Isolated unilateral idiopathic transient hypoglossal nerve palsy.

A 52-year-old Caucasian man presented with sudden onset of difficulty in moving his tongue to the left with preceding left-sided headache with no neck pain. Earlier, he had self-limiting chest infection without rashes or tonsillar enlargement. His medical and surgical history was unremarkable with no recent trauma. Oral examination revealed difficulty in protruding his tongue to the left with muscle bulk loss and fasciculation on the same side, suggesting left hypoglossal nerve palsy. Examination of the rest of the cranial nerves and nervous system was normal. The patient's oropharyngeal and laryngeal examination was unremarkable with no cervical lymphadenopathy. He had normal laboratory investigations and cerebrospinal fluid examination. Extensive imaging of the head, neck and chest failed to reveal any pathology. Further review by an otorhinologist and rheumatologist ruled out any other underlying pathology. He made a good recovery without treatment. English literature search revealed very few cases of idiopathic, transient, unilateral hypoglossal nerve palsy.

Shingles with secondary asymptomatic CNS involvement!

A 32-year-old married Asian woman, previously fit and well, presented with a 3-day history of interscapular back pain followed by a 1-day history of frontal headache and a few episodes of vomiting. She did not have photophobia or neck stiffness. On examination, there was evidence of herpes zoster infection involving the right T3 dermatome. There were no signs of meningeal irritation, cognitive impairment or any neurological deficit. As it is uncommon to have reactivation of herpes zoster infection at a young age, HIV serology was requested to exclude immunodeficiency state. While awaiting serology, a lumbar puncture was performed to exclude opportunistic infections of the central nervous system as she had transient headache and vomiting at the onset. The cerebrospinal fluid showed an elevated level of protein, an increase in lymphocytes and a strongly positive PCR for varicella zoster. The HIV test was negative. Oral acyclovir was changed to intravenous therapy and, a week later, she was discharged with uneventful recovery.

Pulsatile abdominal mass is not always leaking aneurysm!

An 80-year-old male, who presented with a history of unprovoked collapse, was found to have a visible pulsation in the central upper abdomen, which disappeared on raising his arms above his shoulder ('head and shoulder' technique). There was no tenderness noted over the pulsation. He had a ventricular demand inhibited pacemaker inserted 3 weeks ago for a significant bradycardia with atrial fibrillation. His ECG showed heart rate of 32 bpm with underlying atrial fibrillation. No pacing spikes noted. His chest x-ray confirmed displacement of pacing lead into the right subclavian vein. It caused stimulation of phrenic nerve resulting in rhythmical diaphragmatic contraction. He later had his pacemaker re-inserted with no more collapses.

'Idiopathic' chronic bilateral subdural haematoma--a separate entity or a missed cause?

A 65-year-old female was admitted with an 8-week history of gradual onset headache. The headache was worse in the morning and on bending forwards. This was associated with 1 week history of vomiting and 1 day history of difficulty in walking. Medical history was unremarkable apart from treated hypothyroidism. There was no history of trauma. Observations and physical examination were entirely normal. Routine blood tests including the ESR and clotting profile were normal. Given the history had red flags for headache, a CT scan was ordered and this showed bilateral subdural haematomas. The patient was referred to the regional neurosurgical centre where the haematomas were evacuated with good recovery. A follow-up MRI brain and spine did not show any source of bleeding.