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.

References: 

1. Schmitgen. G.F, Utukuri. M.M. Arthroscopic treatment of tibial spine fractures in children: a review of three cases. 2000, Knee 7(2), 115-119. doi:10.1016/S0968-0160(00)00037-5

2. Moore. K.L, Dalley. A.F, Agur. A.M.R – Clinically Orientated Anatomy 6th Edition – Lippincott Williams & Wilkins. 2010.

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

4. Solomon. L, Warwick. D.J, Nayagam. S - Appley’s Concise System of Orthopaedics and Fractures - Third Edition, Published by Hodder Arnold, 2005.

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. http://journals.lww.com/pedorthopaedics/Abstract/1993/05000/Long_Term_Fo...

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. http://www.bjj.boneandjoint.org.uk/content/70-B/2/228.long

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. http://www.bjj.boneandjoint.org.uk/content/63-B/1/89.long

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

Abstract

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
References: 

1. Walsh GO. Jacksonian seizure arising from the contralateral hippocampus. Bull Los Angeles Neurol Soc. 1974;39:150–3. PMID: 4215528
2. Yeh ET, Bickford CL. Cardiovascular complications of cancer therapy: incidence, pathogenesis, diagnosis, and management. J Am Coll Cardiol. 2009 Jun 16;53(24):2231-47. DOI: 10.1016/j.jacc.2009.02.050
3. Iniesta I. John Hughlings Jackson and our understanding of the epilepsies 100 years on. Pract Neurol. 2011 Feb; 11(1):37-41. DOI: 10.1136/jnnp.2010.235192
4. Fisher CM. Concerning recurrent transient cerebral ischemic attacks. Can Med Assoc 1962; 86: 1091–9. PMCID: PMC1849196
5. Baquis GD, Pessin MS, Scott RM. Limb-shaking-a carotid TIA. Stroke 1985; 16: 444–8. DOI: 10.1161/​01.STR.16.3.444
6. Fisch BJ, Tatemichi TK, Prohovnik I, Pedley TA, Mohr JP. Transient ischemic attacks resembling simple partial motor seizures. Neurology 1988; 38: 264.
7. Yanagihara T, Piepgras DG, Klass DW. Repetitive involuntary movement associated with episodic cerebral ischemia. Ann Neurol 1985; 18: 244–50. DOI: 10.1002/ana.410180212
8. Zaidat OO, Werz MA, Landis DM, Selman W. Orthostatic limb shaking from carotid hypoperfusion. Neurology 1999; 53: 650–1. DOI: 10.1212/WNL.53.3.650
9. Schulz UGR, Rothwell PM. Transient ischemic attacks mimicking focal motor seizures. Postgrad Med J 2002; 78: 246–7. DOI: 10.1136/pmj.78.918.246
10. Ali S, Khan MA, Khealani B. Limb-shaking transient ischemic attacks: case report and review of literature. BMC Neurol 2006; 6: 5. DOI: 10.1186/1471-2377-6-5
11. De Silva DA, Lee MP, Wong MC, et al. Limb-shaking transient ischemic attack with distal micro-emboli signals and impaired cerebrovascular reactivity using transcranial Doppler. Ann Acad Med Singapore 2008; 37: 619–20. PMID: 18695780

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
References: 

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

Abstract

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
References: 

1. Kumar and Clark. Clinical Medicine. Seventh Edition.
2. Professor Andrew Kaye. Essential Neurosurgery. Third Edition.
3. Vanderpump M, Higgens C, Wass JAH. UK guidelines for the management of pituitary apoplexy a rare but potentially fatal medical emergency. Emerg Med J. 2011 Jan 7;28(7):550–1. DOI: 10.1136/emj.2010.106898
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
5. Pituitary Apoplexy. 2013 Jan 25 [cited 2013 Aug 26]; Available from: http://emedicine.medscape.com/article/1198279-overview
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

Abstract

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.
References: 

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.

