Clinical Cases

Clinical Case Section Tag

Case Report: Left knee pain in a young female athlete

Jonathan Packer, University of Birmingham, Birmingham, UK

Clinical History

A 14 year old girl was seen in clinic after an injury whilst playing rugby. Although her description was vague, she intimated that a valgus stress had been put on her left leg and described being tackled in rugby practice. She fell on her left knee and heard an audible cracking or ‘pop’ sound, experiencing immediate pain and swelling of the joint. She had no significant past medical history and was taking no regular medication.


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3. Clifford R. Wheeless III, James A. Nunley, II, MD and James R. Urbaniak, MD - Wheeless Textbook of Orthopaedics available at :

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5. Willis RB, Blokker C, Stoll TM, Paterson DC, Galpin RD. Long-term follow-up of anterior tibial eminence fractures. 1993, Journal of Paediatric Orthopaedics 13(3):361-4.

6. Baxter MP, Wiley JJ. ‘Fractures of the tibial spine in children. An evaluation of knee stability’. 1988, Journal of Bone and Joint Surgery Br. 70(2):228-30.

7. Molander ML, Wallin G, Wikstad I. ‘Fracture of the intercondylar eminence of the tibia: a review of 35 patients’. 1981, Journal of Bone and Joint Surgery Br. 63-B(1):89-91.

Jacksonian seizure: A trembling thought

T.B. Stoker, School of Clinical Medicine, University of Cambridge, Addenbrooke’s Hospital, Cambridge, CB2 0SP, England, UK
A.M.H. Young, School of Clinical Medicine, University of Cambridge, Addenbrooke’s Hospital, Cambridge, CB2 0SP, England, UK
A.Y. Allan, School of Clinical Medicine, University of Cambridge, Addenbrooke’s Hospital, Cambridge, CB2 0SP, England, UK
S.R. Large, Papworth Hospital, Papworth Foundation Trust, Cambridge CB23 3RE, UK


Case presentation: A 22 year old male with a 3-year history of impaired left ventricular function and a past medical history of anthracycline-treated acute myeloid leukaemia was admitted with symptoms of worsening cardiac failure. The patient’s symptoms progressed over 3 months, and included diminished exercise tolerance, orthopnoea, paroxysmal nocturnal dyspnoea, nausea, abdominal pain and diarrhoea. He also described an acute nocturnal episode of severe chest pain, shortness of breath, and involuntary twitching, beginning in the left hand and progressing proximally. The patient was diagnosed with dilated cardiomyopathy - a well-documented side effect of anthracycline therapy.

Conclusion: The exact cause of the patient’s nocturnal episode could not be established, but the features closely resembled those of a Jacksonian seizure. Here, the authors suggest the possibility of an acute arrhythmia secondary to cardiomyopathy, resulting in reduced cerebral perfusion, and a Jacksonian seizure.

Figure 1: The motor homunculus

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A case of a single coronary artery arising from the right coronary cusp

Laura Skinner, University of Birmingham, UK

Coronary artery anomalies (CAAs) are present in 1-1.96% of the population [1,2]. The clinical significance of single CAAs differs depending on the course of the artery. Those that take an inter-arterial (malignant) course, between the aorta and pulmonary artery, can present with syncope or sudden death [1,3]. This is attributed to the myocardial ischaemia that ensues when the single coronary artery is compressed between high-flow structures in systole.

