Hypothyroidism presenting as a fissure tongue.

We are reporting a case of hypothyroidism presenting as fissured tongue, demonstrating significant resolution of fissure tongue upon thyroid hormone replacement therapy.

A Painless Thoracic Aortic Dissection.

Thoracic aortic dissection (TAD) has a very high mortality rate and is often missed due to the atypical presentation of patients. We present a case of a man with chronic hypertension, atrial fibrillation (AF) (on regular warfarin) and a previous endovascular aneurysm repair (EVAR), who presented with dyspepsia and was incidentally found to have a ruptured distal thoracic aneurysm on imaging with no obvious clinical signs on examination, nor abnormalities on admission chest x-ray (CXR). LEARNING POINTS: Typical symptoms and signs of thoracic aortic dissection (TAD), such as sudden onset of tearing pain and difference in blood pressure, can be absent in patients.Clinicians should consider imaging of the aorta in high-risk patients who present with syncope, focal neurology and/or atypical chest, back or abdominal pain.There may be a role for D-dimer in the future to rule out the possibility of TAD, similar to pulmonary embolism (PE).

Lesson of the month 1: A review of a diving emergency.

Physicians should consider barotrauma and decompression illness (DCI) in any patient presenting after a recent scuba dive, even apparently shallow dives. If and when DCI is suspected, clinicians should act without delay to transfer the patient to a recompression facility, even if diagnostic certainty has not been attained. We present a case of hyperbaric injury in an asthmatic woman who had an atypical presentation in view of the depth of dive.

Lesson of the month 2: toxic shock syndrome.

Toxic shock syndrome (TSS) represents a fascinating example of immune activation caused by infection resulting in a dramatic and challenging clinical syndrome. TSS is commonly associated with tampon use and still causes significant morbidity and mortality in young healthy women. A misconception is that TSS presents with a skin rash and only occurs in women and children; however, it can occur in males and can present without skin changes. TSS presents initially as a febrile illness and within a few hours can progress to severe hypotension and multiple organ failure (MOF). Staphylococcus aureus and group A beta haemolytic streptococcus (GABHS) can secrete toxins from a small or hidden focus of infection and hence blood culture and sensitivity (C+S) tests can be negative, thereby making diagnosing this condition challenging. Clindamycin is superior to penicillin in the treatment of this condition and significantly decreases the mortality rate in TSS. However, there is also an important role for intravenous immunoglobulins (IVIG). Early intensive care unit (ICU) as well as surgical team involvement (in selected cases) is required to avoid mortality which may approach 70%.

The Use of Denosumab in a Nonagenarian with Primary Hyperparathyroidism.

Denosumab is a monoclonal antibody which is currently licensed in the UK drug market for the prevention of skeletal-related events secondary to malignancy (excluding myeloma). This monoclonal antibody is a 6 monthly subcutaneous injection that works by lowering calcium levels. When used in a 90 year old patient with primary hyperparathyroidism it demonstrated a dramatic reduction in the calcium level which had proven difficult to reduce by bisphosphonates and who was not a candidate for surgical intervention.

Exertional syncope as a presenting feature in Guillain-Barré syndrome.

Guillain-Barré syndrome (GBS) is an acute demyelinating disorder of the peripheral nervous system that results in motor weakness, absent reflexes and autonomic nervous system dysfunction. Autonomic failure is reported in approximately 65 % of patients with GBS and usually follows extensive motor involvement. In this case our patient presented with syncope and other signs of autonomic failure before the motor weakness developed. Few cases in the literature have reported features of autonomic failure before established weakness in GBS; to our knowledge, syncope has not been described previously as a presenting feature of GBS.