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An 11-year-old boy presented with features resembling those described in health alerts on Paediatric Inflammatory Multisystem Syndrome Temporally associated with SARS-CoV-2 (PIMS-TS), including persistent fever, haemodynamic instability and abdominal pain. Laboratory tests, including raised inflammatory markers, D-dimer, troponin and a coagulopathy, were consistent with PIMS-TS. Our patient required transfer to the paediatric intensive care unit; an echocardiography revealed left ventricular dysfunction. He was treated with intravenous immunoglobulins (Igs), corticosteroids and aspirin, with full resolution of clinical symptoms. A follow-up echocardiogram 1 month after discharge was unremarkable.Three SARS-CoV-2 PCRs on respiratory samples, taken over the initial 4-day period, were negative, as was a SARS-CoV-2 PCR on faeces 1 month after presentation; titres of IgG were clearly elevated. The negative PCRs in the presence of elevated titres of IgG suggest that the inflammatory syndrome might have developed in a late phase of COVID-19 infection when the virus was no longer detectable in the upper airway.

Infection with SARS-CoV-2 represents a great source of concern and a new threat for immunocompromised patients. Limited studies are available on COVID-19 in immunocompromised children. This case series aimed to evaluate the clinical and laboratory characteristics, management and outcomes of COVID-19 in five children immunocompromised due to different underlying conditions. All had mild symptoms or were asymptomatic at presentation. All had a benign course of illness. No changes or delays in their treatment regimens occurred, and none experienced a relapse of the original disease, developed severe COVID-19 or died. However, these cases showed a prolonged duration of virus shedding. This report suggests that immunocompromised paediatric patients may not be at a higher risk of developing severe COVID-19. However, further studies are required to elaborate on the pathogenesis of COVID-19 in this vulnerable group.

Clinical manifestations of COVID-19 are known to be variable with growing evidence of nervous system involvement. In this case report, we describe the symptoms of a patient infected with SARS-CoV-2 whose clinical course was complicated with Guillain-Barré syndrome (GBS). We present a case of a 58-year-old woman who was initially diagnosed with COVID-19 pneumonia due to symptoms of fever and cough. Two weeks later, after the resolution of upper respiratory tract symptoms, she developed symmetric ascending quadriparesis and paresthesias. The diagnosis of GBS was made through cerebrospinal fluid analysis and she was successfully treated with intravenous immunoglobulin administration.

The COVID-19 pandemic has created an unprecedented disease burden worldwide, affecting patients of all ages. Recently, there has been a rise in a new inflammatory condition termed paediatric multisystem inflammatory syndrome temporally associated with SARS-CoV-2 (PMIS-TS). We are yet to understand significant risk factors, disease progression and prognosis in children affected. We describe a case of a 9-year-old boy who tested positive concurrently for the SARS-CoV-2 virus 4 weeks apart. He presented with a 2-day history of fever, abdominal pain, headache and diarrhoea. Initial investigations supported PMIS-TS and he went on to develop atypical Kawasaki disease. With no results to differentiate between his positive results, we question whether he remained positive throughout or recovered with reactivation of the virus. There are reports of reactivation in adults but none in children. There are also no reports of children remaining positive for such a prolonged period, which raises public health concerns.

A 30-year-old woman presented with recurrent hiccups, vomiting and painful diminution of vision and gait instability for 1 day. She had one-and-a-half syndrome, bilateral seventh cranial nerve paresis with bilateral symptomatic optic neuritis and left-sided ataxic haemiparesis. We described her disorder as the ‘twenty syndrome’ (11/2+7+7+2+2+½=20). MRI of her brain revealed demyelination predominantly in right posterolateral aspect of pons, medulla and bilateral optic nerves. Serum antiaquaporin-4 antibody came out positive. Thus, she was diagnosed as neuromyelitis optica spectrum disorder (NMOSD). She responded brilliantly to immunosuppressive therapy. This is the first ever reported case of the ‘twenty syndrome’ secondary to cerebral NMOSD.

