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A man in his mid-40s presented to hospital with confusion, headache and feeling generally unwell. He had had a total resection of a grade IV astrocytic glioma 1 year prior. Initial observations, blood tests and CT head scan were unremarkable for acute features to explain the patient’s presentation. However, an MRI head scan on this admission demonstrated a clear communicating hydrocephalus with new abnormal leptomeningeal enhancement, consistent with leptomeningeal metastatic infiltration by glioma. Lumbar puncture cytology and biochemistry supported this interpretation. As a small district general hospital in rural Wales, we discuss the experience of diagnosis and coordination of specialist input from a multidisciplinary team. We share the challenges of managing leptomeningeal disease in the COVID-19 pandemic, in the context of the additional risks this presents with chemotherapy-induced immunosuppression.

Spinal solitary fibrous tumour (SFT) is an uncommon tumour with few cases reported in the literature. It rarely originates at the craniocervical junction. To our knowledge, only eight cases of spinal SFT located at the craniocervical junction have been reported in the literature. We presented a patient with a craniocervical junction SFT and discussed its clinical presentation, radiological features, pathology, management and outcome. This was the first patient reported in the literature with a recurrent craniocervical junction SFT treated with Gamma Knife radiosurgery. The treatment reduced the tumour volume by more than 85% within 12 months.

Pemphigus is a rare autoimmune bullous disease which affects the mucous membranes and skin. Pemphigus vulgaris (PV) is the most prevalent type of pemphigus. PV presents with extremely painful, non-healing oral erosions. However, there are only a handful of reports addressing the pain management of PV. We would like to present a case of a painful PV, which was successfully managed.

We present a case of pyridostigmine-induced coronary artery spasm in a woman with early-onset myasthenia gravis (MG) who suffered from acute chest discomfort a few days after pyridostigmine dose up-titration. Twelve-lead ECG demonstrated ST-segment elevation in inferior limb leads together with sinus arrest. Sublingual nitrate was immediately given, which rapidly relieved her symptoms concomitantly with the resolution of abnormal ECG findings. Coronary angiography showed normal coronary arteries reflecting the transient nature of the disease. A small dose of pyridostigmine was rechallenged under close monitoring in the coronary care unit and reproduced her chest discomfort. After the substitution of pyridostigmine with immunosuppressive agents and prescription of long-acting nitrate, she had no recurrence of chest discomfort, as well as well-controlled MG symptoms.

The authors report two cases of unusually large deposits on their therapeutic bandage contact lens (BCL) following uneventful surgery for congenital ptosis. The first case presented at 6 weeks with decreased vision, large jelly-bump deposits over the contact lens and sterile corneal infiltrates. The infiltrates rapidly resolved with restoration of vision following contact lens removal and topical antibiotics. The second case presented 2 weeks after surgery with visual loss and similar deposits but with no corneal involvement. Following replacement of BCL and topical lubricants, her vision improved to 20/20. Studies on the role of BCL in ptosis surgery are scarce with literature supporting its use for ocular surface protection and minimising postoperative discomfort. The authors hypothesise impaired blink mechanism as the accelerating factor for this unusual occurrence in the early postoperative period and recommend frequent replacement of the contact lens and a closer follow-up in all these cases.

A man in his 20s presents to the emergency department after a water skiing accident and was diagnosed with a grade 3 left renal laceration. He subsequently required cystoscopic insertion of a ureteric stent after failing a trial of conservative management. Over the next 9 months, he re-presented to the hospital twice with increasing flank pain and fevers. Subsequent imaging demonstrated interval progression of the retroperitoneal haematoma with a suspicious calcified lower pole lesion which was biopsied subsequently and revealed malignant tissue. External compression of the kidney by this large haematoma was also thought to be contributing to a state of Page kidney. The patient underwent definitive management with an open left-sided radical nephrectomy which confirmed type 2 papillary renal cell carcinoma. The patient is now normotensive and back to his baseline function. He will undergo surveillance CT imaging and be referred to familial genetic services.

