Here the authors describe a case of a non-healing perianal abscess in a patient from Saudi Arabia which finally responds to TB treatment…

Seema Biswas
Editor-in-Chief

Crohn’s disease or TB – the perennial question and diagnostic pitfalls

A case of Crimean-Congo Viral Haemorrhagic Fever (CCVHF) has been diagnosed for the first time in the UK. The 38-year-old man had visited Afghanistan and fell ill a few days after he returned to Glasgow on a flight from Dubai. He has now been admitted to a specialist unit in the Royal Free Hospital in London.

http://www.bbc.co.uk/news/uk-scotland-glasgow-west-19846300

The clinical features show common dramatic progress characterized by hemorrhage, myalgia, and fever. Besides the direct infection of endothelium, indirect damage by viral or virus mediated host-derived soluble factors that cause endothelial activations and dysfunction occur. In diagnosis, enzyme linked immunoassay and real-time reverse transcription-polymerase chain reaction are used. Early diagnosis is critical for the patient and potential nosocomial infections. Supportive therapy is the essential part of the case management. Ribavirin was suggested as an effective drug in recent studies, and it was found to be beneficial. [1]

CCVHF is an Advisory Committee on Dangerous Pathogens Hazard Group 4 pathogen. Updated guidance on management of these viral haemorrhagic fevers was updated by the Department of Health in July this year. It includes advice on the transfer of confirmed cases to one of the UK’s high security infectious disease units.

1. Ergonul O. Crimean-Congo hemorrhagic fever virus: new outbreaks, new discoveries. Curr Opin Virol 2012 Apr;2(2):215–220. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22482717

A patient on long term therapy for Crohn’s disease presents acutely with bowel obstruction. Laparotomy and bowel resection is performed. Histopathological examination reveals a sinister cause…

Seema Biswas
Editor-in-Chief

Coincident intra-abdominal presentation of lymphoma and tuberculosis after long-term iatrogenic immunosuppression

There are early reports of a new coronavirus not previously seen in humans. One case of severe respiratory infection is in a 49-year-old man being treated in Intensive Care in London. He was from Qatar and was flown to the UK after being admitted to hospital in Doha. A similar case of a 60-year-old man who died in Saudi Arabia is being investigated.

The UK’s Health Protection Agency has notified the World Health Organisation.

“Coronaviruses are causes of the common cold but can also include more severe illness, such as the virus responsible for SARS (Severe Acute Respiratory Syndrome).”

http://www.hpa.org.uk/NewsCentre/NationalPressReleases/2012PressReleases/120923acuterespiratoryillnessidentified/

“The WHO said it was not recommending any travel restrictions but would be seeking further information on the virus.”

http://www.reuters.com/article/2012/09/23/us-virus-who-idUSBRE88M0FV20120923

“Sars is a serious respiratory infection that caused a global outbreak in 2002, spreading from Hong Kong to more than 30 different countries around the world and killing around 800 people. Although it has not been eradicated its spread was fully contained in 2003. Like other coronaviruses, it is spread through droplets of body fluids – produced by sneezing and coughing.”

http://www.bbc.co.uk/news/health-19698335

Case reports are recognised as a powerful tool in identifying the infective agent in new outbreaks. Subsequent contact tracing can help confirm the modes of transmission, infectivity and range of severity.

Air travel is clearly the principle route for international travel of a new virus. There is likely to be debate on the value of screening (especially with new ‘non-contact’ technologies [1-3] ) at airports and controversy over permission to travel whilst ‘unwell’.

1. Bitar D, Goubar A, Desenclos JC. International travels and fever screening during epidemics: a literature review on the effectiveness and potential use of non-contact infrared thermometers. Euro Surveill. 2009 Feb;14(6). Available from: http://www.ncbi.nlm.nih.gov/pubmed/19215720

2. Tan C-C. SARS in Singapore–key lessons from an epidemic. Ann. Acad. Med. Singap. 2006 May;35(5):345–349. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16830002

3. St John RK, King A, de Jong D, Bodie-Collins M, Squires SG, Tam TWS. Border screening for SARS. Emerging Infect. Dis. 2005 Jan;11(1):6–10. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/pmid/15705315/

This report summarises a case history of a 25-year-old woman with a well known complication of tuberculosis, intracranial tuberculoma, manifest clinically with a depressed conscious level and cognitive slowness (“pseudodementia”) a few months after the initiation of anti-TB therapy. CT scan showed several tuberculoma with surrounding oedema. After re-institution of prednisolone the symptoms subside. The learning points, as stated by the authors, are that tuberculoma need not present with focal neurological sequelae and that reversible causes for declining cognitive function should be carefully sought and corrected.

Reviewer
Kirsten Moller

Pseudodementia due to intracranial tuberculomas: an unusual presentation

Declared a global health emergency by the World Health Organisation in 1993, over one third of population of the world is infected with TB and 7% of all deaths in the developing world are attributed to TB.  We present a series of cases that illustrate the varied presentations of TB.

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A small proportion of patients with pulmonary TB develop infection of the genitourinary system. Here the authors report the case of a young woman in India with low back pain and fever…

Seema Biswas
Editor-in-Chief

Paraspinal sinuses? Do remember renal tuberculosis.

How better to revisit the applied anatomy of the thorax than in this case of a 31 year old man with shortness of breath on minimal exertion.

Seema Biswas
Editor-in-Chief

Incidental detection of late presenting co-arctation of the aorta on chest x-ray: the importance of rib notching

Tony Nicklinson who campaigned for the right to die and recently lost his High Court battle for euthanasia has died. He had asked his family to tweet “Goodbye world the time has come, I had some fun“.

He had suffered a stroke in 2005 which left him with quadriplegia and loss of speech. Following the High Court ruling he refused to eat and drink and died just six days later.

In a recent conversation with Guardian journalist Elizabeth Day he said:

“Opponents of giving me the ability to choose life or death will tell you that it will fundamentally alter the doctor-patient relationship,” he wrote. “Why? The vast majority of a GP’s patients already have the ability to commit suicide so it’s the norm.”

His case highlights the continuing debate about assisted dying. Joan Smith of the Independent wrote:

“There’s a clear danger that ethical issues will get lost in this focus on a handful of tragic individuals; it’s also worth noting that doctors, who would be called on actively to end lives if the law were to be changed, oppose a change in the law.”

The BMA recently voted to reject a proposal to adopt a neutral stance on assisted dying.

Learning neuroanatomy may present a challenge at medical school. In clinical context, however, and with the aid of some remarkable images, perhaps this report of a case a spinal lesion resulting in bladder dysfunction may help.

Seema Biswas
Editor-in-Chief

Recurrent intramedullary epidermoid cyst of conus medullaris

Here the authors present the case of a 61 year old man with knee pain at night. The cause becomes clear as investigations are performed. These investigations produce some excellent images to learn or revise the anatomy of the knee and understand the basis of anatomical pathology.

Seema Biswas
Editor-in-Chief

Isolated posterior cruciate ligament calcification