A construction worker in his 30s presented three times in 4 days with progressive upper and then lower limb weakness. On the first two occasions he had no systemic symptoms, but on the third presentation he had fever and cough, starting from day 4 of weakness. Examination identified weakness in all four limbs and areflexia, suggesting a peripheral neuromuscular disorder. Investigations were consistent with Guillain-Barré syndrome and additional COVID-19 (SARS-CoV-2) infection. The patient improved after immunoglobulin treatment. At least four cases of Guillain-Barré syndrome have been reported in the literature with concurrent COVID-19 illness in whom respiratory signs appeared a few days after the onset of neurological signs. With the incubation period for COVID-19 respiratory symptoms believed to be up to 14 days, it is possible that neurological symptoms could develop before respiratory and other symptoms. During the current pandemic, presence of concurrent COVID-19 infection needs to be considered in patients presenting with Guillain-Barré syndrome.

A 71-year-old man presented to the emergency department (ED) with low oxygen saturations and symptoms consistent with COVID-19 infection. Apart from a small left-sided ischaemic stroke 10 years prior with very minor residual deficit, he had been well and in full-time employment until development of symptoms. Within minutes of commencing non-invasive ventilation (NIV) in the ED, he developed a complete left-sided paralysis and hemineglect. This case highlights the significance of the prothrombotic complications associated with COVID-19 infection. It also raises the question whether pressure changes upon commencing NIV could lead to clot migration.

Two 59-year-old male patients with COVID-19 pneumonia developed pulmonary cavitation with air-fluid level, accompanied by right-sided chest pain several weeks after first onset of symptoms. Considering a possible bacterial abscess formation, both patients were started on antibiotics. No microbiological pathogen was detected in further investigations (sputum analysis, bronchoscopy with bronchoalveolar lavage and CT-guided drainage of the cavitation). Histopathological analysis of the drained fluid was non-specific, and the aetiology remained not fully understood. We report pulmonary cavitation as a rare finding in late stage COVID-19 pneumonia. As both our patients presented with localised chest pain prior to detection of the lesions, new onset of this symptom should warrant further investigation.

A 40-year-old man presented with altered mental status after a recenthospitalisation for COVID-19 pneumonia. Cerebrospinal fluid (CSF) analysis showed lymphocytosis concerning for viral infection. The CSF PCR for SARS-CoV-2 was negative, yet this could not exclude COVID-19 meningoencephalitis. During hospitalisation, the patient’s mentation deteriorated further requiring admission to the intensive care unit (ICU). Brain imaging and electroencephalogram (EEG) were unremarkable. He was, thus, treated with intravenous immunoglobulin (IVIg) for 5 days with clinical improvement back to baseline. This case illustrates the importance of considering COVID-19’s impact on the central nervous system (CNS). Haematogenous, retrograde axonal transport, and the effects of cytokine storm are the main implicated mechanisms of CNS entry of SARS-CoV-2. While guidelines remain unclear, IVIg may be of potential benefit in the treatment of COVID-19-associated meningoencephalitis.

The COVID-19 outbreak has spread across the globe at an alarming rate. As the pandemic escalates, experience of COVID-19 in pregnant women is accumulating. We present a case of COVID-19 pneumonia in a 28-week pregnant woman with a known low lying placenta. The patient had deranged liver function tests at presentation, along with elevated bile acids. We discuss the differential diagnosis of these findings, and the possible mechanisms of hepatic injury in COVID-19. The low lying placenta in this patient meant that we had to carefully consider the application of recommendations for thromboprophylaxis in pregnant COVID-19 patients. With supportive management, this patient improved enough to be discharged, and has gone on to deliver a healthy neonate at term.

Transoral drainage of peritonsillar abscess during the COVID-19 pandemic is a high-risk procedure due to potential aerosolisation of SARS-CoV-2. This case describes conservative management of peritonsillar abscess in a 21-year-old male with COVID-19.

This case aims to remind all providers to scrutinise for atypical presentations of multisystem inflammatory syndrome in children (MIS-C) which may mimic a more routine diagnosis. In the absence of mucocutaneous symptoms, the diagnosis of MIS-C can be missed. Given the potential for rapid deterioration of patients with MIS-C, early treatment and inpatient interventions are necessary.

On 31 December 2019, the first case of COVID-19, was reported in Wuhan. A public health emergency of international concern was declared on 30 January 2020 and the first case in Scotland, on 2 March. The effect of COVID-19 appears to be less in the paediatric population and there are fewer cases reported in the literature in comparison to the adult population. Here, we report a case of a previously well 5-week-old infant who presented with fever and increased sleepiness. There was no known contact with any unwell individuals. COVID-19 was identified through a septic screen work up. The infant’s course was uneventful and she has made a full recovery. This case highlights the need to have a low index of suspicion in the diagnosis of COVID-19 and the need to be vigilant in use of personal protective equipment, even in paediatric patients with subtle symptoms.