Oncocytic adrenocortical neoplasms are a rare histopathological subtype of adrenal tumours which are usually benign and, if malignant, are less likely to metastasise. We report a case of a non-functioning oncocytic adrenocortical tumour, identified incidentally in a middle-aged woman. It was initially reported as a left-sided 3.5×3.4×5.6 cm adrenal adenoma. It however increased in size to 5.4×4.0×4.3 cm on follow-up scans. Subsequent review of the scans revealed an indeterminate lesion with a precontrast density of 30 Hounsfield units, an absolute washout of 42.6% and a relative washout of 28.6%. As a result, laparoscopic left adrenalectomy was performed. Histology confirmed oncocytic adrenocortical carcinoma when using the Lin-Weiss-Bisceglia system, though it was deemed benign when using the Helsinki scoring system. There has been no evidence of recurrence to date. This case highlights the potential pitfalls in the diagnosis of oncocytic neoplasms and the increased specificity of the Helsinki score in assessing metastatic potential.

We report the case of a woman in her 60s with intravascular leiomyomatosis. She suffered from numerous non-specific symptoms including weight loss, anaemia and sudden swelling of the left lower extremity. CT imaging showed the presence of an enlarged left ovary and a thrombus extending from the left ovarian venous plexus intruding into the right atrium of the heart. Cancer antigen 125 was 20 U/mL. Pelvic transvaginal ultrasound examination identified two normal ovaries and a mass adjacent to the left ovary. A second opinion on the CT scan was requested at a oncogynaecological multidisciplinary team meeting, where the radiologist of the team identified an intervascular leiomyomatosis. After further investigation, surgical treatment was planned and completed in collaboration with the departments of cardiothoracic and vascular surgery. The patient recovered fully.

Systemic sclerosis is an autoimmune disease that can result in lung fibrosis, and is strongly associated with the presence of serum anti-topoisomerase-I autoantibodies. A young man with genetic muscular dystrophy caused by titin-cap/telethonin (TCAP) gene mutation, developed a severe restrictive lung disease due to a fibrosing interstitial pneumonia secondary to systemic sclerosis with positive anti-topoisomerase-I antibodies. Using amino acid sequence alignment and protein structure modelling, we found that mutant telethonin exposes an amino acid sequence with significant homology to an immunodominant site of topoisomerase-I. Abnormal telethonin results in a loss of integrity of the sarcomere structure, which might result in rhabdomyolysis and abnormal protein exposure to the immune system. Our preliminary analysis suggests a possible role for mutant sarcomere protein telethonin as an immunogenic target recognised by anti-topoisomerase-I antibodies, which could explain the development of systemic sclerosis in this particular patient.

We describe the case of a woman in her 60s admitted to the intensive care unit after a first generalised tonic-clonic seizure in the context of alcohol withdrawal. She was placed under invasive mechanical ventilation due to persistence of coma despite antiepileptic treatment. Despite continuous sedation with propofol, the frequency and intensity of seizure increased. Seizures were very similar to epileptic tonic-clonic seizures and were recorded with video and electroencephalogram (EEG). A diagnosis of tetanus was considered after a scalp wound was discovered. The patient’s husband revealed that a trismus had appeared a few days before hospital admission after a head trauma. EEG showed a pattern of diffuse spikes, which disappeared after a cisatracurium bolus. The diagnosis of tetanus was later confirmed by cultures from wound samples. Therefore, severe tetanus can mimic both the clinical and EEG features of status epilepticus and could be added to the differential diagnosis of epilepsy.

