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A 90-year-old woman is referred six months after a transient ischaemic attack (TIA) with asymptomatic cholestatic liver function test (LFT) derangement. Following the TIA, atorvastatin and clopidogrel therapy are initiated. This is added to pre-existent once daily nifedipine for hypertension. Nifedipine (a weak inhibitor of CYP3A4 and competing substrate) and clopidogrel (a competitive inhibitor of CYP3A4) may have affected the metabolism of atorvastatin, resulting in the elevation of serum alkaline phosphatase levels to over six times the upper limit of normal. More often, statin therapy elevates serum alanine aminotransferase levels. Drug-induced liver injury (DILI) was deemed ‘probable’ as judged by the Roussel Uclaf Causality Assessment Method score. Statin therapy remains overwhelmingly safe, with benefits outweighing risks in the vast majority. The UK recommended LFT monitoring regime facilitates early recognition of DILI. Case reports are examined where similar drug combinations resulted in severe morbidity and mortality.

Sitagliptin is a dipeptidyl peptidase-4 inhibitor commonly used in the treatment of type 2 diabetes mellitus for glycaemic control. Concerns have arisen regarding adverse events caused by this drug, particularly concerning arthralgias. Here, we report on a 56-year-old man being treated with sitagliptin who developed inflammatory arthritis after taking the drug for 6 months. The patient presented with pain, swelling and erythema in multiple joints and was eventually diagnosed with seronegative rheumatoid arthritis (RA) under the 2010 American College of Rheumatology/European League Against Rheumatism classification criteria. His symptoms continued for several months after stopping sitagliptin and eventually went into remission after a tapered course of steroids, hydroxychloroquine and methotrexate. Furthermore, the patient is HLA-DRB3 positive, a genetic marker that is still being investigated for its role in the pathogenesis of RA and that may have been a predisposing factor in the development of this patient’s inflammatory arthropathy.

A 76-year-old woman was treated with oral bisphosphonate, alendronate, for osteoporosis in an outpatient clinic. Routine blood tests 4 months after alendronate prescription surprisingly revealed severe hypophosphataemia. The patient was hospitalised and treated with intravenous and oral phosphate supplements. Alendronate was later reintroduced as treatment for osteoporosis and the patient once again presented with severe hypophosphataemia in subsequent routine blood tests. The patient had only presented with lower extremity pain, muscle weakness and difficulty walking. Blood tests in the emergency department both times reconfirmed severe hypophosphataemia. Plasma (p-)ionised calcium levels were normal or slightly elevated and p-parathyroid hormone levels were normal or slightly suppressed. The p-25-hydroxyvitamin-D and p-creatine were in the normal range. Critical illness, malabsorption, nutritional issues and genetics were reviewed as potential causes but considered unlikely. Phosphate levels were quickly restored each time on replacement therapy and the case was interpreted as bisphosphonate-induced severe hypophosphataemia.

A man in his early 50s presented with jaundice, mild shortness of breath on exertion and dark urine. He had had coryzal symptoms 2 weeks prior to admission. Medical history included obstructive sleep apnoea and hypertension. His initial blood tests showed a mild hyperbilirubinaemia and acute kidney injury stage 1. Chest X-ray and CT pulmonary angiogram were negative for features suggestive of COVID-19. He later developed a drop in haemoglobin and repeat bloods showed markedly raised lactate dehydrogenase and positive direct antiglobulin test. These results were felt to be consistent with a haemolytic anaemia. A nasopharyngeal swab came back positive for COVID-19. We suspect the cause of his symptoms was an autoimmune haemolytic anaemia secondary to COVID-19 which has recently been described in European cohorts.

Haemoperitoneum was observed in a peritoneal dialysis (PD) patient after undergoing endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). EUS-FNA was performed to evaluate a pancreatic cyst seen on a prekidney transplant evaluation abdominal CT scan. Haemoperitoneum cleared with a PD exchange. In this case report, we discuss aetiologies for bleeding risks in patients with chronic kidney disease and focus on haemoperitoneum in patients receiving PD. We will also explore treatment options to minimise bleeding associated with an abdominal procedure such as EUS-FNA.

Upper gastrointestinal (GI) endoscopies are performed for several reasons. The overuse of endoscopy has negative effects on the quality of healthcare and pressurises endoscopy services. It also results in the complications. These complications include pneumoperitoneum, pneumomediastinum and subcutaneous pneumomediastinum. However, it is worth noting that these complications rarely occur during endoscopy of the upper GI tract. These complications, when they occur, indicate perforation of the retroperitoneal space or peritoneal cavity. In this article, we discuss a case of pneumoperitoneum, pneumomediastinum and subcutaneous emphysema after upper GI endoscopy.

