BMJ Case Reports最新文献

Neurological complications in inflammatory bowel disease are rare but can increase morbidity. The risk is higher in poorly controlled disease with recurrent flare-ups.We discuss an adolescent girl with difficult-to-treat Crohn's disease (CD) complicated by haemorrhagic stroke. While she was under treatment for an episode of flare-up, she developed haemiparesis, facial nerve palsy and focal seizures. In the past, she had experienced multiple admissions for recurrent abdominal pain and altered bowel habits. A thorough evaluation confirmed the diagnosis of CD. Though her disease status required administration of biologicals in the initial phase, due to financial constraints, it was not possible. In the present admission for a relapse, she developed a stroke. Neuroimaging with angiography suggested infarction with haemorrhagic transformation in the left posterior parietal lobe and thrombosis of the superior sagittal sinus and left transverse sinus.Emergency stabilisation was done with antiepileptics and anticoagulants. She was initiated on infliximab during the rehabilitation phase. The primary disease is under partial remission, and facial and limb weaknesses have recovered completely.

Tuberculosis-triggered IgA nephropathy (TB-IgAN) is a rare but important renal manifestation that often goes unrecognised due to its non-specific presentation. We report the case of a woman in her 30s who presented with progressive oedema, decreased urine output, frothy urine, intermittent dark-coloured urine and a short history of productive cough. She was diagnosed with pulmonary Mycobacterium tuberculosis (MTB) and biopsy-confirmed IgAN, revealing TB-IgAN as the cause of her rapidly progressive kidney disease. This case highlights the importance of evaluating haematuria and proteinuria in patients with TB, as early identification of TB-related renal involvement (TB-IgAN in this case) can significantly alter the management of IgAN. Although a kidney biopsy is challenging in the context of active MTB, it remains essential for accurate diagnosis. MTB can manifest with atypical features and trigger immune-mediated renal complications such as IgAN, warranting a high index of suspicion in compatible clinical settings.

Solitary nodular pulmonary amyloidosis is a rare benign condition that is most often detected incidentally during routine health examinations. Although calcification within the nodule is a well-recognised characteristic finding, there are few reports that document its chronological progression. We describe the case of a man in his 70s with an incidentally identified solitary pulmonary nodule in the right lower lobe, which was followed for more than 7 years from the initial detection. During this period, the calcification advanced from partial involvement to diffuse distribution throughout the nodule, in parallel with nodule enlargement. This case demonstrates that calcification in nodular pulmonary amyloidosis represents a dynamic process reflecting long-term amyloid deposition and associated subtle tissue alterations, rather than a static lesion. Furthermore, it highlights that temporal changes in calcification density may provide important diagnostic clues.

A female in her early 40s with a lifelong asthma diagnosis presented with worsening exertional dyspnoea and a dry cough despite being medically optimised. A clinical review revealed inspiratory stridor and swallowing difficulties, prompting further investigations. Spirometry showed an obstructive pattern and an elevated Empey index. This, along with a supporting flow-volume loop, raised suspicion of upper airway obstruction. Subsequent CT imaging (including an aortic angiogram) revealed a right-sided aortic arch with an aberrant left subclavian artery arising from a Kommerrell diverticulum. This formed a vascular ring compressing the trachea and oesophagus. Surgical intervention resulted in significant symptomatic and physiological improvement, with a markedly increased FEV₁ and peak expiratory flow on repeat spirometry. This case highlights the importance of reconsidering diagnoses in patients unresponsive to standard therapy and the diagnostic utility of the Empey Index and flow-volume loops when identifying conditions mimicking asthma.

A term, appropriate for gestational age (AGA) baby with no dysmorphism and no significant maternal risk factors, who cried immediately after birth, developed hypoglycaemic seizures at 10 hours of life. The baby had a positive sepsis screen and was treated with empirical antibiotics. Blood culture grew coagulase-negative Staphylococcus He developed hypoglycaemia requiring an increasing glucose infusion rate (GIR), going up to 23 mg/kg/min for 10 days. Critical sample analysis did not reveal hyperinsulinaemia. Urine for reducing substance was positive, but serum galactose was within normal limits. Tandem Mass Spectrometry and Gas Chromatography Mass Spectrometry reports were unremarkable, and whole exome sequencing was non-contributory. Intravenous hydrocortisone and oral diazoxide were added sequentially. With progressive resolution of sepsis, the infant's hypoglycaemia gradually improved, which allowed a stepwise reduction in glucose infusion requirements. By the 24th day of life, the GIR could be safely tapered off, and the baby was successfully transitioned to full breastfeeding. In addition, he developed portal venous thrombosis and was managed with low molecular weight heparin. On follow-up at 8 months, the baby was growing well on breastfeeding and neurodevelopmentally unremarkable.

