Chest pain in a young patient: an unusual complication of Epstein-Barr virus.

A 29-year-old man presented with sudden left-sided pleuritic chest pain on a background of sore throat during the preceding week. On examination he had tender cervical lymphadenopathy, he was tachycardic and had a 24 mm Hg blood pressure difference between the left and right arms. Bloods revealed deranged liver function tests and a lymphocytosis. His D-dimer was raised, hence he was treated for presumed pulmonary embolism before imaging was available. Monospot test was positive. He subsequently had both a CT pulmonary angiogram and a CT angiogram of the aorta to exclude pulmonary embolism and aortic dissection. The CT revealed splenomegaly with a large subdiaphragmatic haematoma secondary to splenic rupture. This had likely caused referred pain through diaphragmatic irritation. He was taken to theatre for urgent splenectomy. The unifying diagnosis was infectious mononucleosis complicated by spontaneous splenic rupture secondary to Epstein-Barr virus infection.

Primary tuberculosis of the thyroid gland: an unexpected cause of thyrotoxicosis.

We describe a 38-year-old Indian man who presented with a 2-week history of fever, night sweats and neck swelling who was found to be clinically thyrotoxic with a nodular goitre, tachycardia and high fever. Biochemical investigation revealed hyperthyroidism in association with deranged liver function tests and raised inflammatory markers. Ultrasound and CT scans of the neck revealed multinodular thyroid enlargement. He was considered most likely to have an acute infectious thyroiditis with a differential diagnosis of a toxic multinodular goitre and was started on carbimazole and antibiotics. He underwent fine needle aspiration of the thyroid which revealed necrotic cells and acid-fast bacilli, confirming a diagnosis of primary tuberculosis (TB) of the thyroid gland with no evidence of any other organ involvement on systemic imaging. He was started on TB therapy for 6 months and discharged with outpatient follow-up. Symptoms and biochemical markers subsequently resolved.

Birt-Hogg-Dubé syndrome: a rare cause of cystic lung diseases.

Cystic lung diseases are characterised by multiple intrapulmonary cysts. They can be mimicked by other more common causes of focal parenchymal lucencies such as emphysema, bronchiectasis and honeycombing. The various conditions have differing managements and prognoses, thus correct evaluation is essential. Birt-Hogg-Dubé (BHD) syndrome is an autosomal dominant disorder, that is, a rare cause of cystic lung disease. It is seen in approximately 200 families worldwide. This case describes a 37-year-old woman who presented to a District General Hospital with symptoms of pleuritic chest pain and breathlessness. A CT pulmonary angiogram arranged to assess for pulmonary emboli excluded this but it demonstrated multiple intrapulmonary cysts. After further investigation and subsequent genetic testing this was confirmed to be BHD syndrome.