Scoping a perforated bleeding peptic ulcer: learning points.

Peptic ulcer perforation and haemorrhage is not unusual as a complication of peptic ulcer disease. In the older patientspresentation can be dramatic and atypical. The authors are presenting a case of duodenal ulcer perforation and haemorrhage which was misdiagnosed as a gastric malignancy and thus failure to have Helicobacter pylori eradication, recurrence with complication and hesitancy in surgical intervention due to initial label of malignancy.

Haemoptysis in a patient of achalasia cardia: pulmonary actinomycosis, not tuberculosis.

Actinomycosis is an infectious disease caused by anaerobic gram-positive, non-spore forming bacteria of the genus Actinomyces that affects the oropharynx, digestive tract, and genitalia. Thoracic actinomycosis may affect the respiratory tract and the pleura, even extending to the chest wall. Pulmonary actinomycosis occurs in immunocompetent persons during the fourth and fifth decades of life, with greater prevalence in men, and is generally due to Actinomyces israelii or A meyeri. It is frequently misdiagnosed as primary or metastatic lung cancer or conventional lung infections (eg, tuberculosis). The accepted predisposing factors for bronchopulmonary actinomycosis are poor dental hygiene, alcoholism and various chronic debilitating diseases, hiatus hernia, and gastro-oesophageal reflux. We report an interesting case of pulmonary actinomycosis presenting with haemoptysis, associated with achlasia cardia, and treated as tuberculosis.

Gastric antral vascular ectasia (GAVE) in a non-cirrhotic patients with diabetes: case report and possible pathophysiological mechanism.

Gastric antral vascular ectasia (GAVE) syndrome is an uncommon but well-described cause of recurrent upper gastrointestinal bleeding or iron deficiency anaemia. Atiology is unknown but several associated diseases have been reported like connective tissue or autoimmune disorders or cirrhosis. Cases have been reported in systemic sclerosis, achlorhydia, atrophic gastritis and chronic renal failure. The most common cause is portal hypertension and portal hypertensive gastropathy. This is especially so after eradication of oesophageal varices by sclerotherapy or banding. Diabetic complications are characterised by microvascular diseases especially in the retina, glomerulus and vasa nervorum. It involves apoptosis and remodelling of endothelial cells. Hyperglycaemia is an essential cause of reactive oxygen species (ROS)-mediated oxidative stress in this complication. Angiopathy of gastric mucosa in diabetes mellitus has not been reported so far in the literature. We are presenting an interesting case of diabetes mellitus with gastric vascular ectasia without evidence of any other systemic illness.

Practice of symptomatic treatment in the era of evidence-based medicine: report of 2 cases of diagnosis of Sheehan's syndrome delayed till eighth decade.

Sheehan's syndrome, first described in 1937, is characterised by postpartum haemorrhage, pituitary necrosis, lactational failure and hypopitutarism. Presentation is variable and late presentations are not unusual due to partial ischaemic injury of the pituitary and gradual loss of endocrine function. A history of postpartum haemorrhage is usual but in some cases it is not elicited. Presentations such as malaise, fatigue, hypoglycaemia, decline in cognition, hyponatraemia, pancytopoenia, osteoporosis, secondary infertility, confusion and coma have all been reported. Two interesting cases of Sheehan's syndrome are presented that were diagnosed in the eighth decade; one due to atypical presentation of recurrent hyponatraemia and confusion, another from hypoglycaemic coma and symptoms of malaise and lethargy.

Catastrophic cerebral antiphospholipid syndrome presenting as cerebral infarction with haemorrhagic transformation after sudden withdrawal of warfarin in a patient with primary antiphospholipid syndrome.

Catastrophic antiphospholipid syndrome (APS) is caused by thrombotic vascular occlusions that affect both small and large vessels, producing ischaemia in the affected organs. The "catastrophic" variant of the antiphospholipid syndrome (cAPS) develops over a short period of time. Although patients with cAPS represent <1% of all patients with APS, they are usually life threatening with a 50% mortality rate. A strong association with concomitant infection is thought to act as the main trigger of microthromboses in cAPS. Several theories have been proposed to explain these physiopathological features. Some of them suggest the possibility of molecular mimicry between components of infectious microorganisms and natural anticoagulants, which might be involved in the production of cross-reacting antiphospholipid antibodies. We present a case of catastrophic cerebral APS characterised by massive temporal lobe infarction and subsequent haemorrhagic transformation after sudden withdrawal of warfarin.

Skin rash, headache and abnormal behaviour: unusual presentation of intracranial haemorrhage in dengue fever.