A 66-year-old man was admitted to hospital with a right frontal cerebral infarct producing left-sided weakness and a deterioration in his speech pattern. The cerebral infarct was confirmed with CT imaging. The only evidence of respiratory symptoms on admission was a 2 L oxygen requirement, maintaining oxygen saturations between 88% and 92%. In a matter of hours this patient developed a greater oxygen requirement, alongside reduced levels of consciousness. A positive COVID-19 throat swab, in addition to bilateral pneumonia on chest X-ray and lymphopaenia in his blood tests, confirmed a diagnosis of COVID-19 pneumonia. A proactive decision was made involving the patients’ family, ward and intensive care healthcare staff, to not escalate care above a ward-based ceiling of care. The patient died 5 days following admission under the palliative care provided by the medical team.

The COVID-19 pandemic with its severe respiratory disease has caused overflow to hospitals and intensive care units. Elevated troponins and natriuretic peptides are related to cardiac injury and poor prognosis. We present a young woman with COVID-19 infection with haemodynamic instability caused by acute perimyocarditis and cardiac tamponade. Troponin T was modestly elevated. Focused cardiac ultrasound made the diagnosis. Echocardiography revealed transient thickening of the myocardial walls. After pericardial drainage and supportive care, she improved significantly within 1 week without targeted therapy. The case illustrates the importance of cardiac diagnostic imaging in patients with COVID-19 and elevated cardiac biomarkers.

Kidney transplant recipients have been reported at a particularly high risk of severe COVID-19 illness due to chronic immunosuppression and coexisting conditions. Yet, here we describe a remarkably mild case of COVID-19 in a 62-year-old female who had a kidney transplantation 10 years earlier due to autosomal dominant polycystic kidney disease. The patient was admitted for 1 day; immunosuppressive therapy with tacrolimus and low-dose prednisolone was continued; and the patient recovered successfully without the use of antiviral agents or oxygen therapy. The case demonstrates that kidney transplant recipients are not necessarily severely affected by COVID-19. Withdrawal of immunosuppressive therapy could be associated with poorer outcomes and should not be implemented thoughtlessly.

The clinical implications of COVID-19 in pregnancy remain unknown. While preliminary reports demonstrate that pregnant patients have a similar symptomatic presentation to the general population, the appropriate management and timing of delivery in these patients is still unclear, as pregnancy may impose additional risk factors and impede recovery in gravid patients. In this brief report, we present a case of COVID-19 in a pregnant patient with severe respiratory compromise, whose clinical status significantly improved after caesarean delivery. We also address the potential benefits of experimental therapy, including tocilizumab, a monoclonal antibody that targets interleukin-6 receptors.

Since December 2019, coronavirus disease 2019 (COVID-19) has been an international public health emergency. The possibility of COVID-19 should be considered primarily in patients with new-onset fever or respiratory tract symptoms. However, these symptoms can occur with other viral respiratory illnesses. We reported a case of severe acute respiratory syndrome coronavirus 2 and influenza A virus coinfection. During the epidemic, the possibility of COVID-19 should be considered regardless of positive findings for other pathogens.

A 41-year-old man with no significant medical history presented with acute behavioural disruption on the background of a 1-day history of severe headache and a 10-day history of dry cough and fever. He was sexually disinhibited with pressured speech and grandiose ideas. His behaviour worsened, necessitating heavy sedation and transfer to intensive care for mechanical ventilation despite no respiratory indication. Investigations confirmed that he was positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Neuroimaging and a lumbar puncture were normal. Initial screening for SARS-CoV-2 in the cerebrospinal fluid was negative although no validated assay was available. The patient’s mental state remained abnormal following stepdown from intensive care. Psychiatric assessment found features consistent with acute mania, and he was detained under the Mental Health Act. This case indicates the need to consider COVID-19 in a wider series of clinical presentations and to develop a validated assay for SARS-CoV-2 in the cerebrospinal fluid.

