Non-purulent pharyngitis: adult still’s disease

 Adult Still’s disease is rare and may present as pyrexia of unknown origin. Due to lack of expertise, diagnosis may be delayed inadvertently. The patient usually presents with spiked fever, polyarthralgia or arthritis, evanescent skin rash, non-purulent pharyngitis, lymphadenopathy and hepatosplenomegaly. Leukocytosis, predominantly of neutrophils, elevated erythrocyte sedimentation rate and C-reactive protein without obvious infection are the hallmarks of the disease. Delay in diagnosis may expose the patient to the side effects of antibiotics as they are repeatedly prescribed in view of elevated leukocytes. The majority of patients report pain in the throat without evidence of infection. This was an important clue to our diagnosis of this patient. Grossly elevated serum ferritin is diagnostic of adult onset still's disease. As the white cell counts are grossly elevated, a bone marrow examination to rule out hematological malignancy may be mandatory. Serum ferritin value has prognostic value too. Minor illness may respond to non-steroidal anti-inflammatory drugs (NSAIDs), but steroids are the mainstay of the treatment.  Methotrexate is of additional value for those presenting predominantly with arthritis. Anakinra, Infliximab and Tocilizumab are other options. Those patients presenting with severe disease and organ involvement require high dose intravenous steroids followed by high dose oral steroids.

Wheezy adult with chicken bone in the chest

A large foreign body aspiration in a healthy adult is rare in the literature. It is a frequent problem in children and adolescents. Adults are affected in altered sensorium, either due to sedation or neurological problems. Acute upper airway obstruction though rare in adults requires establishment of an airway using Laryngoscope or rigid bronchoscope. At times we have to recourse to tracheostomy to save the life. Foreign body often travels down the right sided airways, here we present a case of 30mm Chicken bone being lodged in the left main bronchus. The patient presented with unremitting cough and normal chest skiagram. Monophonic wheeze on auscultation and focused attention on the patient narration made us clinch the diagnosis. New onset wheezy chest or unremitting chronic airway disease on adequate therapy, with history of choking needs special attention. The CT scan is a better modality of the investigation. Three dimensional CT with multi-slice virtual bronchoscopy is advantageous. We discussed foreign body aspirations in adults, the various causes and presentations. Fiber optic bronchoscopy is the ideal method for visualization and extraction of non-life-threatening foreign bodies in adults. Once a foreign body is identified, it has to be removed as early as possible. Retained foreign bodies can precipitate many complications related to infection and inflammation. At rare incidence we may have to resort to thoracotomy to remove a complicated foreign body.