We present a case of a 75-year-old man who was admitted to an Australian tertiary emergency department with severe hypotension, wheeze, widespread urticarial rash and diarrhoea. On arrival to the emergency department following initial resuscitation by ambulance staff, he was admitted to the intensive care unit with a presumptive diagnosis of gastroenteritis. This diagnosis was later revised following the availability of tryptase levels and clarification of his presenting circumstances, which established a clear temporal relationship between his anaphylactoid symptoms and the oral ingestion of Chlorella vulgaris supplements. While there are a few case studies describing allergic/anaphylactic reactions to several other species of Chlorella, this appears to be the first reported case of anaphylaxis to C. vulgaris.

A 23-year-old man with a history of end-stage renal disease was admitted to the hospital due to fever and shock, which occurred during his dialysis. One week prior, he developed an erythematous rash on his chest, face and back, associated with generalised eruption of pustules. In hospital, his status did not improve with norepinephrine and empirical broad-spectrum antibiotics. Following this, methylprednisolone was administered with remarkable improvement. Cultures revealed no infectious aetiology. Based on the morphology of the rash and a compatible skin biopsy, the diagnosis of acute generalised exanthematous pustulosis (AGEP) was established and considered the cause of his shock. The causative agent of his AGEP remained unknown. AGEP is a rare condition, most frequently associated with drug exposure. The removal of the offending agent is the treatment of choice. It can be complicated by shock in rare cases. In that scenario, systemic corticosteroids seem to improve outcomes greatly.

A 74-year-old man presented with acute small bowel obstruction secondary to recurrence of a caecal tumour. The patient underwent laparotomy and formation of loop ileostomy and had a nasogastric tube (NGT) inserted in the theatre. A decision was made to remove the patient’s NGT postoperatively, which was found to be stuck. High-quality imaging demonstrated a knot in the tube within the nasopharynx; so, subsequent removal via the oral route necessitated sedation. This case highlights the importance of considering rare or unusual complications of NGT insertion when a patient describes more pain or discomfort than would otherwise be expected. The clarity of imaging highlights clearly the underlying findings when compared with the few other documented cases. We offer a number of learning points specific to this complication.

Some patients with metastatic medulloblastoma can be successfully treated with targeted therapy. We report the case of a 42-year-old woman who was diagnosed with sonic hedgehog (SHH)-subgroup medulloblastoma. She was treated with surgery, radiation and chemotherapy. She then developed bone pain. A positron emission tomography (PET) scan confirmed widespread bone metastases from her medulloblastoma. She was started on vismodegib, an oral smoothened inhibitor that targets her tumour type. Her bone pain resolved. A repeat PET scan showed resolution of almost all metastases. Fourteen months after starting vismodegib, her disease recurred and she was transitioned to temozolomide chemotherapy. We document an important case of prolonged response to vismodegib in a patient with systemic SHH-subgroup medulloblastoma metastases.

A 4-year-old girl presented with confusion, ataxia and hallucinations 3 hours after an accidental overdose of 108 μg per kg of hyoscine hydrobromide (Kwells Kids). She was hypotensive and tachycardic at presentation. Investigations revealed QTc prolongation on ECG. The girl was admitted for observation overnight and was noted to have persistent visual and auditory hallucinations, which resolved without treatment. To our knowledge, this is the first reported case of an overdose of hyoscine hydrobromide at such a young age. Clinicians should be aware that unintentional ingestions in this age group may present with psychiatric manifestations. Hyoscine hydrobromide is easily accessible and available over the counter. It has serious consequences in overdose. Its packaging and appearance are attractive to young children making it susceptible to unintentional ingestions. We argue that its container should be altered to be more childproof.

A 45-year-old woman was admitted for diabetic ketoacidosis (DKA). Aggressive rehydration and continuous intravenous insulin resulted in improved blood glucose levels; however, metabolic acidosis persisted. One day prior to admission, the patient took a single dose of a sodium–glucose cotransporter 2 (SGLT2) inhibitor and this likely contributed to the prolonged euglycemic DKA. A single dose of this drug remained effective for over 100 hours as evidenced by massive excretion of urine glucose continuing long after blood glucose normalisation. SGLT2 inhibitor use should be refrained in cases in which DKA has already occurred as they may result in increasing severity or prolonged DKA.

Immune-related myositis is one of the rare immune-related adverse events whose underlying precise mechanisms are not fully understood. Here, we describe a case of immune-related myositis that developed after four cycles of combination therapy with nivolumab plus ipilimumab for the treatment of metastatic renal cell carcinoma. Negative results of autoimmune antibodies, including anti-acetylcholine receptor and anti-muscle-specific kinase antibodies suggested a T-cell-mediated mechanism. After recovery with steroid therapy, the patient resumed nivolumab monotherapy and survived without any evidence of disease progression or refractory of myositis. Differential diagnosis between T-cell-mediated and B-cell-mediated immune-related myositis and its impact on optimal management are discussed.