References: 

1. Kumar P, et al. Clinical Medicine. Sixth edition. Elsevier Saunders; 2005; 1016-1017.

2. Singh S, et al. Neurological Syndromes Following Organophosphate Poisoning. Neurology India. 2000; 48: 308-313.

3. Wadia RS, et al. Electrophysiological studies in acute organophosphate poisoning. Journal of Neurology, Neurosurgery, and Psychiatry. 1987; 50: 1442-1448.

4. Chaudhry R, et al. A food borne outbreak of organophosphate poisoning. BMJ. 1998; 317: 268-269.

5. Gunnell D, et al. Suicide by intentional ingestion of pesticides: a continuing tragedy in developing countries. International Journal of Epidemiology. 2003; 32: 902-909.

6. Rang, et al. Pharmacology. Fifth Edition. Churchill Livingstone. 2003.

7. Barile FA. Clinical Toxicology: Principles and Mechanisms. CRC Press. 2004.

8. Eddleston M, et al. Management of acute organophosporous pesticide poisoning. Lancet. 2008; 37: 597-607.

9. Nishijima DK. Toxicity, Organic Phosphorous Compounds and Carbamates. eMedicine. 2007. Available on: http://www.emedicine.com/EMERG/topic346.htm. Accessed October 5th 2008.

10. Poojara L, et al. Organophosphate poisoning: Diagnosis of intermediate syndrome. Indian Journal of Critical Care Medicine. 2003; 7(2): 94-102.

11. Eyer P. The role of oximes in the management of organophosphorous pesticide poisoning. Toxicological Reviews. 2003; 22(3): 165-190.

12. International Programme on Chemical Safety. Available on: http://www.who.int/ipcs/en/. Accessed October 6th 2008.

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
References: 

(1) PEXIVAS Trial, Birmingham Clinical Trials Unit, University of Birmingham. http://www.bctu.bham.ac.uk/pexivas/

(2) Bosch X et al. Treatment of antineutrophil cytoplasmic antibody-associated vasculitis: A systematic review. JAMA. 2007;298:655-667

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

(4) Bruce I et al. A comparison of two nomenclature systems for primary systemic vasculitis. British Journal of Rheumatology. 1997;36:453-458

(5) Jennette J et al. Nomenclature of systemic vasculitides. Proposal of an international consensus conference. Arthritis Rheum. 37 (2): 187–92.

(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

Presentation:

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

References: 

1. Alaedini A, Okamoto H, Briani C et al. 2007. Immune Cross-Reactivity in Celiac Disease: Anti-Gliadin Antibodies Bind to Neuronal Synapsin I. The Journal of Immunology 78: 6590-6595

2. Brusse E, Maat-Kievit JA, van Swieten JC. 2007. Diagnosis and management of early- and late-onset cerebellar ataxia. Clinical Genetics 71: 12-14
http://dx.doi.org/10.1111/j.1399-0004.2006.00722.x

3. Dalmau J and Rosenfeld MR. 2008. Paraneoplastic syndromes of the CNS. The Lancet Neurology April 7(4): 327-340

4. Dalmau JO, Posner JB. 1997. Paraneoplastic syndromes affecting the nervous system. Seminars in Oncology 24:318-328

5. Graus F, Delattre JY, Antoine JC et al. 2004. Recommended diagnostic criteria for paraneoplastic neurological syndromes. Journal of neurology, neurosurgery, and psychiatry Aug;75(8):1135-40.

6. Hadjivassiliou M, Grunewald R, Sharrack B et al. 2003 Gluten ataxia in perspective: epidemiology, genetic susceptibility and clinical characteristics. Brain 126: 685-691.
http://dx.doi.org/10.1093/brain/awg050

7. Wenning GK, Colosimo C, Geser F et al. 2004 Multiple system atrophy. The Lancet Neurology 3: 93-103
http://dx.doi.org/10.1016/S1474-4422(03)00662-8

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