A 57-year-old man presented with a progressive flaccid symmetrical motor and sensory neuropathy following a 1-week history of cough and malaise. He was diagnosed with Guillain-Barré syndrome secondary to COVID-19 and started on intravenous immunoglobulin. He proceeded to have worsening respiratory function and needed intubation and mechanical ventilation. This is the first reported case of this rare neurological complication of COVID-19 in the UK, but it adds to a small but growing body of international evidence to suggest a significant association between these two conditions. Increasing appreciation of this by clinicians will ensure earlier diagnosis, monitoring and treatment of patients presenting with this.

COVID-19 became a global pandemic in early 2020. While well known for its pulmonary manifestations, the virus also has a number of cardiac manifestations as well. Takotsubo syndrome has scarcely been reported in patients with COVID-19, but it is possible that the cytokine storm associated with the infection can trigger Takotsubo syndrome in patients with underlying risk factors for Takotsubo (emotional distress, physical distress, history of psychiatric disorders).

The coronavirus disease (COVID-19) outbreak caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first reported in Wuhan, China, in late 2019 and has affected more than 1 270 000 people worldwide. The numbers of reported cases continue to rise and threaten global health. Transmissions among family members are frequently observed, although the route of transmission is partially known. Here we report three cases of SARS-CoV-2 infection within one family. Sequencing of the S gene of the viral genome showed 100% identity among samples, suggesting that the same strain caused the infection. Following treatment with oseltamivir and short-term methylprednisolone combined with symptomatic management, all three patients recovered within 3 weeks, as evidenced by the disappearance of their symptoms, clearance of pulmonary infiltrates and consecutive negative molecular diagnostic test findings. Our observations suggest the importance of preventing family transmission and the efficacy of current integrated treatment for mild/moderate pneumonia in COVID-19 cases.

We present a case of a 38+1 weeks pregnant patient (G1P0) with a proven COVID-19 infection, who was planned for induction of labour because of pre-existent hypertension, systemic lupus erythematosus, respiratory problem of coughing and mild dyspnoea without fever during the COVID-19 pandemic in March 2020. To estimate the risk of vertical transmission of Severe Acute Respiratory Syndrome CoronaVirus 2 (SARS-CoV-2) during labour and delivery, we collected oropharyngeal, vaginal, urinary, placental and neonatal PCRs for SARS-CoV-2 during the period of admission. All PCRs, except for the oropharyngeal, were negative and vertical transmission was not observed. Labour and delivery were uncomplicated and the patient and neonate were discharged the next day. We give a short overview of the known literature about SARS-CoV-2-related infection during pregnancy, delivery and outcome of the neonate.

Schizophrenia likely represents a cluster of diseases presenting with delusions, hallucinations, disorganised behaviour and disorganised thought. Currently, medical therapy struggles to treat a substantial portion of patients, but with improved stratification of component diseases, it may be possible to better understand and treat schizophrenia. The overlap between schizophrenia, schizo-obsessive disorder and obsessive-compulsive disorder is discussed within the context of a clinical case and neuroimaging data. Furthermore, the use of obsessive-compulsive disorder deep brain stimulation protocols for schizo-obsessive disorder is discussed and may yield an advance in neurosurgical treatment of psychiatric conditions.

Parkinsonism-hyperpyrexia syndrome (PHS) is a neurologic potentially fatal emergency that mimics neuroleptic malignant syndrome. It commonly presents as systemic inflammatory response syndrome, acute onset worsening of muscular rigidity, autonomic instability, hyperpyrexia, confusion, diaphoresis and high creatine phosphokinase. The most common trigger for PHS is reduction or withdrawal of anti-Parkinson’s medications, especially levodopa. It was also reported in a few cases following deep brain stimulation of the subthalamic nucleus surgery shortly after anti-Parkinson’s medications were discontinued. Rare causes of PHS include deep brain stimulator (DBS) malfunction due to battery depletion. To the best of our knowledge, PHS following DBS battery depletion was reported only in three occasions. Here, we report a case of PHS due to DBS battery depletion presented as sepsis and was successfully treated with the administration of dopamine agonists, intravenous fluids and changing the DBS battery.

We present a case of COVID-19 in an immunocompetent patient with risk factors for severe disease who recovered after prolonged swab positivity of 61 days postsymptom onset without significant respiratory and organ dysfunction. We discuss the reasons behind her prolonged swab positivity in the context of current SARS-CoV-2 knowledge, document the trend in her inflammatory response and swab results, and discuss the implications swab positivity had on her isolation and recovery.