A 53-year-old woman with atypical chest pain underwent a dobutamine stress echocardiogram (DSE) and developed a coronary spasm (CS) with severe pain and dramatic ST-segment elevation 9 min after dobutamine infusion was discontinued. The spasm resolved after sublingual nitroglycerin administration. The same-day coronary angiogram showed non-significant stenosis in the three coronary territories. Retrospectively, we found that the patient had vasospastic angina (VSA), a condition that has been strongly associated with the development of dobutamine-induced CS. Mechanisms of dobutamine-induced CS are not fully understood and include endothelial dysfunction leading to deficient nitric oxide-mediated coronary vasodilation in response to increased myocardial oxygen demand as well as imbalance between β1 and β2 adrenergic effects of dobutamine. Dobutamine-induced CS has also been much more frequently reported in patients from Asian descent with VSA. VSA should be systemically recognised in patients considered for DSE and, if present, other modalities of stress imaging should be discussed.

A 41-year-old woman presented to the hospital because of left flank pain. CT scan of the kidneys revealed left-sided calculi and an incidental right adrenal mass, no other symptoms noted. She then underwent shockwave lithotripsy (SWL). However, immediately postoperatively, she had elevated blood pressure and remained hypertensive despite having four different medications. How SWL could have increased blood pressure could not be identified. On endocrine consult 16 months after SWL, she was found to now exhibit signs and symptoms of Cushing’s syndrome. Further workup revealed the adrenal incidentaloma to be cortisol-secreting. After undergoing right laparoscopic adrenalectomy, her blood pressure normalised, cortisol levels decreased and signs of Cushing’s syndrome gradually improved. We hypothesise that the performance of the SWL could have triggered the adenoma to ‘awaken’ from being non-functioning to cortisol-producing since this was the only intervening event. Observations of other patients are needed to validate our hypothesis.

Intra-articular steroid injections are widely prescribed for management of osteoarthritis when oral medication or physiotherapy treatment fails to relieve patient’s pain. Septic arthritis is an uncommon side effect of steroid injection. Common causal micro-organisms are bacterial with Staphylococcus aureus being the most frequent. Fungal septic arthritis is rare and does not usually present beyond the neonatal period. We present a rare case of septic arthritis secondary to fungal infection.

Certain medications have been implicated in causing acute myocardial infarctions (AMI). Sumatriptan, a medication usually prescribed for acute migraine and cluster headaches has been documented as potentially causing coronary vasospasm, thereby leading to MI. This is usually seen in patients with strong risk factors for coronary artery disease (CAD) or in those with established CAD. Most cases thus far have been reported in patients using the subcutaneous preparation of sumatriptan. Here, we present a case of a patient without prior risk factors for CAD and angiographically unremarkable coronary arteries who presented with evidence of an AMI after oral sumatriptan use for migraines.

In this case, a patient presented in a delayed fashion after blunt trauma is found to have a large left-sided pneumothorax, and tube thoracostomy is performed. After placement of the apically oriented tube, he developed haemothorax. CT imaging showed an area of questionable extravasation from the left subclavian artery, directly anterior to the thoracostomy tube. His haemothorax was refractory to adequate drainage with a new thoracostomy tube. He ultimately required angiography, coil embolisation and covered stent placement, followed by thoracoscopic evacuation of the haemothorax.

A 46-year-old man with antiphospholipid syndrome (APS) and previous pulmonary embolism on anticoagulation with rivaroxaban was brought in to the hospital after a syncopal episode. He was found to be hypotensive and tachycardic and later admitted to the intensive care unit. Clinical presentation and laboratory findings were consistent with adrenal insufficiency. MRI revealed bilateral adrenal haemorrhage and he received appropriate steroid replacement therapy. Symptoms slowly subsided and anticoagulation regimen was changed to warfarin. Adrenal haemorrhage was likely caused by APS and rivaroxaban, which brings into question whether novel oral anticoagulants are safe in this patient population.

Acute ischaemic stroke is a known risk of percutaneous coronary intervention (PCI). The incidence of such complications has increased in frequency over the last decade due to higher comorbidity burden and increased complexity of PCI procedures. The overall incidence of post-PCI ischaemic stroke remains low at 0.56%, but some groups of patients have significantly higher risk. Risk factors include atherosclerotic plaques, atrial fibrillation, cardiogenic shock, older age and arterial disease. Although the overall incidence of acute ischaemic stroke following PCI is low, it can result in lifelong disability and is associated with high morbidity, mortality and significant costs. Spinal infarctions due to PCI are exceedingly rare. Here, we discuss a 71-year-old woman who presented with a non ST-elevation myocardial infarction and developed both stroke and spinal infarction post PCI due to a thromboembolic event resulting in long-term debility.