Dengue viral infections are one of the most important mosquito borne diseases in the world. The dengue virus is a single stranded RNA virus belonging to the Flaviviridae family. There are four serotypes (DEN 1-4) classified according to biological and immunological criteria. Patients may be asymptomatic or their condition may give rise to undifferentiated fever, dengue fever, dengue haemorrhagic fever (DHF), or dengue shock syndrome. Annually, 100 million cases of dengue fever and half a million cases of DHF occur worldwide and 2.5 billion people are at risk. At present, dengue is endemic in 112 countries. Early recognition and prompt initiation of appropriate treatment are vital if disease related morbidity and mortality are to be limited. We present an interesting case of dengue fever with headache, skin rash and abnormal behaviour who had a massive intracranial haemorrhage with fatal outcome.

An economically viable method for the removal of selected divalent metal ions from aqueous solutions using activated rice husk.

Biosorption of divalent metal ions, i.e. Pb(II), Cd(II), Zn(II) and Cu(II) onto rice husk activated (RHA) is investigated over pH range (1-10) via batch adsorption technique. The chemical and thermal activation of rice husk with 0.1M HNO(3) and 1M K(2)CO(3) at 473 K enhanced the removal efficiency of RHA (35+/-2.1-99+/-0.5%, 33+/-1.2-97+/-0.6%, 32+/-1.3-96+/-0.8% and 28+/-1.8-95+/-0.9% before and after treatment, respectively). The surface area analysis of RHA by BET (Brunauer, Emmett and Teller) nitrogen adsorption method provided pore area and average pore diameter to be 542+/-2.3m(2)g(-1) and 1076+/-5.6 nm respectively. SEM and FTIR analyses of RHA were carried out to determine the surface morphology and functional groups involved in metal binding mechanism, respectively. The adsorption equilibrium was well described by Freundlich, Langmuir and Dubinin-Radushkevish (D-R) isotherm models by employing (4.8-48, 8.9-89, 15.3-153 and 15.7-157)x10(-5)M solution concentrations of sorbates, respectively, at equilibrium time of 20 min at pH 6 and onto 0.2g of sorbent. The kinetics of mass transfer and intra-particle diffusion for metal ions sorption onto RHA were studied with Lagergren and Morris-Weber kinetic models. The numerical values of thermodynamic parameters indicated the exothermic nature, spontaneity and feasibility of the sorption process. The desorption study of metal components from RHA surface was carried out with 0.1M HCl. The sorption mechanism developed illustrates the strong interactions of sorbates with the active sites of the sorbent coupled with efficient and environmentally clean exploitation of rice waste product.

Sorption of organophosphorous pesticides onto chickpea husk from aqueous solutions.

The sorption efficiency of chickpea husk of black gram variety (BGH), for the removal of organophosphorous pesticides (OPPs), i.e. triazophos (TAP) and methyl parathion (MP) from aqueous media has been investigated. Optimization of operating sorption parameters, i.e. particle size, sorbent dose, agitation time, pH, initial concentration of sorbates, and temperature has been studied. The sorption data fitted well to Freundlich, Langmuir and Dubinin-Radushkevich (D-R) sorption isotherms. The maximum sorption capacities of BGH for TAP and MP were calculated to be 3.5+/-0.45 and 10.6+/-0.83 mmol g(-1) by Freundlich, 0.0077+/-0.021 and 0.025+/-0.0094 mmol g(-1) by Langmuir and 0.48+/-0.037 and 0.15+/-0.077 mmol g(-1) by D-R isotherms respectively, employing 0.2g of sorbent, at pH 6, 90 min agitation time and at 303 K. Application of first order Lagergren and Morris-Weber equations to the kinetic data yielded correlation coefficients, close to unity and showed partial intra-particle diffusion. The negative values of thermodynamic parameters, i.e. DeltaH (kJ mol(-1)), DeltaS (J mol(-1) K(-1)) and DeltaG (kJ mol(-1)) indicate the exothermic and spontaneous nature of the sorption process. The sorbed pesticides were recovered by sonication with methanol, making the regeneration and reutilization of the sorbents promising. The investigated sorbent exhibited potential applications in water decontamination, treatments of industrial and agricultural waste waters and thus productively demonstrated viable use of agricultural waste material.

Utilization of organic by-products for the removal of organophosphorous pesticide from aqueous media.

Sorption potential of rice (Oryza sativa) bran and rice husk for the removal of triazophos (TAP), an organophosphate pesticide, has been studied. The specific surface area were found to be 19+/-0.7 m(2)g(-1) and 11+/-0.8m(2)g(-1) for rice bran and rice husk, respectively. Rice bran exhibited higher removal efficiency (98+/-1.3%) than rice husk (94+/-1.2%) by employing triazophos solution concentration of 3 x 10(-5) M onto 0.2 g of each sorbent for 120 min agitation time at pH 6 and 303 K. The concentration range (3.2-32) x 10(-5) M was screened and sorption capacities of rice bran and rice husk for triazophos were computed by different sorption isotherms. The energy of sorption for rice bran and rice husk was assessed as 14+/-0.1 and 11+/-0.2 kJ mol(-1) and kinetics of the sorption is estimated to be 0.016+/-0.002 and 0.013+/-0.002 min(-1), respectively. Intraparticle diffusion rate was computed to be 4+/-0.8 and 4+/-0.9 nmol g(-1)min(-1/2). Thermodynamic constants DeltaH, DeltaS and DeltaG at varying temperatures (283-323 K) were also calculated.

