Pseudo-pneumothorax: skin fold is an excellent imitator

Description

A 79-year-old hospitalised woman underwent central venous catheterisation for high-calorie infusion. Chest radiography to check the position of the catheter showed a curvilinear line at the lateral zone of the right lung (figure 1A). We suspected pneumothorax and performed CT of the chest. However, it revealed the absence of pneumothorax; the curvilinear mimicked pneumothorax was revealed to be a skinfold (figure 1B).

Figure 1

(A) Initial chest radiograph showed a curvilinear line at the right lateral zone of the right lung. (B) CT of the chest revealed the absence of pneumothorax.

The lateral margin of the skinfold artefact, caused by compression of flaccid back skin against the film, can be sharply outlined by a lucent line.1 This line is an edge enhancement phenomenon at the margin between objects with different contrast or luminance (Mach band effect).

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Diagnostic dilemma of micropapillary variant of mucinous breast cancer

An elderly woman presented with an enlarging left breast lump. Breast imaging revealed a large suspicious mass associated with cystic components. Core biopsy however was non-diagnostic and only revealed necrotic papillary tissue. The patient then underwent excision of the lesion that revealed a large area of intracystic papillary ductal carcinoma in situ with a focus of micropapillary variant of mucinous cancer. This case describes how this rare subtype could present as necrotic papillary tissue on core biopsy, resulting in a diagnostic dilemma, which had not been previously reported. A literature review of this rare subtype was performed too.

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EGFR inhibitor-induced cut-like skin lesions of the fingers

Cetuximab and osimertinib are epidermal growth factor receptors (EGFRs) inhibitors used in the treatment of several malignancies. These agents have been associated with several skin lesions, the most common being papulopustular acneiform rash involving the face, neck, chest and back. Herein, we describe a unique toxic effect of these agents involving the fingertips and lateral aspects of fingers in a small patient series. The lesions presented approximately 4 weeks into treatment were cut-like and caused local discomfort/pain. Application of a colloidal solution allowed for partial resolution of these lesions in one patient, while discontinuation of the drug led to the disappearance of the lesions in another. Thus, we call for awareness of this unique skin toxicity with the use of EGFR inhibitors in patients with cancer.

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Rare breast metastasis from adenoid cystic carcinoma of the submandibular gland

Adenoid cystic carcinomas (ACCs) are rare malignant neoplasms of exocrine glands, most commonly found in salivary glands. This report describes a 67-year-old woman with metastatic ACC to the breast, only the third reported case of its kind. The salivary gland ACC was first diagnosed 5 years prior. Routine mammogram identified a Breast Imaging and Reporting Systems (BIRADS) 4 lesion. Core breast biopsy demonstrated findings consistent with metastatic ACC to the breast. The patient ultimately underwent local excision but suffered a recurrence of disease less than 2 months later despite chemotherapy. She passed away 15 months after excision due to complications associated with a small bowel obstruction and decompensated respiratory status from pulmonary metastases. While metastatic salivary ACC to the breast is rare, it is important to be able to distinguish metastatic salivary ACC to the breast from primary ACC of the breast as the treatment considerations for the two disease processes differ significantly.

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Cervical spinal cord stimulation for the treatment of essential tremor

A patient with refractory essential tremor of the hands and head/neck refused deep brain stimulation and requested consideration for spinal cord stimulation (SCS). Trial of a cervical SCS system using a basic tonic waveform produced positive outcomes in hand tremor, head-nodding and daily functioning. The patient proceeded to implant and received regular programming sessions. Outcomes were recorded at follow-ups (1, 3, 6, 12, 23 months postimplant) and included patient self-reported changes, clinical observations, handwriting assessments and The Essential Tremor Rating Assessment Scale scores. Trial of a paraesthesia-free burst waveform programme produced a small improvement in head-nodding, without uncomfortable paraesthesias. With continued programming, the patient reported further improvements to tremor and functionality, with minimal tremor remaining at 12–23 months. No major side effects were reported.