Drug-induced thrombocytopenia (DITP) is suggested by severe thrombocytopenia with subsequent recovery of platelet count after removal of the offending drug. The diagnosis is ascertained when there is reproducibility of thrombocytopenia with repeated exposure. Filgrastim is used during peripheral blood progenitor cell harvest during autologous stem cell transplantation in the setting of multiple myeloma to prolong event-free survival and overall mortality. The following case illustrates all of the suggestive features of DITP after filgrastim exposure during elective stem cell harvest. Due to the inability to tolerate filgrastim, autologous stem cell transplant was aborted in this patient and he was maintained on induction chemotherapy.

In conjunction with BMJ Case Reports , DTB will feature occasional drug-relatedcases that are likely to be of interest to readers. Thesewill include cases that involve recently marketed drugs for which there is limited knowledge of adverse effects and cases that highlightunusual reactions to drugs that have been marketed for several years. We present a case of a young Asian female with rheumatoid arthritis who received latent tuberculosis infection (LTBI) treatment prior to treatment with a biologic agent, and developed shock with resistant hypotension on re-exposure to rifampicin. We discuss the epidemiology, pathophysiology and management of rifampicin induced shock, concluding that clinicians should be aware of this rare, but potential adverse effect, and be aware that adverse reactions to rifampicin are more frequent during re-exposure or longer dosing interval regimes. The evidence for desensitisation following such a reaction is lacking and this approach is not currently recommended. We would suggest close collaboration between specialties prescribing immunosuppression and the tuberculosis team when LTBI treatment is required after a reaction, with patient involvement to discuss the risks and benefits of treatment options. Rifampicin induced shock is extremely uncommon with few cases in the literature. It is usually described following intermittent doses or re-exposure. It is an important complication that physicians should be aware of when prescribing anti-tuberculosis (TB) medications, or working in healthcare centres where those receiving treatment might present. A 25-year-old Asian female with seropositive rheumatoid arthritis who had failed trials of methotrexate and hydroxychloroquine (stopped due to chest pain and shortness of breath) and sulfasalazine (stopped due to rash), and in whom a trial of the anti-tumour necrosis factor drug etanercept was being considered, was referred for latent tuberculosis infection (LTBI) screening in keeping with current guidelines.1 She had no significant medical history and a family history significant only …

Irinotecan is a novel anticancer drug that has worked wonders in combination with other anticancer drugs. It can be used as a single chemotherapy agent in colonic cancer treatment or in combination with 5-fluorouracil. Irinotecan has been found a better salvage therapy in patients who are resistant to 5-fluorouracil. It is also used in combination with cisplatin and other drugs for cancers such as pleural mesothelioma, Ewing’s sarcoma, lung cancer and others, and has helped reduce tumour burden. Irinotecan is generally associated with gastrointestinal side effects including nausea, vomiting and diarrhoea, while cardiovascular toxicity (5%) has been reported mainly as vasodilatation and possible bradycardia with no known incidence. A case was reported in 1998 by Miya et al of a 65-year-old man with bradycardia which was managed with atropine without modifications in the dosage of irinotecan or in the rate of infusion. We report a case of a patient with small round cell cancer who presented with sinus pause bradycardia after infusion with irinotecan. The patient was managed with atropine during chemotherapy.

Cisplatin is a widely used chemotherapeutic agent for many cancer types. Its toxicity profile includes drug-induced vascular damage. Clinicians should be aware of its varied presentation, including acute and chronic vascular events involving the arterial and venous system. This is a case of an otherwise well 32-year-old man with testicular cancer who received bleomycin/etoposide/cisplatin, and presented following two cycles of chemotherapy with homonymous hemianopia secondary to acute stroke. Acute arterial complications are rare, but clinicians should maintain a high index of suspicion for such events, even in a patient who otherwise has no vascular risk factors. Primary and secondary prevention measures including lifestyle modifications (smoking cessation, diet and exercise), blood pressure and cholesterol management, and antiplatelet therapy should be considered in patients exposed to cisplatin, during and following their treatment.