Image 1: Right Coronary Artery
Image 2: Left Main Stem arising from Right Coronary Cusp
Image 3: The interventricular course of the LMS and bifurcation into LAD and Cx

1. Laspas F, Roussakis A, Mourmouris C, Kritikos N, Efthimiadou R, Andreou J. Coronary artery anomalies in adults: imaging at dual source CT coronary angiography. J Med Imaging Radiat Oncol. 2013 Apr;57(2):184-90. DOI: 10.1111/j.1754-9485.2012.02428.x
2. Erol C, Seker M. Coronary artery anomalies: the prevalence of origination, course, and termination anomalies of coronary arteries detected by 64-detector computed tomography coronary angiography. J Comput Assist Tomogr. 2011 Sep-Oct;35(5):618-24. DOI: 10.1097/RCT.0b013e31822aef59
3. Angelini P, Flamm SD. Newer concepts for imaging anomalous aortic origin of the coronary arteries in adults. Catheter Cardiovasc Interv. 2007 Jun 1;69(7):942-54. DOI: 10.1002/ccd.21140
4. Shoemake BD, Patterson BA, Schussler JM. Clinical significance of a single coronary artery arising from the right sinus of valsalva with the left anterior descending anterior to the pulmonary artery and a retro-aortic left circumflex. Am J Cardiol. 2011 Oct 15;108(8):1196. DOI:10.1016/j.amjcard.2011.06.023
5. Lipton MJ, Barry WH, Obrez I, Silverman JF, Wexler L. Isolated single coronary artery: diagnosis, angiographic classification, and clinical significance. Radiology. 1979;130:39-47. DOI: 10.1148/130.1.39

It’s all in the Head?

Lisa Sabir, School of Clinical Medicine, University of Cambridge, UK


69 year old male with sudden onset headache, deteriorating vision accompanied by features of hypopituitarism.

Profound field defect in left eye, almost complete.
Temporal defect in right eye.
Figure 1.1: Coronal MRI
Figure 1.2: Sagittal MRI
Figure 2.1: Monomorphic appearance of tumour cells and haemorrhage
Figure 2.2: Necrotic cells in the centre correlating with apoplexy changes
Left eye visual field, 4 weeks post op
Right eye visual field, 4 weeks post op

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4. Murad-Kejbou S, Eggenberger E. Pituitary apoplexy: evaluation, management, and prognosis. Curr Opin Ophthalmol. 2009 Nov;20(6):456–61. DOI: 10.1097/ICU.0b013e3283319061
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6. Rajasekaran S, Vanderpump M, Baldeweg S, Drake W, Reddy N, Lanyon M, et al. UK guidelines for the management of pituitary apoplexy. Clin Endocrinol (Oxf). 2011;74(1):9–20. DOI: 10.1111/j.1365-2265.2010.03913.x
7. Sibal L, Ball SG, Connolly V, James RA, Kane P, Kelly WF, et al. Pituitary apoplexy: a review of clinical presentation, management and outcome in 45 cases. Pituitary. 2004;7(3):157–63. DOI: 10.1007/s11102-005-1050-3

The Unconsidered Differential Diagnosis of Recurrent Acute Abdomen

Shirley Sze, Hull York Medical School, UK


A 32-year-old from Turkey (Kurdistan province) presented with a 4-year history of recurrent, severe, vague abdominal pain requiring numerous hospitalizations. The pain was non-radiating, dull and constricting in nature with acute onset. There were no associated symptoms apart from constipation. His C-reactive protein and white cell count were always raised during these acute episodes. The pain resolved spontaneously without any specific treatment. He was completely well in between these acute episodes. Investigations including diagnostic laparoscopy, endoscopy and colonoscopy, CT scans and porphyria and infection screens were performed and were found to be negative / normal. Subsequent analysis of the MEFV gene detected two pathogenic variants (Met680IGC and Glu148Gln) on exon 2 and 10 and a diagnosis of familial Mediterranean fever was made. He had no further acute episodes after colchicine treatment was initiated.

Figure 1: The WCC and CRP during acute episodes.