Bernard-Soulier syndrome (BSS) is a rare congenital bleeding disorder of the platelet, and it is mainly inherited as an autosomal recessive trait. It is caused by both qualitative and quantitative deficiency of the platelet membrane glycoprotein (GP) Ib-IX-V receptor complex, thereby causing abnormal platelets adhesion.We report a case of a primigravida in her 20s with history of BSS diagnosed in childhood due to family history. Her preconception period was challenging as she suffered from severe menorrhagia often requiring hospital admission, blood and platelet transfusions.At 35 weeks gestation, she developed temporal crowded retinal detachment of the left eye and had a successful left scleral buckling surgery under general anaesthesia (GA).She had a multidisciplinary team care with a successful elective GA caesarean section at 39+3 weeks gestation with peridelivery platelet transfusion and intravenous recombinant factor VIIa. Regional anaesthesia, intramuscular injections and anticoagulation were avoided.

We detail the case of a man in his 80s who was a Jehovah’s Witness, presenting to hospital for the second time in 1 week with atraumatic, severe bruising affecting his right thigh and flank. He was subsequently diagnosed with idiopathic acquired haemophilia A (AHA) and was urgently treated with recombinant factor concentrate and immunosuppressive therapy. Management of his bleeding disorder and resultant severe anaemia was adapted in line with his religious beliefs. AHA is a rare bleeding disorder which should be considered in patients with an isolated prolonged activated partial thromboplastin time and a history of recent or acute bleeding. Prompt diagnosis and management are essential as delays may result in increased mortality. Given that this patient declined blood transfusion, management of his bleeding disorder presented a unique challenge.

We describe an infant presenting with intermittent discolouration and swelling of her fingers and toes occurring with changes in ambient temperature. Extensive investigations revealed raised inflammatory markers as well as sclerotic lesions within the phalanges and diffuse marrow oedema. Infectious and inflammatory causes were considered and excluded based on the clinical presentation and investigation findings. The persistence of symptoms prompted further investigation with MRI. Correlation of the MRI findings with previous case reports resulted in a diagnosis of microgeodic disease—an uncommon, self-limiting condition thought to be due to cold-induced vasospasm leading to avascular necrosis of the bone.

A toddler presented with melaena on a background of a possible enteric duplication cyst, diagnosed in the neonatal period which ‘vanished’. What was later confirmed to be a small bowel duplication cyst was not seen on follow-up ultrasounds and thus the patient was managed expectantly until presentation as an emergency. Our case highlights the challenges faced in managing cystic abdominal structures in infancy and the potential consequences of expectant management. We discuss whether cross-sectional imaging or diagnostic laparoscopy should be advocated when duplications cysts are considered amongst the differentials of a lesion on ultrasound.

Nivolumab is an immune checkpoint inhibitor acting on programmed cell death protein 1 (PD-1) that has been used to treat a growing number of malignancies. Cutaneous side effects are common with nivolumab treatment, though they are typically self-limited. Here we present a case of persistent lichenoid dermatitis in a patient treated with nivolumab for renal cell cancer. The patient then developed Stevens-Johnson syndrome 9 months after initiation of nivolumab, with no other identifiable offending medication in the interim. Although an unusual presentation, a growing number of cases have reported delayed Stevens-Johnson syndrome/toxic epidermolytic necrosis-like reactions to immune checkpoint inhibitors. Awareness of this phenomenon is imperative for prompt recognition and treatment of potentially life-threatening cutaneous side effects.

Nasopharyngeal and otitis media tuberculosis are rare extrapulmonary manifestations of Mycobacterium tuberculosis infection. We present a case of a middle-aged woman with manifestations of both conditions along with a description of the anatomical and temporal evolution of the disease. This case also highlights the difficulty of diagnosis and management of this condition, requiring a multidisciplinary approach. Extrapulmonary tuberculosis must be considered in the differential diagnosis of multiple head and neck conditions, including refractory chronic rhinosinusitis and otitis.