Immune checkpoint inhibitors, including antiprogrammed death cell protein 1 (anti-PD-1) and anti cytotoxic T-lymphocyte-associated protein 4 (anti-CTLA-4), have been associated with a range of autoimmune-related side effects since their introduction in cancer treatment. Small vessel digital necrosis, referred to as the acral vascular syndrome, is a rare but serious complication that can result in loss of digits. Here we present a case report of acral vascular syndrome and review possible aetiologies. A 45- year-old woman with invasive ductal carcinoma of the left breast presented to the emergency department during neoadjuvant treatment with carboplatin, docetaxel and pembrolizumab with complaints of severe pain in her right third digit. She had physical findings consistent with ischaemic necrosis and gangrene of the distal phalanx. Angiography demonstrated Raynaud’s phenomenon in the distal portion of the digits. Laboratory testing showed a weakly positive RNA polymerase III antibody level. Her case resulted in surgical amputation of her affected digit after partial resolution of symptoms with prednisone, vasodilators and antibiotics.

A 54-year-old Chinese woman presented for radiofrequency ablation (RFA) of benign thyroid nodules. A few hours after the procedure, the patient developed neck swelling and tenderness. Doppler ultrasound (US) images of the neck revealed haematoma with a vascular hypoechoic mass at the RFA site, suspicious for pseudoaneurysm. These findings were confirmed on subsequent on-table fluoroscopy following direct US-guided needle puncture and injection of contrast, demonstrating opacification of the mass and extravasation. Successful occlusion of the pseudoaneurysm was performed using US-guided thrombin injection. The patient made a good recovery with follow-up US 1 month later showing no recurrence of haematoma or pseudoaneurysm.

A 45-year-old woman with a medical history of ulcerative colitis (UC) presented with difficulty in breathing. The patient was diagnosed with UC a month prior to presentation and was started on mesalamine suppository. Chest x-ray (CXR) on presentation showed bilateral pleural effusion, which was confirmed on CT angiogram of the chest. Diagnostic and therapeutic thoracentesis was performed and 0.7 L of pleural fluid was removed from the left side. The pleural fluid analysis was consistent with exudative pleural effusion with eosinophilia. Symptomatic improvement was noted after thoracentesis. Mesalamine was stopped and repeat CXR was obtained on the follow-up visit, which showed no pleural effusion. The Naranjo score was calculated to be 7, indicating that the eosinophilic pleural effusion was most probably secondary to adverse reaction from mesalamine.

Neurotoxicity from intrathecally administered chemotherapeutic drugs is frequent, particularly with some agents like methotrexate, which are more prone to developing adverse effects. Myelopathy ranks among the most frequently reported neurological entities; with the diagnosis being straightforward, after ruling out infectious, metabolic, autoimmune or paraneoplastic causes. Scarcity of cases precludes evidence-based recommendations for the management of these complications. The most common therapeutic approach consists of the suspension of chemotherapy, exclusion of infectious and neoplastic causes, with prompt administration of high-dose steroids. We report a 21-year-old patient with acute lymphoblastic leukaemia, who developed acute transverse myelitis and bilateral sensorineural hearing loss, after five rounds of intrathecal methotrexate and cytarabine. Although neurotoxicity from both agents has been documented, this combination has not been previously reported.

A 64-year-old woman with refractory cellulitis in the lower legs was referred for inadequate glycaemic control. Physical examination revealed cushingoid features including central obesity. CT of the abdomen revealed a right adrenal mass that was positive on 131I-adosterol imaging. Findings on endocrine evaluation confirmed a diagnosis of Cushing’s syndrome, which was cured with a right adrenalectomy. Two months after surgery, the patient complained of pain and marked swelling of the hands during hydrocortisone replacement therapy (20 mg per day) given for postoperative adrenal insufficiency. Laboratory examination was unremarkable. However, contrast-enhanced T2-weighted MRI of the hands revealed enhanced signals surrounding the flexor tendons, leading to a diagnosis of remitting seronegative symmetrical synovitis with pitting oedema. Prednisolone (15 mg per day) was then initiated, and the symptoms disappeared within a few days. This case illustrates the possibility that successful treatment of Cushing’s syndrome may trigger emergence of a glucocorticoid-responsive disease.

A 65-year-old comorbid female patient presented to our urology department with a history of multiple interventions to treat severe overactive bladder symptoms. She had a history of clam ileocystoplasty, which was then converted to an ileal conduit due to failure to resolve her symptoms. She subsequently developed multiple complications, most significantly ureteroileal stenosis, managed with bilateral ureteric stents. She later decided on bilateral nephrostomies and subsequent antegrade stent insertion. At follow-up, the proximal end of the left stent remained within the kidney and the distal end was free within the abdominal cavity. There was further migration of the stent in its entirety into the lumen of the terminal ileum on subsequent imaging. She denied any significant gastrointestinal symptoms, signs or peritonitis. Consideration was made for the endoscopic removal of the stent by the gastrointestinal team; however, the patient refused any further procedures preferring to be monitored.