1. Livneh A, Langevitz P, Zemer D, et al. Criteria for the diagnosis of familial Mediterranean fever. Arthritis Rheum. 1997, 40(10):1879–1885. DOI: 10.1002/art.1780401023

2. Sohar E, Gafni J, Pras M, Heller H. Familial Mediterranean fever: A survey of 470 cases and review of the literature. Am J Med. 1967, 43: 227-253. DOI: 10.1016/0002-9343(67)90167-2

3. Inoue. K, Torii. K, Yoda. A, et al. Familial Mediterranean Fever with onset at 66 years of age. Intern Med. 2012, 51: 2649-2653. DOI: 10.2169/internalmedicine.51.6846

4. Yamane T, Uchiyama K, Hata D, et al. A Japanese case of familial Mediterranean fever with onset in the fifties. Intern Med. 2006;45(8): 515–517. DOI: 10.2169/internalmedicine.45.1593

5. Tunca M, Akar S, Onen F, et al. Familial Mediterranean fever (FMF) in Turkey: results of a nationwide multicenter study. Medicine (Baltimore).2005;84(1):1–11. PMID:15643295 PMID:15643295

6. Ozen S, Bakkaloglu A, Yilmaz E, et al. Mutations in the gene for familial Mediterranean fever: do they predispose to inflammation? J Rheumatol.2003; 30(9):2014–2018. PMID:12966608

7. Ryan JG, Masters SL, Booty MG, et al. Clinical features and functional significance of the P369S/R408Q variant in pyrin, the familial Mediterranean fever protein. Ann Rheum Dis. 2010;69(7):1383–1388. DOI: 10.1136/ard.2009.113415

8. Imirzalioglu N, Dursun A, Tastan B, Soysal Y, Yakicier MC. MEFV gene is a probable susceptibility gene for Behçet’s disease. Rheumatol. 2005;34(1):56–58. PMID: 15903027

9. Ayaz NA, Ozen S, Bilginer Y, et al. MEFV mutations in systemic onset juvenile idiopathic arthritis. Rheumatology (Oxford). 2009;48(1): 23–25. DOI: 10.1093/rheumatology/ken409

10. Tsuchiya-Suzuki A, Yazaki M, Nakamura A, et al. Clinical and genetic features of familial Mediterranean fever in Japan. J Rheumatol. 2009; 36(8):1671–1676. DOI:10.3899/jrheum.081278

Organophosphate Poisoning – The Danger of Insecticides

Dr Janine Lumley, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0SP
Dr Nicola Knight, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0SP

Dr Janine Lumley and Dr Nicola Knight discuss a case of organophosphate poisoning in India from a clinical and public health perspective.


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A case of Wegener's Granulomatosis

Angus McKnight, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0SP

Mrs X, a 38 year old thoroughbred race horse breeder, presented to the medical admissions unit (MAU) after referral from her district general hospital (DGH) with a worsening cough, shortness of breath and a swollen right arm.

Figure 6: Mrs X's renal biopsy showing crescentic glomerulonephritis.  PAS stain
Figure 5: Chest radiograph showing position of PICC and central line
Figure 4: Ultrasound right subclavian vein showing thrombosis
Figure 3: CTPA showing left lower lobe consolidation
Figure 2: Chest radiograph showing left basal consolidation
Figure 1: HRCT showing left basal consolidation

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(3) Wilde B et al. New pathophysiological insights and treatment of ANCA-associated vasculitis. Kidney international. 2010. doi:10.1038

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(6) De Groot K et al. Randomized trial of cyclophosphamide versus methotrexate for induction of remission in early systemic antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Rheum. 2005 Aug;52(8):2461-9.

(7) Jones RB et al. Rituximab versus cyclophosphamide in ANCA-associated renal vasculitis. N Engl J Med. 2010 Jul 15;363(3):211-20.

A case of Cerebellar Ataxia

Jamie MJ Weaver, University of Cambridge School of Clinical Medicine, 
Addenbrooke's Hospital, Road, Cambridge, CB2 0SP
Alana G Brown-Kerr, University of Cambridge School of Clinical Medicine, 
Addenbrooke's Hospital, Road, Cambridge, CB2 0SP


Mr X, a 66-year-old gentleman, presented to the emergency department with progressively worsening unsteadiness on his feet, double vision, nausea and vomiting.


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