Trastuzumab has been widely used in breast cancers. Despite its efficacy, trastuzumab-induced pneumonitis (TIP) remains a rare yet potentially fatal complication. While corticosteroids are the mainstay of treatment, steroid-refractory cases pose significant challenges due to the lack of standardised guidelines and limited data on additional therapies. We describe a case of grade 4 TIP in a female in her early 70s, initially managed with steroids and intravenous immunoglobulin, resulting in minimal clinical improvement. Due to the lack of response, advanced immunosuppressive therapy with infliximab was initiated which led to a marked improvement in her condition. This suggests that infliximab may be used to treat severe, corticosteroid-resistant TIP, particularly in cases when conventional therapy is ineffective. The findings obtained here urge additional research to better characterise further interventions like infliximab in TIP therapy and highlight the need for updated guidelines that incorporate advanced immunosuppressive medicines.

Ureterosciatic herniation is a rare cause of ureteral obstruction. A bilateral presentation is especially uncommon. We present a female patient in her late 80s diagnosed with bilateral ureterosciatic herniation. She presented with 24 hours of severe left flank and suprapubic pain. A CT scan of the abdomen/pelvis revealed moderate to severe left-sided hydronephrosis and hydroureter, and a laterally coursing distal left ureter. Retrograde pyelograms revealed bilateral 'curlicue sign' pathognomonic for ureterosciatic herniation with left-sided hydronephrosis. Management required left percutaneous nephrostomy (PCN), which was later converted to percutaneous nephroureteral stent (PCNU). The patient elected for routine left PCNU exchanges every 3 months. Bilateral ureterosciatic herniation is an exceptionally rare cause of ureteral obstruction. Retrograde pyelograms are diagnostic. Initial management achieves renal decompression and hernia reduction with a ureteral stent or PCN/PCNU. Surgical correction offers definitive repair. For patients not amenable to surgery or ureteral stent exchanges, routine PCNU exchanges are a reasonable approach for management.

A man in his 40s from a rural area presented with progressive pain and functional limitation of the right arm without trauma. Imaging revealed an aggressive lytic lesion with pathological fracture of the distal humerus. Staging studies excluded other lesions. Percutaneous biopsy confirmed osseous hydatid disease. Preoperative albendazole was administered, followed by wide en bloc resection of a 15 cm humeral segment with preservation of neurovascular structures. Reconstruction was achieved using a modular distal humerus endoprosthesis. Postoperative albendazole continued for 6 weeks. At 12 months, the patient was disease-free, with a painless range of motion from 0° to 120°, full independence in daily activities and a Toronto Extremity Salvage Score of 75. This case demonstrates the importance of considering hydatid disease in the differential diagnosis of lytic bone lesions in endemic areas and supports limb-sparing reconstruction as a viable alternative.

We report the case of a young infant who presented with an acute episode of apnoea and hypotension requiring ventilation and stabilisation. The investigations did not show evidence of metabolic derangements, central nervous system infections or sepsis. At 15 hours of admission, the treating team obtained a history of accidental nasal instillation of brimonidine eye drops. The caregiver mistakenly administered glaucoma eye drops at home instead of the normal saline nasal drops and noticed the error only when the brimonidine drops were found in the medicine kit of the baby 15 hours after admission. The baby was successfully treated primarily with supportive measures and a single dose of naloxone. This case highlights the importance of identifying patients with brimonidine toxicity (an alpha-adrenergic agonist) based on symptomatology. Intranasal administration as a route of brimonidine toxicity is rare. The mainstay of treatment is supportive measures, and naloxone may be beneficial in some cases.

A young female in her 30s presented with right lumbar and flank pain after performing deadlift exercises at the gym. Whilst initially thought to have a presentation of acute musculoskeletal back pain, she had two unexpected syncopal episodes whilst in the waiting room. She went on to be diagnosed with an unexpected grade V renal injury and active retroperitoneal haemorrhage. She became haemodynamically unstable and was treated using the hospital major haemorrhage protocol. The patient was ultimately transferred to a tertiary centre, where she underwent renal artery embolisation successfully.Atraumatic renal injury is rare and has only been described in a few case reports. Classic signs, as well as point-of-care ultrasound, are sometimes unreliable for diagnosing retroperitoneal haemorrhage. Therefore, emergency physicians must keep renal injuries within the differential diagnosis of flank pain even in the absence of overt trauma.