Fascioliasis is a trematode flatworm infection caused by Fasciola hepatica. Humans are incidental hosts, and the infection is most often acquired by eating watercress grown in contaminated water in livestock-rearing areas. Triclabendazole is the only highly effective treatment, with a reported cure rate of >90%. Treatment failure may be due to several factors, though resistance is rare in humans and scarcely reported, most probably a reflection of the widespread use of anthelmintics in livestock. There are three papers describing cases of treatment failure, possibly due to resistance, in the Netherlands, Chile and Peru. We document for the first time one case of failure after multiple treatment courses with triclabendazole in Portugal, probably due to resistance to the anthelmintic. Our aim is to alert for the emergence of resistance across continents, with consequent predictable difficulties in the management of the disease and encourage more investigation in the field.

Hypersensitivity pneumonitis (HP), also known as extrinsic allergic alveolitis, is a granulomatous, non-IgE-mediated hypersensitivity reaction of the alveoli and distal bronchioles presenting as an acute, subacute or chronic condition. It is most commonly associated with exposure to extrinsic allergens (eg, avian dust, mould and tobacco) and medications including antiarrhythmics (eg, amiodarone), cytotoxics (eg, methotrexate) and antiepileptics (eg, carbamazepine). Individuals diagnosed with this condition can present with severe hypoxia and respiratory failure. The fundamental principle of management is to remove the causative allergen. Evidence implicating selective serotonin reuptake inhibitors as a causative agent is limited, and this case report describes a rare clinical presentation of HP associated with sertraline, how it was diagnosed and subsequently treated. It is anticipated that raising awareness of this interaction will assist multidisciplinary teams, managing patients diagnosed with HP, to be more cognisant of sertraline as being an aetiological factor for this condition.

A patient undergoes intracranial stent insertion for stent-assisted coiling of a basilar tip aneurysm and left middle cerebral artery aneurysm. A flow diverting stent is also placed across an anterior communicating artery aneurysm. Prior to the procedure, the patient takes dual antiplatelet medications, being aspirin and clopidogrel. Because of the concern regarding in-stent thrombus and thromboembolic complications related to intracranial stenting and the high rate of clopidogrel resistance, preoperative platelet function testing (PFT) was undertaken to ensure platelet inhibition. In this case, PFT was performed on a platelet function analyser which demonstrated platelet inhibition. Ten days following the procedure, the patient represented with thromboembolic stroke. Repeat PFT performed with whole blood impedance aggregometry and despite full medication compliance demonstrated clopidogrel resistance. Clopidogrel was then ceased and prasugrel commenced. This case demonstrates the importance of appropriate platelet inhibition in patients with intracranial stents and the controversy surrounding PFT.

The differential diagnosis of shock following percutaneous coronary intervention (PCI) is vast. Access site complications and bleeding can cause hypovolemic shock. Peri-procedural myocardial infarction, abrupt closure, stent thrombosis, coronary dissection and coronary perforation have a stormy presentation. Vasovagal shock is manifested by bradycardia and hypotension and quickly responds to atropine. Anaphylactic shock secondary to contrast administration can be stormy but usually responds to steroids or adrenaline. Septicemia due to unsterile techniques can cause a less dramatic shock. Acute adrenal insufficiency causing shock following PCI has not been described to the best of our knowledge. We report the case of a 54-year-old woman who underwent successful multivessel PCI. She had refractory unexplained shock following the PCI with no much response from inotropic or intra-aortic balloon pump. After ruling out all possible causes of shock and clinical suspicion of adrenal insufficiency, she was treated with steroids resulting in dramatic improvement in her hemodynamics.

A 30-year-old man with a history of severe right iliac fossa pain was referred to the surgical emergency unit. His symptoms began 3 days prior as mild, non-specific abdominal pain which progressively localised to the right iliac fossa and worsened in severity. Investigations were suggestive of acute appendicitis, and therefore a laparoscopic appendicectomy was planned. Laparoscopy revealed a thickened, necrotic appendix with a mass at the base of the appendix, in keeping with the appearance of an appendiceal malignancy. Subsequently a right hemicolectomy was performed. Histology revealed active chronic inflammation and granulomas highly suggestive of appendiceal Crohn’s disease. Since, the patient has made a good recovery and presently shows no further signs of Crohn’s disease. This case is demonstrative of one of many rare findings on histological examination of the appendix. It emphasises the need for a wide differential when investigating right iliac fossa pain.

A 56-year-old man undergoing immunotherapy treatment for metastatic melanoma presented with sudden onset testicular pain radiating into his abdomen. On examination, the abdomen was generally tender with associated guarding. Imaging revealed a perforation of the small bowel at the site of a metastatic lesion. Histology revealed that this process was non-inflammatory in nature. A diagnosis of small bowel perforation secondary to immunotherapy driven rapid tumour regression was made. The patient was treated with a small bowel resection plus anastomosis and made a full recovery. This case highlights the rare potential side effect of immunotherapy in causing non-inflammatory bowel perforations secondary to rapid tumour regression.

