BMJ case reports
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A 16-year-old girl presented with primary amenorrhea and had had cyclical abdominal pain for almost a year. At examination we observed a painful mass in the lower abdomen and normal secondary sex characteristics. Perineal examination showed a bluish bulging hymen. ⋯ An imperforate hymen occurs in 0.05% of women. It is important to be aware of this while examining a female adolescent presenting with cyclical abdominal pain and primary amenorrhea. Late discovery of an imperforate hymen may lead to pain, infections, hydronephrosis and endometriosis with subfertility as a possible consequence.
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Chronic neutrophilic leukaemia (CNL) is a rare myeloproliferative disorder of elderly patients characterised by sustained neutrophilia. The diagnosis of CNL requires the exclusion of BCR/ABL positive chronic myelogenous leukaemia and leukemoid reaction. We present here a case of a 61-year-old Egyptian man with CNL and 21 months of follow-up. ⋯ While hydroxyurea decreased the total leucocytic count, it could not affect the fatal course of the disease. The survival course of our patient extended to 21 months after presentation. The cause of death was attributed to disease progression.
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Mediastinitis caused by oesophageal perforation usually presents as a severe disease that can quickly progress to sepsis and death. We report a case with an indolent form of mediastinitis, caused by fish bone ingestion, which was successfully and exclusively treated with antibiotics. ⋯ The diagnosis was difficult to obtain because of this atypical clinical presentation. The chest computed tomography scan combined with the thoracic pain and the history of fish bone ingestion allowed us to confirm the diagnosis and initiate treatment.
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An unusual case of penile incarceration in a 13-year-old boy is presented, with lessons to be learned for Accident and Emergency Department junior doctors in particular and for all in general. The presentation was misleading and the condition would have gone undiagnosed with fatal consequences without a team effort. The object used was a wedding ring in this case. ⋯ The need for development of necessary paediatric history taking and examination techniques among Emergency Department doctors and staff is highlighted. Recalling the basics, this case report emphasises the importance of thorough physical examination. With early diagnosis and treatment, lifelong disabilities can be prevented.
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Acute delirium is a commonly encountered problem in the intensive care unit (ICU), which has a myriad of causes and contributes to poor outcomes. We present the case of an alcoholic critically ill patient who developed prolonged acute ICU delirium wrongly diagnosed as sedation and alcohol withdrawal. Protracted vomiting, swallowing disorders and continuous aspirations prevented him from enteral feeding and discontinuation of mechanical ventilation. ⋯ After thiamine supplementation, his state improved but he was discharged only on day 32. Wernicke's encephalopathy is an acute reversible neuropsychiatric emergency, which is falsely considered as uncommon, and is largely misdiagnosed, especially in critically ill patients. Thiamine should be systematically given to all critically ill alcoholic patients, especially those with protracted vomiting.