphasia, left upper limb numbness and thrombocytopenia 12 days after receiving the ChAdOx1 nCoV-19 vaccine (AstraZeneca/Vaxzevria). MRI of the brain was unremarkable. Microangiopathic haemolytic anaemia with thrombocytopenia was noted on her peripheral blood film. A diagnosis of thrombotic thrombocytopenic purpura (TTP) was confirmed through the findings of absent ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) activity and markedly raised titre of ADAMTS13 autoantibodies. Prompt treatment with plasma exchange, adjunctive steroids and rituximab was commenced. A remission of TTP was achieved and she was discharged 3 weeks after admission. While other immune-mediated conditions have been documented after receipt of the vaccine, this report highlights the first case of immune-mediated TTP diagnosed after administration of the ChAdOx1 nCoV-19 vaccine.
COVID-19 presents with a spectrum of severity, ranging from asymptomatic or mild symptoms to those with acute respiratory distress syndrome. Corticosteroids are widely used for their efficacy in reducing inflammatory responses. However, its use may be limited to patients with immunosuppression. An adjunct therapy for cytokine storm in COVID-19 is extracorporeal blood purification therapies using high adsorptive filters, such as oXiris, to remove cytokines. We share our experience in using continuous renal replacement therapy with oXiris haemofilter as a temporising measure to high-dose corticosteroids in managing cytokine storm in a deteriorating COVID-19 patient with concomitant bacterial infection.
Acoustic neuroma (AN) usually manifests with asymmetric hearing loss, tinnitus, dizziness and sense of disequilibrium. About 10% of patients complain of atypical symptoms, which include facial numbness or pain and sudden onset of hearing loss. Patients with atypical symptoms also tend to have larger tumours due to the delay in investigation. We report a particularly interesting case of a patient presented to us with numbness over her right hemifacial region after a dental procedure without significant acoustic and vestibular symptoms. Physical examination and pure tone audiometry revealed no significant findings but further imaging revealed a cerebellopontine angle mass. The changing trends with easier access to further imaging indicate that the presentation of patients with AN are also changing. Atypical symptoms which are persistent should raise clinical suspicion of this pathology among clinicians.
A young adult patient with 46XX congenital adrenal hyperplasia (CAH) presented with recurrent painful haematuria. CAH was diagnosed at birth following ambiguous genitalia. Hormonal treatment was started, female gender was assigned and feminising genitoplasty was planned, however the patient was lost to follow-up. Gender dysphoria started to occur during childhood which prompted the family to raise the patient as a boy. He eventually identified himself as a male. Examination revealed a male phenotype with severely virilised genitalia. Imaging studies confirmed the presence of uterus with low confluent urogenital sinus. Total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed, and the troublesome symptoms were cured.
A 79-year-old smoker with a background history of a treated glottic carcinoma and chronic obstructive pulmonary disease presented with progressive hoarseness, symptoms of aspiration and shortness of breath for 6 months. Examination revealed an ulcero-fungating mass over the posterior commissure of the larynx. A tracheostomy, direct laryngoscopy and biopsy of the mass was performed to secure his airway and to exclude recurrent glottic carcinoma. Reassuringly, a histopathological examination of the mass revealed numerous fungal yeast bodies. He was then treated with itraconazole for 4 weeks and was followed up as and outpatient with complete resolution and no recurrence of the disease.
A woman in her 70s presented with reduced vision in her left eye, progressive narrowing of right eye opening for 6 months and anosmia. On examination, she had right enophthalmos and pseudoptosis with inferior globe dystopia. Her visual acuity was 6/9 and nil light perception in the right and left eyes, respectively. Extraocular muscle examination showed limited right up gaze. Funduscopy showed a normal right optic disc and left optic disc atrophy. Systemic examination revealed left breast ulceration with skin tethering. CT revealed an infiltrative mass invading the ethmoidal sinuses, frontal sinuses and both orbits. A histological diagnosis of infiltrative ductal breast carcinoma was made after nasal endoscopic and left breast biopsy. She underwent palliative chemoradiotherapy and survived with good disease control after 1 year. Metastatic carcinoma is a differential diagnosis of a sino-orbital mass, and comprehensive clinical assessment is indicated for all patients presenting with non-acute eye injury.
We report an elderly man who presented with giddiness and right-sided weakness, constipation and constitutional symptoms for 6 months duration. Blood investigations indicated hypercalcaemia with normal serum phosphate and acute kidney injury. Serum intact parathyroid hormone was suppressed. CT revealed bilateral tiny lung nodules with right upper lobe tree in bud appearance and incidental findings of bilateral adrenal lesion. Tuberculosis was ruled out. CT adrenal showed multiseptated hypodense rim enhancement adrenal lesion bilaterally. Adrenal function tests were normal except for low dehydroepiandrosterone (DHEA). Right-sided cervical lymph node biopsy confirmed fungal infection with the presence of intracellular and extracellular fungal yeast. Serum cryptococcus antigen titre was positive. Our final diagnosis was disseminated cryptococcosis with lungs, bilateral adrenal gland and lymph nodes involvement. The patient was then treated with antifungal treatment. Serum calcium was normalised after 1 month with marked clinical improvement.