Octreotide is a somatostatin analogue used for treating congenital chylothorax and congenital hyperinsulinism in infants. By increasing splanchnic arteriolar resistance and decreasing gastrointestinal blood flow, octreotide indirectly reduces lymphatic flow in chylous effusions.Splanchnic ischaemia following octreotide predisposes infants to necrotising enterocolitis (NEC). Although NEC occurrence in infants treated with octreotide for hyperinsulinaemic hypoglycaemia has been reported widely, its incidence in infants with chylothroax is low. We describe a case of congenital chylothorax in a preterm infant who had poor response to thoracentesis. Although octreotide initiation lead to resolution of chylothorax, he developed NEC. Cessation of octreotide and medical management resulted in rapid resolution of NEC. Since octreotide is generally used as the first-line treatment for chylous effusion, the risk of NEC should be considered, especially when the dosage is increased. Infants on octreotide should be closely observed for early signs and symptoms of NEC to avert surgical emergency.

Anti-N-methyl-d-aspartate (NMDA) receptor encephalitis usually presents with prominent neuropsychiatric symptoms and many patients experience cognitive sequelae. Electroconvulsive therapy (ECT) has been suggested as a part of the treatment, particularly for catatonia, but concerns that ECT may worsen the cognitive function and long-term outcome may limit its use. We present a case of anti-NMDA receptor encephalitis with severe neuropsychiatric manifestations including refractory catatonia and behavioural change. A pre-ECT neuropsychological assessment revealed dysfunction in multiple cognitive domains in spite of intensive pharmacological treatment. Twenty days after the ninth and last ECT treatment, the patient underwent the same neuropsychological tests, which showed normalised test results within all cognitive domains and no need of rehabilitation. The case demonstrates that the use of ECT in anti-NMDA receptor encephalitis with severe pretreatment cognitive dysfunction can be associated with a highly favourable cognitive outcome.

Colistin-induced nephrotoxicity is commonly associated with elevation of serum creatinine level or a reduction of urine output. Uncommonly, tubulopathy associated with colistin has been reported. Here we present a unique case of a 46-year-old man who developed polyuria, hypokalaemia, hypocalcaemia, hypomagnesemia and metabolic alkalosis after 3 days of therapy with intravenous colistimethate sodium. After ruling out other causes, a diagnosis of colistin-induced acquired Bartter syndrome was made. The patient required daily aggressive intravenous repletion of fluids and electrolytes. However, polyuria and metabolic abnormalities abated only after drug discontinuation.

Odontoid fractures are injuries that can either be benign or devastatingly progress to quadriplegia and significant morbidity and mortality. Management is not clear cut for patients who already present late and with severe neurological deficits. We present a case of a type 2 odontoid fracture with associated complete spinal cord injury (American Spinal Injury Association A) initially untreated for 3 months but was subsequently managed with posterior decompression, instrumentation and occipitocervical fusion. The patient fully recovered all deficits and is independent of activities of daily living.

A 48-year-old male patient requiring extracorporeal membrane oxygenation (ECMO) support for hypoxaemic respiratory failure failed to achieve therapeutic anticoagulation with bivalirudin after continuous dose escalations, and continued to have recurrent fibrin stranding in the circuit over a 6-day course of treatment. Suspecting bivalirudin resistance, the patient was transitioned to argatroban and achieved a therapeutic response in less than 24 hours. The case describes the challenges of anticoagulation in ECMO supported patients. The interplay between bivalirudin metabolism, renal replacement therapy, and immunological effects leading to a heparin-like-effect, inflammatory mediators, and thrombotic burdens may all impact the clinical effect during bivalirudin therapy. The structural biochemistry of thrombin and bivalirudin likely plays a role in the presented patient’s successful response to argatroban. Bivalirudin may fail at achieving therapeutic anticoagulation in patients with genetic thrombin mutations or structural defects that alter the binding pockets at the thrombin exosites.

In the prevention and treatment of thromboembolic disease, novel oral anticoagulants have emerged as alternatives to warfarin. A major challenge continues to be the reversal of their anticoagulant effect in the case of life-threatening haemorrhagic complications. We report a case of spontaneous splenic rupture treated by splenic artery embolisation in a 77-year-old woman who was anticoagulated with rivaroxaban.