Sertoli-Leydig cell tumours (SLCTs) represent a rare cause of hyperandrogenic state. SLCTs are sex cord ovarian neoplasms, accounting for

A man in his early 50s presented with a spontaneous large left-sided retroperitoneal haematoma (RPH), on a background of therapeutic anticoagulation with warfarin for homozygous factor V Leiden. His international normalised ratio was found to be supra-therapeutic at 9.0 on presentation. He was treated non-operatively with prompt reversal of the coagulopathy and close monitoring. On day 4 of the admission, the patient reported scrotal pain and swelling. An urgent scrotal ultrasound revealed infarction of the left testis and the patient was taken to an emergency scrotal exploration. Intraoperatively, the left testis was found to be no longer viable with the left spermatic vein and venules completely thrombosed with extensive clots, while the left testicular artery remained intact. Consequently, a left orchidectomy was performed. Therapeutic anticoagulation was recommenced on day 3 postoperatively. It is thought that the large RPH caused extrinsic compression of the left testicular vein, in addition to the patient’s pre-existing factor V Leiden, which resulted in thrombosis of the blood vessel.

A woman in her 30s presented to the emergency department with new-onset sore throat and fever. She had recently been diagnosed with Graves’ disease 3 months prior. As a result, she was initiated on atenolol and methimazole for management. Her methimazole dosing had been stable at 15 mg daily for the month prior to presentation. Investigation revealed severe neutropenia and jaundice. She was found to have concomitant agranulocytosis and cholestatic jaundice secondary to methimazole.Methimazole was discontinued on admission and the patient received granulocyte colony-stimulating factor for an absolute neutrophil count (ANC) of zero. She was placed on broad-spectrum antibiotics and intravenous steroids for epiglottic and supraglottic oedema noted on bedside laryngoscopy. ANC and bilirubin improved over a 2-week hospital course. She was discharged on a temporary regimen of propranolol, dexamethasone and potassium iodide until she was able to undergo successful thyroidectomy for definitive management of Graves’ disease outpatient.

Benign tumours of salivary glands represent 2%–3% of all tumours and parotid gland is most often affected. Keratocystoma is a rare benign tumour with multilocular cystic lesions filled with keratin materials. Histologically, it is characterised by solid epithelium islands containing keratinised lamellae with multicystic spaces. We report a case of a woman in her mid-70s with painless mass in her left parotid gland which increased in size over 1 year. Ultrasound scan revealed a 38×20 mm diameter hypoanechoic mass. Neck CT with contrast medium and fine needle aspiration were performed with diagnostic hypothesis of Warthin tumour. So, extracapsular parotid dissection with no facial nerve damage was performed. Histological examination revealed a keratocystoma. The patient had a 16-month follow-up without signs of relapse or malignancy. Despite its rarity, keratocystoma must be considered among the possible differential diagnostic hypotheses when we find parotid masses, to ensure the best treatment to the patient.

Haemophagocytic lymphocytic histiocytosis (HLH) is a rare, life-threatening condition caused by abnormal activation of cytotoxic T lymphocytes, natural killer cells and macrophages resulting in hypercytokinaemia and immune-mediated injury of multiple organ systems. Secondary HLH occurs in the setting of a malignant, infectious or autoimmune stimulus. Macrophage activation syndrome (MAS) is the term used to describe HLH that develops secondary to rheumatological diseases such as lupus and juvenile idiopathic arthritis, among others. Commonly observed and documented symptoms include fever, organomegaly and lymphadenopathy. Given the potential for multiorgan failure in HLH/MAS, early identification, diagnosis and initiation of treatment is essential. We present a case of secondary HLH/MAS with acute inflammatory gastroenteritis in a middle-aged woman with a history of systemic lupus erythematosus.

The case of a man in his early 30s, presenting with slowly progressive, asymmetrical onset, pure motor quadriparesis over 9 months with bulbar involvement, absence of upper motor neuron features and significant weight loss, is reported. In view of presentation with diffuse lower motor neuron involvement of short duration, the diagnostic possibilities are discussed. Apart from motor neuron disease, its mimics including muscle and neuromuscular junction disorders were also considered and evaluated for. Carefully assessed clinical and electrophysiological markers which finally clinched the diagnosis of the rare disorder Lambert-Eaton myasthenic syndrome are elaborated. In the present context, recognition of the oddities on clinical and laboratory evaluation is of paramount importance to rule in causes of pure motor quadriparesis.