Most Mycobacterium fortuitum infections described involve direct inoculation through skin lesions. We describe the case of a patient without risk factors who presented with an intracranial mass and a pulmonary infection with M. fortuitum. As M. fortuitum are rarely pathogens, there is little knowledge about the optimal treatment and outcome of such infections: what is the best mode of administration, what is the best therapy duration and is surgery always required are some of the unanswered questions. In our patient, surgical removal of the mass associated with a 1-year antimycobacterial therapy led to a full recovery. Even though M. fortuitum was rapidly identified in sputum, it was initially considered non-pathogenic and the definitive diagnosis required almost 6 weeks of investigations. New molecular techniques will probably lead to more identifications of M. fortuitum in the next few years and a better knowledge of their possible pathogenicity and optimal treatment.

A 35-year-old woman presented with a widespread petechial rash and pancytopenia. She underwent simultaneous pancreas and kidney transplantation for type 1 diabetes 8 years previously followed by a renal transplant 1 year prior to presentation, and was taking tacrolimus as long-term immunosuppression. The full blood count showed haemoglobin 97 g/L, platelet count 2×109/L and neutrophil count 0.22×109/L. Peripheral blood film examination confirmed genuine thrombocytopenia in the absence of any haemolytic or malignant features. Serological testing identified autoantibodies against all three blood lineages, consistent with a diagnosis of autoimmune pancytopenia. Treatment with steroids, intravenous immunoglobulins, romiplostim and mycophenolate mofetil achieved only fleeting remissions. Blood counts eventually normalised following the administration of rituximab and a change from tacrolimus to ciclosporin immunosuppression. Cytopenias are a well-recognised complication of post-transplantation care but we believe this to be the first reported case of autoimmune pancytopenia following solid organ transplantation. In this case report, we discuss the approach to investigation of haematological abnormalities post-transplant and the rationale for, and outcome of, the management of this rare case.

Peripheral artery disease affects nearly a quarter billion of the world’s population, and it is one of the most important causes of decreased quality of life. Primary peripheral slow flow without significant stenosis in peripheral arteries has not been previously reported in the literature. In this case report, we present a slow flow phenomenon that extended from the right external iliac artery to the distal peripheral bed observed during peripheral angiography in a patient who exhibited pain and claudication in the right lower extremity after walking 50 m. Medical treatment provided symptomatic improvement in coronary slow flow and led to a decrease in claudication. Future randomised controlled studies conducted on patients with suspected peripheral slow flow phenomenon would increase our knowledge on both the aetiology and treatment of this condition.

Myocarditis is well known to be caused by viral infections such as Coxsackie virus group B, human herpes virus 6 and parvovirus B19. However, during the current emerging outbreak of SARS-CoV-2, there have been few case reports describing myocarditis as a possible presentation. In our case report we describe, early cardiac manifestations of SARS-CoV-2 in a UK District General Hospital. A 44-year-old Caucasian woman without any comorbidities presented with SARS-CoV-2 related fulminant myocarditis without initial respiratory symptoms. Patient underwent treatment with milrinone and methylprednisolone that showed reduction in myocardial inflammation and significantly improved myocardial contractility. This was then followed by a second phase of SARS-CoV-2 associated pneumonia and renal failure requiring ventilatory support and haemofiltration. Although, not described in the literature, we have found conjunctive use of milrinone and methylprednisolone effective in patient with SARS-CoV-2 fulminant myocarditis.

The SARS-CoV-2 infection has caused a pandemic with a case rate of over 290 000 lab-confirmed cases and over 40 000 deaths in the UK. There is little evidence to inform the optimal management of a patient presenting with new or relapsed acute idiopathic thrombocytopaenic purpura with concurrent SARS-CoV-2 infection. We present a case of severe thrombocytopaenia complicated by subdural haematoma and rectal bleed associated with COVID-19. A 67-year-old man, admitted with a non-productive cough and confusion, was found to be positive for COVID-19. Ten days after admission, his platelets decreased from 146×109/L to 2×109/L. His platelets did not increase despite receiving frequent platelet transfusions. He was non-responsive to corticosteroids and intravenous immunoglobulins. Romiplostim and eltrombopag were given and after 9 weeks of treatment, his platelet count normalised. He was deemed medically fit with outpatient follow-up in a haematology clinic.