Transcatheter aortic valve implantations (TAVIs) may be complicated by a need for permanent pacemaker implantation post procedure, usually due to local trauma or compression on the conduction system. There are some features that might help predict that a patient is high risk for developing conduction disease following TAVI, for example, underlying right bundle branch block or use of certain types of TAVI. It might also become apparent during the procedure, or before temporary wire removal post procedure. Higher risk patients may undergo rhythm monitoring for longer periods post TAVI. We present a case where a patient required an unexpected emergency pacemaker following a TAVI, despite low risk clinical features, a low risk baseline ECG, and the use of a low risk TAVI valve. In addition, this very significant conduction disease only became apparent over 72 hours following implantation, despite normal resting ECGs and telemetry up to that point.

A 63-year-old woman with a medical history of chronic myelogenous leukaemia treated with dasatinib, chronic obstructive pulmonary disease and heart failure with preserved ejection fraction presented with difficulty in breathing. Chest X-ray showed large right-sided pleural effusion, which was confirmed on a CT angiogram of the chest. Echocardiogram showed an ejection fraction of 61% with moderate to severely dilated right ventricle and right ventricular systolic pressure of 60 mm Hg. Diagnostic and therapeutic thoracentesis was performed, and 2.2 L of pleural fluid was removed. Pleural fluid analysis was consistent with chylothorax. Significant symptomatic improvement was noted after thoracentesis. In the absence of an alternate explanation, chylothorax was attributed to dasatinib, which was switched to nilotinib. This resulted in resolution of her pleural effusions.

Acute gastrointestinal (GI) immune-related adverse events (irAE) are commonly reported by patients with cancer undergoing treatment with immune checkpoint inhibitors (CPI); however chronic irAEs are rare. We present a case of a 71-year-old woman with metastatic gastro-oesophageal junction (GOJ) adenocarcinoma who developed delayed-onset chronic intestinal pseudo-obstruction (CIPO) while receiving second-line pembrolizumab. Repeated CT scans of the abdomen/pelvis found no small bowel obstruction, and evaluations for bowel inflammation, infection and paraneoplastic syndrome were negative. Bowel rest and glucocorticoids were associated with transient symptom resolution; however, symptoms recurred within 1 month. The patient was ultimately supported with total parenteral nutrition and intestinal motility agents. After 4 months, the GOJ cancer remained stable with no signs of progression. As CPI use expands, the incidence of rare irAEs, such as CIPO, may increase.

Ocular graft-versus-host disease (GVHD) is one of the most frequent and long-term complications affecting patients after haematopoietic stem cell transplantation. It is associated with significant morbidity and a marked reduction in quality of life. Although common, currently there are no widely accepted guidelines available for its management, and no suggested regime of treatment that is completely satisfactory. So far, prophylactic treatment strategies for ocular GVHD have yet to be developed and treatment is normally initiated based on symptoms often after permanent ocular tissue changes and surface damage has occurred. Here we describe a case of recurrent ocular GVHD and its associated complications that was highly refractory to treatment.

A case illustrating significant hyperglycaemia with azacitidine therapy for myelodysplastic syndrome is presented. The significance of treatment-induced hyperglycaemia with regard to increased risk of infection, and possible mechanisms of azacitidine-induced hyperglycaemia are discussed.

In the perioperative setting, norepinephrine is used to increase blood pressure, an effect mediated mostly via arterial and venous vasoconstriction. Thus, norepinephrine is, allegedly, less likely to cause or worsen left ventricular outflow tract obstruction (LVOTO) than other inotropes. We report a case of norepinephrine-associated dynamic LVOTO and systolic anterior movement in a predisposed patient. This report highlights that unrecognised dynamic LVOTO may worsen shock parameters in patients treated with norepinephrine who have underlying myocardial hypertrophy.

A 27-year-old woman with moderate congenital ptosis and a positive Marcus-Gunn jaw winking reflex underwent levator resection surgery to correct the ptosis. Preoperatively, a normal Bell’s reflex was documented. Postoperatively, she developed an inverse Bell’s reflex and increased symptoms of ocular surface exposure. The Bell’s reflex normalised in a week, with resolution of the corneal exposure. Reversal of the Bell’s reflex can be an unforeseen complication following maximal levator resection. The early postoperative care in such cases is crucial, and the cornea must be protected from exposure changes. Accurate documentation of the Bell’s phenomenon preoperatively is vital to recognise this rare event and plan management.

Nasal fracture accounts for over 50% of facial fractures and is a frequent presentation to ear, nose and throat emergency clinics. Optimal management of nasal injuries with deformity is by manipulation under anaesthetic and should be offered when appropriate. A healthy 27-year-old woman presented with a lateral nasal wall mass with purulent discharge 1 month following manipulation. CT imaging revealed a mass arising from fragments of the nasal bone, consistent with an abscess. Bone fragments and purulent material were initially debrided, with a subsequent formal excision of a persistent granuloma performed with an excellent cosmetic outcome. This appears to be the first description of a granuloma resulting from a closed reduction—manipulation of a nasal fracture.