In developing tropical countries, rhino-orbital-cerebral mucormycosis has been a cause of severe morbidity and mortality during the COVID-19 pandemic. Classically, it develops as an aggressive angioinvasive destruction of nasal, orbital and cerebral involvement. Blindness is a major disabling complication. The association of mucor in cancer is linked with immunosuppression caused by radiation and/or chemotherapy. In this case report, we tried to explore the diverse possibilities of neck swelling, nasal discharge, ocular swelling and dimness of vision in a teenage boy. Rhabdomyosarcoma is a rare tumour of the soft tissue, connective tissue or bone. This type of unusual association or coexistence of rhabdomyosarcoma with mucormycetes is rarely seen in literature.

A teenage boy presented to the clinic complaining of poor vision in both eyes. His best-corrected visual acuity was 20/25. The slit lamp examination revealed vertically oval corneas, crescentic peripheral inferior corneal thinning and ectasia in both eyes. Corneal topography showed against-the-rule astigmatism with mean keratometry (Km) of 45.1 and 45.2 dioptres in the right and left eyes, respectively. High-resolution optical coherence tomography corroborated the clinical findings, and the patient was diagnosed with pellucid marginal corneal degeneration (PMD). Collagen cross-linking was performed in the right eye. Left eye cross-linking is awaited. Although PMD is typically seen in middle-aged (third-fourth decade) patients, it can also occur at earlier ages. Collagen cross-linking can be considered to prevent the progression of the condition.

We described a case of a man in his 90s with gastric volvulus of which point-of-care ultrasound (POCUS) contributed to a rapid diagnosis. The patient had Borchardt’s triad and POCUS showed a distended and fluid-filled stomach, which allowed us to strongly suspect gastric volvulus even prior to the abdominal CT scan. Gastric volvulus is a rare but life-threatening condition that may lead to tissue ischaemia and perforation. Therefore, a prompt diagnosis is extremely important. This case suggests that POCUS can be a powerful tool when clinicians suspect gastric volvulus.

The purpose of this report is to present the outcomes of Descemet’s stripping endothelial keratoplasty (DSEK), followed by deep anterior lamellar keratoplasty (DALK), as an alternative to penetrating keratoplasty (PKP) for different indications. Patients in this retrospective case series underwent manual DSEK, followed by manual DALK, for tectonic and/or visual reasons. It includes three cases that underwent DSEK followed by DALK as an alternative to PKP for the following conditions: failed PKP and stromal scarring, aphakic bullous keratopathy and herpetic stromal scarring, and herpetic corneal perforation. All cases had successful anatomical repair with visual improvement. Many corneal conditions involving endothelium and stroma have been traditionally managed with PKP. However, in certain settings with high risk of complications, this might not be an appropriate option. Therefore, for these cases, we propose management with DSEK followed by DALK as an alternative approach in a ‘closed anterior chamber’ fashion, which can reduce the risk of significant, sometimes irreversible, complications.

Here, we report a case of malignant psoas syndrome presented to us during the second peak of the COVID-19 pandemic. Our patient had a medical history of hypertension, recently diagnosed with left iliac deep vein thrombosis and previous breast and endometrial cancers. She presented with exquisite pain and a fixed flexion deformity of the left hip. A rim-enhancing lesion was seen within the left psoas muscle and was initially deemed to be a psoas abscess. This failed to respond to medical management and attempts at drainage. Subsequent further imaging revealed the mass was of a malignant nature; histology revealing a probable carcinomatous origin. Following diagnosis, palliative input was obtained and, unfortunately, our patient passed away in a hospice shortly after discharge. We discuss the aetiology, radiological findings and potential treatments of this condition and learning points to prompt clinicians to consider this diagnosis in those with a personal history of cancer.