Analgesics are not always the culprits: isolated gastric fundal varices as the cause of recurrent upper GI bleed in a patient with SLE, rheumatoid arthritis and polymyositis overlap syndrome.

The most common cause of upper gastrointestinal bleeding in patients with systemic rheumatic diseases is non-steroidal drug use; this is the case with COX-2 inhibitors, especially when used concomitantly with corticosteroids. Bleeding from varices is unusual in the absence of liver disease. We present an interesting case of a patient with systemic lupus erythematosus, rheumatoid arthritis and polymyositis overlap syndrome with recurrent upper gastrointestinal bleeds from isolated fundal gastric varices and a normal liver.

Congenital cataract and congenital chloride diarrhoea-a unique combination and antenatal diagnosis.

Congenital chloride diarrhoea (CCD) is a serious inherited defect of intestinal electrolyte absorption transmitted in an autosomal recessive way. The molecular pathology involves an epithelial Cl(-)/HCO(3)(-) exchanger protein, encoded by the solute carrier family 26 member 3 gene (SLC26A3) and known DRA (down regulated in adenomas) in the distal ileum and colon. Polyhydramnios, premature birth, ileus without meconium passage, hypochloremia, and hyponatremia are typical features of CCD in the neonate followed by chronic metabolic alkalosis, hypokalemia, hypochloremia, retarded growth and renal impairment in older children and adults if the disease is not adequately treated. Antenatal diagnosis if made on the basis of findings on ultrasonography-a non-invasive diagnostic test-can help in early management of the disorder immediately after birth and, thus, prevent the sequelae. We present an interesting case of CCD diagnosed antenatally and found to have congenital cataract, which is a unique occurrence not reported in literature so far.

Delirium in a 74-year-old man: correct imaging revealed the truth.

Delirium is a cognitive disorder. DSM-IV criteria for delirium must include both acute onset and fluctuating symptoms; disturbance of consciousness (including inattention); at least one of the following: disorganised thinking, disorientation, memory impairment or perceptual disturbance; and evidence of a putative causal medical condition. Traditionally, the course has been described as transient in which recovery is likely to be complete if the underlying aetiological factor is promptly corrected or is self-limited. The most common precipitating causes in elderly include sepsis, dehydration and drugs. Work-up for delirium is limited to septic screening, baseline investigations and imaging. Patients with delirium without focal signs and with either evidence for a medical aetiology of delirium or pre-diagnosed dementia are at a very low risk of having focal lesions in their contrast-enhanced CT or MRI. We are presenting an interesting case of delirium with urosepsis whose imaging revealed milliary brain tuberculomas on contrast-enhanced MRI.

Chest wall swelling: unusual presentation of an aggressive mediastinal tumour.

The majority of patients with primary mediastinal lymphoma are symptomatic at the time of diagnosis and commonly have fever, weight loss and/or night sweats. Symptoms due to compression of adjacent mediastinal structures are infrequent, but may include pain, dyspnoea, stridor, or superior vena cava syndrome. Local infiltration into the chest wall, pleura and pericardium is not uncommon.In the present report, two interesting cases of chest wall swellings that in fact were extensions of primary mediastinal lymphoma are given. Histopathology of the tumour was large B cell lymphoma (CD20+). The first case was in a 23-year-old woman, with dramatic onset but a good outcome. The second was in a 34-year-old Pakistani woman, with insidious onset and poor outcome due to extent and invasion by the tumour. Interesting CT images are presented showing chest wall and left supraclavicular swelling.

Don't live in a town where there are no doctors: toxic epidermal necrolysis initially misdiagnosed as oral thrush.

Toxic epidermal necrolysis (TEN) is a rare but life threatening skin disease that is most commonly drug induced. The exact pathogenesis of TEN is still unknown and many drugs, including prednisolone, cyclosporin and intravenous immunoglobulin (IVIG), have been used in an attempt to halt the disease process. The use of IVIG in particular is controversial. Recently, the US Food and Drug Administration (FDA) has made a labelling change to the drug information for carbamazepine. Owing to recent data implicating the HLA allele B*1502 as a marker for carbamazepine induced Stevens-Johnson syndrome and TEN in Han Chinese, the FDA recommends genotyping all Asians for the allele. We present an interesting case of carbamazepine induced TEN which was confused with oral thrush, had no skin lesions on presentation, and had an excellent response to a 5 day course of methylprednisolone and high dose IVIG in combination.