Since the beginning of the COVID-19 pandemic, healthcare providers worldwide have faced many obstacles in the diagnostic evaluation of patients for severe acute respiratory syndrome coronavirus 2, the causative virus. Even with the application of statistical inference by Bayes’ theorem to estimate the probability of a diagnosis, with and without testing capabilities, some cases may still carry a degree of uncertainty. This has important implications for limiting the spread of disease. The basis for isolation and quarantine is a known diagnosis. This case is an example of a diagnostic conundrum that required more thorough use of testing methods, particularly serological testing, to guide the isolation recommendations for a patient with COVID-19. This will be helpful to other diagnosticians by providing an example of how serological findings may be effectively applied in the course of individual COVID-19 management.

Coronavirus disease 2019 (COVID-19) is a novel infection of which we still have much to learn. Microvascular and macrovascular complications are increasingly recognised as being among the drivers of morbidity and mortality in patients with this condition. Here we present a case of a woman with COVID-19 who suffered massive and bilateral middle cerebral artery strokes, which presented as reduced consciousness several days into admission. Clinicians need to be aware of possible causes of reduced consciousness in COVID-19 patients, particularly as delirium appears to be a common complication, and revisit working diagnoses if the clinical picture does not fully fit. Studies into both anticoagulation and the management of stroke in the context of COVID-19 are urgently needed to help inform future practice.

We report a case of a hospitalised patient with COVID-19 who developed subacute thyroiditis in association with SARS-COV-2 infection. The patient presented with tachycardia, anterior neck pain and thyroid function tests revealing hyperthyroidism together with consistent ultrasonographic evidence suggesting subacute thyroiditis. Treatment with corticosteroids resulted in rapid clinical resolution. This case illustrates that subacute thyroiditis associated with viruses such as SARS-CoV-2 should be recognised as a complication of COVID-19 and considered as a differential diagnosis when infected patients present with tachycardia without evidence of progression of COVID-19 illness.

A 19-year-old man vaping with tetrahydrocannabinol presented with dyspnoea and right pneumothorax. History, imaging and negative infectious workup were consistent with E-cigarette, or vaping, product use-associated lung injury (EVALI). Treated with systemic steroids, he developed acute respiratory distress syndrome and was intubated requiring veno-venous extracorporeal membrane oxygenation (VV-ECMO) by hospital day 3. Using VV-ECMO, very-low tidal volume ventilation of 1.5 cc/kg was achieved, as was daily ambulation. VV-ECMO was decannulated on hospital day 9 and the patient was extubated the next day. He was discharged home on hospital day 13 without oxygen. At post-intensive care unit clinic follow-up, he had lost 20 kg of weight while hospitalised and reported nightmares. Patients with EVALI may be supported with VV-ECMO, which allows ultra-lung-protective mechanical ventilation that may minimise ventilator-induced lung injury. Follow-up in patients with EVALI is essential to diagnose and treat comorbidities, follow lung function and prevent relapses.

COVID-19 is a viral disease with a high infectivity rate. The full spectrum of the disease is not yet understood. This understanding may help in limiting potential exposure. We present a young man with diarrhoea, abdominal pain and hyponatraemia who turned out to be positive for COVID-19.

COVID-19 is a novel viral infection caused by severe acute respiratory syndrome-coronavirus-2 virus, first identified in Wuhan, China in December 2019. COVID-19 has spread rapidly and is now considered a global pandemic. We present a case of a patient with minimal respiratory symptoms but prominent bilateral groundglass opacities in a ‘crazy paving’ pattern on chest CT imaging and a negative initial infectious workup. However, given persistent dyspnoea and labs suggestive of COVID-19 infection, the patient remained hospitalised for further monitoring. Forty-eight hours after initial testing, the PCR test was repeated and returned positive for COVID-19. This case illustrates the importance of clinical vigilance to retest patients for COVID-19, particularly in the absence of another compelling aetiology. As COVID-19 testing improves to rapidly generate results, selective retesting of patients may uncover additional COVID-19 cases and strengthen measures to minimise the spread of COVID-19.