Nephropathic apolipoprotein L1 (APOL1) risk alleles (G1/G2) have been associated with focal segmental glomerulosclerosis, HIV-associated nephropathy, Systemic lupus erythematosus (SLE)-associated collapsing glomerulopathy and other glomerulonephritides. These alleles confer protection from Trypanosoma brucei infections which are enriched in sub-Saharan African populations. We present a young woman with obesity, hypertension, subnephrotic range proteinuria who was found to have obesity-related glomerulopathy on kidney biopsy while harbouring two high-risk APOL1 alleles (G1/G2). Given the potential effects on lipid metabolism and their association with obesity, the presence of APOL1 risk alleles may impact cardiovascular health in addition to renal disease in these patients.

We report a case of cardiac amyloid A (AA) amyloidosis due to unicentric Castleman disease (UCD) in a patient whose cardiac function was restored 15 years after surgical resection of the mesenteric lymph node lesion. A man in his 40s had recurrent palpitations and fainting spells. ECG revealed torsades de pointes. Increased C-reactive protein, interleukin-6 and serum AA levels, and marked concentric thickening of the left ventricular (LV) wall with diastolic restrictive filling pattern were observed. Duodenal biopsy revealed AA amyloid deposits. He had a mesenteric tumour, comprising many plasma cells. He was diagnosed with plasma cell-type UCD associated with secondary AA amyloidosis. C-reactive protein, interleukin-6 and serum AA levels were normalised 2 months postresection. Episodes of lethal ventricular arrhythmias decreased. LV wall thickness was gradually reduced. Approximately 15 years postresection, the LV wall thickness nearly normalised and ventricular arrhythmias disappeared. Better outcomes are expected following surgical tumour resection.

Flap displacement is a rare but vision-threatening complication of laser-assisted in situ keratomileusis (LASIK). A young male patient underwent uneventful microkeratome-assisted LASIK. One-week postoperatively, flap displacement was noted in his right eye with its lower edge folded inwards, macrostria at the superior edge and the epithelium covering the bare stroma and into the interface. Anterior segment optical coherence tomography (AS-OCT) delineated the morphology of the displaced flap and the extent of epithelial ingrowth. The flap was repositioned by unrolling the fold and all the exposed surfaces were debrided to remove the epithelial ingrowth. Two months later, his corrected distance visual acuity improved to 20/30, and a smooth surface could be achieved. Infolded LASIK flap is a rare complication, which requires timely surgical intervention to achieve successful anatomical and functional outcomes. AS-OCT can be pivotal in determining the extent of infolding as well to delineate the extent of epithelial ingrowth within the interface.

A woman in her 50s was referred to nephrology clinic due to progressive chronic kidney disease. She exhibited features of proximal renal tubulopathy, namely Fanconi syndrome, including normoglycaemic glycosuria, normal anion gap metabolic acidosis, and intermittent hypouricaemia and hypophosphataemia. Kidney biopsy showed tubulointerstitial inflammation and focal chronic damage. In addition, antimitochondrial antibodies were present and she had abnormal liver blood tests. A unifying diagnosis of primary biliary cholangitis with an associated renal tubulopathy and interstitial nephritis was made. She was commenced on sodium bicarbonate, ursodeoxycholic acid and oral prednisolone, leading to an improvement in liver biochemistry. Kidney function was stabilised, but a sustained improvement was not seen. This case acts as a reminder of the rare association of tubulointerstitial nephritis and Fanconi syndrome with primary biliary cholangitis, which may be an under-recognised phenotype.

