AS, DISH or something else?

A 68-year-old farmer presented with progressively worsening pain in multiple joints associated with stiffening for 9 months. Locomotor examination revealed grossly restricted movement of the axial skeleton. There were no neurological deficits. Radiological evaluation demonstrated diffuse bone densification and extraspinal calcification with bony ankylosis reminiscent of ankylosing spondylitis. Laboratory tests subsequently yielded the true diagnosis. The patient was counselled accordingly and started on appropriate therapy.

A young woman with seizures and psychosis.

We present a case of a 24-year-old woman with abnormal behaviour of recent onset. She had been diagnosed previously with epilepsy and had been started on antiepileptic medication. Clinical examination confirmed features of psychosis including paranoid delusions and auditory hallucination. Neurological examination showed nystagmus and dysmetria. Further evaluation revealed the underlying cause for her symptoms. She responded promptly to appropriate therapy with complete resolution of psychosis.

Haemolytic anaemia--PNH type II cells presenting a diagnostic dilemma.

A 28-year-old man presented with a history of intermittent haematuria over the past 10 years usually following fever episodes and requiring blood transfusions during the episodes. History of any thrombotic complications, chest pain or erectile dysfunction was not forthcoming. Examination revealed severe pallor with mild icterus and mild splenomegaly. His blood picture showed pancytopenia with elevated reticulocytes and indirect hyperbilirubinaemia. Indirect Coombs test was positive but direct was negative, serum lactate dehydrogenase was elevated and agglutinins were found to be of IgG type. Bone marrow showed a hypercellular marrow with myeloid and megakaryocytes suppressed. Donath-Landsteiner antibodies were found to be negative ruling out paroxysmal cold haemoglobinuria. Flow cytometry was performed with a suspicion of paroxysmal nocturnal haemoglobinuria (PNH) and was shown to be partially negative for CD59 but positive for CD55, a pattern consistent with type II PNH.

Hot and cold: coexistent Graves' disease and Hashimoto's thyroiditis in a patient with Schmidt's syndrome.

A 37-year-old housewife presented with generalised fatigue, palpitations and weight loss over the past 3 months. Physical examination revealed signs of hyperthyroidism. Thyroid function tests confirmed the presence of thyrotoxicosis. Pertechnetate radionuclide imaging of the thyroid showed diffusely increased radiotracer uptake consistent with Graves' disease and a cold nodule in the right lobe. Needle aspiration from the nodule yielded evidence of Hashimoto's thyroiditis. The patient also tested strongly positive for antithyroid peroxidase antibodies. Simultaneous laboratory evaluation revealed primary adrenal failure and probable pernicious anaemia, thus producing a diagnosis of Schmidt's syndrome. The patient was initiated on appropriate medical therapy for endocrinopathy. Graves' disease was treated with radioablation.

Difficult to wean: think of the diaphragm.

A 65-year-old woman, treated for non-ST segment elevation myocardial infarction and unexplained type 2 respiratory failure, was referred to our hospital in view of difficulty in weaning off the ventilator. She was evaluated in detail for persistent hypercapnia. Ultrasound of the diaphragm showed minimal excursion of diaphragm while she was off the ventilator and fluoroscopy confirmed bilateral diaphragmatic palsy. As extensive radiological, immunological and microbiological workup ruled out other possible aetiologies, a diagnosis of idiopathic Bell's palsy of the diaphragm was made. She was treated with valacyclovir and steroids after which she gradually recovered and was weaned off the ventilator.

Simultaneous occurrence of internal capsule infarct and cerebellar haemorrhage in a patient with hemiplegia.

A 68-year-old woman with hypertension with no history of cerebrovascular events presented with a left-sided hemiplegia which had developed acutely 2 days ago. She was not on maintenance therapy with antiplatelets or anticoagulants. A CT scan showed acute ischaemic infarction of the right internal capsule and cerebellar haemorrhage. Cardiac evaluation was normal. Doppler ultrasonography of the extracranial carotid and vertebral arteries showed diffuse arteriosclerotic changes, but did not reveal any haemodynamic occlusion. The simultaneous development of dual strokes was considered to be an extension of the same arteriosclerotic process to the intracranial carotid and basilar arteries.