Immunoglobulin G4-related disease (IgG4-RD) is becoming increasingly documented. It was first described in relation to autoimmune pancreatitis. Features of the disease include tissue infiltration by IgG4 plasma cells with associated fibrosis and the growth of pseudotumours. A 71-year-old woman presented with increasing right cheek swelling and mild proptosis. Ten years earlier, she had a similar presentation and was diagnosed with an inflammatory pseudotumour. Examination revealed a lesion in the right nasal cavity. CT and MRI confirmed a mass within the right maxillary antrum extending into the nasal cavity. Endoscopic biopsies showed florid plasma cell infiltrate with marked increase in IgG+ plasma cells. Immunostaining expressed IgG4 (70%). She was started on a course of prednisolone and her symptoms resolved. IgG4-RD is becoming an emerging disease entity. Its involvement in the paranasal sinuses can mimic nasal tumours. Major surgical resection should be avoided as patients can often be treated medically.

We describe an unclassified overgrowth syndrome characterised by unregulated growth of dermal fibroblasts in the lower limbs of a 35-year-old woman. A PIK3CA gene mutation resulted in lower limb gigantism. Below the waist, she weighed 117 kg with each leg measuring over 100 cm in circumference. Her total adiposity was 50% accounted for by her legs mainly. Liposuction and surgical debulking were performed to reduce the size of the limbs but had exacerbated the overgrowth in her lower limbs. Systemic sepsis from an infected foot ulcer necessitated treatment by an above-knee amputation. Postoperatively, the stump increased in size by 19 kg. A trial of rapamycin to reverse the growth of the stump has shown promise. We discuss the clinical and genetic features of this previously unclassified disorder and the orthopaedic considerations involved.

The main pancreatic duct can become dilated in a number of conditions. We describe a patient with gross dilatation of the main pancreatic duct without evidence of causative underlying pathology suggesting congenital dilatation of the pancreatic duct. A 36-year-old man presented with signs of intestinal obstruction and a history of surgery for congenital pyloric stenosis. Incidental findings on CT showed a massively dilated main pancreatic duct. On MRI there was no duct irregularity or solid mural nodule, making a main duct intraductal papillary mucinous neoplasm unlikely. Endoscopic ultrasound findings were in keeping with those on MRI. Fine needle aspiration revealed a non-viscous fluid with a low carcinoembryonic antigen and high amylase concentration, consistent with normal pancreatic fluid levels rather than a mucinous collection. After 1 year, the cyst remains unchanged. This patient will be kept under surveillance with yearly MRI.

Myxoid liposarcoma (MLS) represents one of the three main morphological subgroups of liposarcomas. Extrapulmonary recurrence to the retroperitoneum and abdomen is common in MLS. A pregnant patient was referred to our hospital due to abdominal pain and obstipation. In the past, she had received a multimodal treatment of an MLS of the left dorsal thigh. Now, MRI revealed a 14.6×10.1×12.4 cm-sized tumour adjacent to the uterus with a known twin pregnancy (26th week). We performed surgery under tocolytic therapy. The tumour has been completely removed. The histopathological examination revealed a nodular manifestation of a moderately differentiated MLS arising from the mesentery. Eleven weeks later, our patient delivered healthy twins. This is the first report of surgical resection of MLS during a twin pregnancy. With a multidisciplinary approach and a concerted treatment by surgeons and obstetricians, surgical resection resolved malignant intestinal obstruction and enabled an uncomplicated continuation of pregnancy.

Blastomycosis-associated acute respiratory distress syndrome (ARDS) has a rare incidence. We report the case of a 29-year-old man with blastomycosis-associated ARDS receiving extracorporeal membrane oxygenation and managed with high-dose liposomal amphotericin B. This case illustrates the importance of timely diagnosis of pulmonary blastomycosis and appropriate dosing of antifungal therapy.

Entero-urinary fistulas are uncommon in urological practice and may have widely varying aetiologies ranging from benign to malignant or iatrogenic in nature. All permutations of entero-urinary fistulas have been reported in the literature except an appendico-renal fistula. Here, we present one such case, presenting with urinary tract infections and perineal urethrocutaneous fistulae. He was ultimately diagnosed to have a spontaneous appendico-renal fistula as underlying pathology behind the symptoms.

We present here two-term neonates presenting with right lower limb hypertrophy, a port-wine stain, acral abnormalities and clubfeet. These neonates had overlapping features of Klippel Trenaunay syndrome and congenital lipomatous overgrowth, vascular malformation, epidermal nevi and scoliosis/skeletal abnormalities. Such overgrowth syndrome has not been previously described in the literature. Both the neonates are doing well and are under regular follow-up.