For hepatocellular carcinoma, the IMbrave150 trial demonstrated that combination atezolizumab and bevacizumab had significantly better overall survival compared with sorafenib in patients with unresectable disease. However, as more immune checkpoint inhibitors are approved as first-line agents in gastrointestinal cancers, there have been few reports on whether sequential PD-1/PD-L1 blockade is beneficial in the treatment of these diseases. We present a patient with hepatocellular carcinoma who had disease progression on atezolizumab, a PD-L1 inhibitor, but subsequently had a remarkable response to pembrolizumab, a PD-1 inhibitor.

An acute ectopic pregnancy is one of the most common gynaecological emergencies in clinical practice. The diagnosis is usually established by a combination of clinical examination findings, correlated with sonographic and laboratory results. However, a chronic ectopic pregnancy (CEP) may occur when the ectopically implanted gestation, mostly in the fallopian tubes, invades the underlying structures, causing protracted destruction at the site of implantation. Individuals may present with subacute or chronic abdominal pain, abnormal vaginal bleeding, amenorrhoea and a low bHCG. The correct diagnosis is often only established following laparoscopy or even histologically after the operation. The authors present the case of a woman in her 30 s presenting with severe right sided abdominal pain and a failing pregnancy at 10 weeks gestation. Her urine pregnancy test was negative, but her serum bHCG was 18 IU/L. A transvaginal ultrasound scan confirmed a ruptured right tubal ectopic pregnancy. A laparoscopic salpingectomy was performed. This case provides an important reminder that a CEP should always be considered in the differential diagnosis of women of reproductive age presenting with acute lower abdominal pain, despite a negative urine pregnancy test.

Recurrent episodes of vomiting and diarrhoea in a child can present as a diagnostic dilemma and be easily misdiagnosed as recurrent viral gastroenteritis episodes. Primary adrenal insufficiency can present with recurrent episodes of vomiting and diarrhoea with the presence of metabolic acidosis and can be life-threatening if left undiagnosed and untreated. A high index of suspicion should be kept for diagnosing primary adrenal insufficiency in a child presenting with recurrent episodes of vomiting and diarrhoea with laboratory evidence of metabolic acidosis and hypoglycaemia. Primary adrenal insufficiency, in a male child specifically, should raise alarm for X-linked adrenoleukodystrophy (X-ALD). Very-long-chain fatty acids and confirmatory genetic testing for an ABCD1 gene mutation can help confirm the diagnosis. Addison’s disease often presents prior to the onset of the cerebral form of X-ALD. Early diagnosis of X-ALD allows for MRI screening for the development of cerebral disease in its early stages when treatment with stem cell transplant can halt the disease and be lifesaving.

Adrenal insufficiency (AI) in a newborn due to hypothalamic–pituitary–adrenal (HPA) axis suppression after maternal glucocorticoid therapy during pregnancy is a rare condition. We report an AI triggered by a nosocomial infection in a premature newborn. The suspected mechanism was the suppression of the HPA axis due to high doses of maternal glucocorticoid treatment during pregnancy. AI was revealed by recurrent hypoglycaemia and mild hyponatraemia during the neonatal period. His twin brother did not develop AI, showing the variable sensitivity of adrenal suppression after exposure to the same glucocorticoid dose. The affected boy was substituted with hydrocortisone until the age of 2 years. At this age, basal morning values for cortisol and Adrenocorticotropic hormone (ACTH) had normalised. The patient also suffers from galactosaemia. We suggest screening for AI, by testing for hypoglycaemia and hyponatraemia, in newborns who were exposed to high doses of maternal methylprednisolone treatment during the pregnancy and to include galactosaemia in national neonatal screening programmes.

Tracheostomy is a common surgical procedure for securing a patent airway. Anatomical variations of major vessels overlying the trachea may pose significant bleeding risk during the procedure. Hence, thorough preoperative assessment of the neck and surgeon’s intraoperative vigilance are essential. Open tracheostomy is a safer option than percutaneous dilatational tracheostomy. Extra caution with stoma wound care and change of tracheostomy tube are necessary postoperatively if any major vessel is detected in close proximity with the tracheal stoma.