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Delayed presentation of bilateral central hip protrusio acetabuli: evidence-based management

This is a case of a previously healthy 51-year-old man who sustained bilateral central hip dislocations following a sudden presentation of epileptic seizures. The patient was initially treated conservatively for a period of 9 months. On presentation, he had gross disability due to stiffness in both hips and left peroneal nerve paresis. Through minimally invasive direct anterior approaches, bilateral total hip arthroplasties were performed using tripolar head articulations. These were cemented into a biologic acetabular buttress constructed out of autologous bone graft. The femoral heads and necks were used as plugs and pressed into the acetabular defects, putting the medial acetabular walls under tension. At 24 months' follow-up, there was a good clinical outcome, and the acetabular walls remodelled bilaterally. In conclusion, in traumatic protrusio acetabuli, a functional, biologic reconstruction of the acetabular wall can be facilitated with the application of distraction osteogenesis (tension-stress) principles while using minimally invasive surgical techniques.

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Metastatic pancreatic adenocarcinoma presenting as an occipital haemorrhage

We report a case of a 63-year-old woman who was presented to the emergency department with an occipital haemorrhage secondary to a pancreatic cerebral metastasis. Pancreatic cancer is the ninth most common cancer in women in Australia, and distant disease is present in 70% of patients with pancreatic cancer at the time of diagnosis. However, metastases to the brain are rare, accounting for only 0.33%–0.57% cases antemortem. Herein, we discuss the management of this unusual case to highlight the importance of recognising unusual central nervous system involvement of cancers, a problem which may be increasing in prevalence.

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Post-extracorporeal shockwave lithotripsy perirenal haematoma

Description

A previously healthy 50-year-old man presented with intermittent left flank pain for 3 months. The patient denied any history of diabetes and hypertension. On evaluation with X-ray Kidney-Ureter-Bladder and ultrasound (USG) of abdomen, he was found to have left upper ureteric calculus (size: 13 mm) with left mild hydronephrosis and normal right kidney. He subsequently underwent uneventful extracorporeal shockwave lithotripsy (ESWL) with Dornier compact alpha electromagnetic lithotripter for the calculus. Three thousand shockwaves were delivered to the stone. The procedure was uneventful and the patient was discharged. Twenty-four hours later, the patient presented with severe left flank pain. On clinical examination, he had tachycardia (pulse rate: 100/min), normal blood pressure (138/76 mm Hg) and tenderness in the left flank region. Laboratory examination revealed the following parameters:

Haemoglobin: 10.2 g/dL.

Haematocrit: 30.6%.

Total leucocyte count: 7500 /mm³.

Platelet count: 3.5 lacs /mm³.

Blood urea: 44 mg/dL.

Serum creatinine:...

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Unusual Monteggia type 1 variant in adult: a rare finding in a rare fracture

Description 

A 56-year-old female patient presented to the orthopaedic outpatient department with alleged history of slip from stairs about 10–12 in number and fall on the outstretched hand about 3 weeks ago. Following the injury, she developed severe pain, swelling abnormal mobility of lower arm and restriction of movement of the right elbow. She also admitted that post trauma, she had received treatment from traditional bone setters which had reduced her pain. On examination of her limb, there was a flexion deformity of right elbow along with extra articlar varus deformity of lower arm  which was mobile with tenderness and bony crepitus at both at arm and the elbow. There was no distal neurovascular deficit.

Radiographs of the right arm and forearm with shoulder, elbow and wrist joints revealed fractures of the lower shaft humerus and proximal ulna (metaphyseal with intra-articular fragment and coronal split from metaphyio-diaphysis junction extending up to half of...

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Case 23-2018: A 36-Year-Old Man with Episodes of Confusion and Hypoglycemia

Presentation of Case. Ms. Sarah J. Grzybinski (Emergency Medicine): A 36-year-old man was admitted to this hospital because of episodes of altered mental status. The patient had been well until 6 years before admission, when his wife observed an episode of unusual behavior. During the episode, the…

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