We present a case of a 23-year-old man with history of fever followed by painless complete vision loss, with subsequent new-onset refractory status epilepticus (NORSE). He initially developed bilateral retinitis. A few days later, he started having focal seizures, and subsequently developed super-refractory status epilepticus, requiring anaesthetic agents. MRI brain revealed multifocal cortical and subcortical hyperintensities in occipital and temporoparietal regions without contrast enhancement. MRI repeated a month later showed new lesions with non-visualisation of some previous lesions. Finally, a brain biopsy was done which revealed presence of lymphocytic infiltrate with SV40 inclusions in oligodendrocyte. We propose the affliction of an atypical virus affecting the retina and brain grey and white matter, presenting with NORSE in our patient. Future similar cases and isolation of the virus may help in establishing the conclusive diagnosis.

Renal cell carcinoma is historically known as the 'great masquerader' with 40% of patients experiencing a paraneoplastic syndrome. Translocation carcinoma represents one-third of renal cancer in paediatric patients but less than 3% of renal cancers in patients aged 18-45 years where the clinical course is often rapidly terminal. There are less than 10 reported cases of leucoclastic vasculitis associated with clear cell carcinoma reported in the literature and 10 case reports of translocation carcinoma in adults. To our knowledge, we present the first reported case of Xp11 translocation carcinoma presenting as cutaneous vasculitis, as part of a paraneoplastic syndrome, in an adult patient. Our case highlights that renal cell cancers are truly the 'great masquerader' and a rash can be the first sign of renal malignancy.

Loperamide is a common over-the-counter antidiarrheal considered safe in a broad range of dosages and thought devoid of abuse potential. We describe the first case of a patient with loperamide dependence due to misuse of its opiate-like effects achieved by chronic massive oral ingestions. A 26-year-old man who was taking 800 mg of loperamide per day presented requesting detoxification referral. Loperamide has potential for euphoric effects and information on how to facilitate such effects is easily available. It is important for physicians to be aware of the potential for misuse of and dependence on loperamide, with symptoms mimicking opiate use.

A Littre's hernia is an unusual phenomenon where a Meckel's diverticulum protrudes through a potential abdominal opening. We wish to present a unique case of a 79-year-old man with respiratory distress following a fall from standing, initially managed as a haemothorax. After a chest drain was placed, bowel contents were drained from the pleural cavity and he was taken to theatre. He had a history of minimally invasive oesophagectomy for cancer and had subsequently developed a diaphragmatic hernia. A blind ending diverticulum with a perforation at its tip was found in the left oblique lung fissure that was subsequently confirmed histologically as a perforated Meckel's diverticulum. The patient had a prolonged stay on the intensive care unit with a left-sided empyema that was managed radiologically prior to discharge. Unfortunately 4 months postoperatively, he passed away from hospital-acquired pneumonia on a rehabilitation ward.

A 57-year-old woman with frequent respiratory infections was initially diagnosed with IgG subclass deficiency based on low levels of IgG subclasses 2 and 3. Three years later, she progressed to having IgA deficiency as well. With a normal total IgG level, she does not meet criteria for common variable immunodeficiency (CVID). This may represent a variant of CVID. This also highlights the importance of immunoglobulin subclass estimation in patients where immunodeficiency is suspected clinically. She is being treated with rotational antibiotics the first 10 days of every month, monthly intravenous immunoglobulin (IVIG) infusion and osteopathic manipulation one to two times per month. On this regimen, although she has had several viral respiratory infections, she has avoided further hospitalisation for more than 1 year.

The antiemetic properties of marijuana are well known, but there is increasing evidence of its paradoxical hyperemetic effects on the gastrointestinal tract and central nervous system, known as 'cannabinoid hyperemesis syndrome' (CHS). We report a case of CHS encountered in our outpatient clinic. We also completed a review of the literature using PubMed in patients over 18 years of age with CHS. Understanding the diagnostic criteria and risk factors associated with CHS may reduce the ordering of unnecessary and expensive investigations, and pursuing inappropriate medical and surgical treatments. Ultimately, abstaining from cannabis use leads to resolution of symptoms in the majority of patients.