Invading beyond bounds: extraintestinal Clostridium difficile infection leading to pancreatic and liver abscesses

Clostridium difficile has become a common healthcare-associated infection over the past few years and gained more attention. C. difficile was estimated to cause almost half a million infections in USA in 2011 and 29 000 died within 30 days of the initial diagnosis. Although colitis due to C. difficile is the most common presentation, there have been reported cases of extraintestinal infections. As per our review of literature, this is the third reported case of liver abscess due to the organism.

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Elephantiasis nostras verrucosa: a rare complication of lower limb lymphoedema

We reported a case of a 49-year-old man who had chronic lymphoedema of bilateral lower limbs for 30 years, but he did not seek treatment. His disease was complicated with irreversible changes of elephantiasis nostras verrucosa and had recurrent admissions due to infection. He was not keen for surgical intervention. This case report illustrated a rare and non-reversible complication of a common skin disease, lymphoedema and also the importance of identifying and treating it early.

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Dilemma of diagnosing sulphonylurea overdose in children: deliberations and considerations before reaching a diagnosis

A 15-year-old non-diabetic Caucasian girl presented with sudden onset of seizures, unrecordable blood glucose readings and acute renal failure. She denied any medication ingestion and no other precipitating factors were encountered for this acute presentation. She was treated with intravenous glucose infusion and hydrocortisone injection. Investigations showed a non-ketotic hypoglycaemia with high C-peptide and insulin levels. It took several days and multiple investigations to establish the exact cause of her persistent hypoglycaemia before it was concluded to be secondary to gliclazide overdose in a suicide attempt by the young girl. She made a complete recovery in a week with no apparent lasting neurological or renal impairment.

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Hypertensive bipolar: chronic lithium toxicity in patients taking ACE inhibitor

A patient with bipolar I disorder has been treated with lithium and haloperidol for the last 20 years and received an ACE inhibitor for his hypertension since 9 years ago. Despite regular clinic follow-ups and blood monitoring, he recently developed tremors and delirium. On hospital admission, serum level of lithium was far above toxic level. Mental state examination revealed an anxious and disorientated man with irrelevant speech. Immediate discontinuation of lithium resulted in slow reduction of serum lithium levels and gradual resolution of tremor but his delirium persisted for 2 weeks. His condition took a turn for the worse when he developed acute renal failure and arm abscess. We discussed about lithium toxicity and the vulnerability factors which have induced delirium and renal failure in this patient.

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Novel oral anticoagulant and kidney injury: apixaban-related acute interstitial nephritis

Non-vitamin K oral anticoagulants (NOACs) are being increasingly prescribed. These drugs act rapidly, have predictable dose-related anticoagulation effect and require no routine laboratory monitoring, making them attractive for both patients and healthcare providers. All NOACs are at least partially excreted thought the kidneys. Renal injury related to NOAC use is being increasingly reported. NOAC-related acute interstitial nephritis (AIN) has only been reported once and that was in context of dabigatran use. We describe the first case of apixaban-related AIN. This case adds an important differential diagnoses that should be considered for any patient presenting with renal injury while being treated with NOACs.

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Abdominal tuberculosis and spontaneous miscarriage

We present a case report of a 23-year-old Pakistani woman who had a second trimester spontaneous miscarriage while visiting her family in the Kingdom of Saudi Arabia. A dilatation and curettage (D&C) was done after the miscarriage. She developed sepsis and acute respiratory distress syndrome, requiring intensive care unit admission a few days after the D&C. An exploratory laparotomy was done and she was found to have a pelvic abscess. Despite adequate broad spectrum antimicrobial cover, she continued to drain a copious amount of serous fluid from the peritoneal cavity, with persistent fever and a stiff lung with difficult weaning off mechanical ventilation. Tuberculosis PCR of the peritoneal fluid came back positive. A histological finding of necrotising granuloma from the postoperative omental specimen and a positive culture from the ascitic fluid confirmed the diagnosis of Mycobacterium tuberculosis. Antituberculous treatment was started and she made a speedy recovery.

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Multiple sclerotic fibromas of the skin: an important clue for the diagnosis of Cowden syndrome

Cowden syndrome is a rare autosomal dominant condition characterised by mucocutaneous hamartomas and, most importantly, predisposition to various extracutaneous benign and malignant tumours. This disorder is associated with a germline mutation in the phosphatase and tensin homologue gene, a tumour suppressor gene, located on 10q23 chromosome. The expressivity of this genodermatosis is highly variable, therefore many of the cases remain undiagnosed. Skin and mucous findings are very common in Cowden syndrome and may represent the initial clinical manifestation leading to the diagnosis. The authors describe a case of a 58-year-old man with multiple cutaneous sclerotic fibromas associated with a previously unrecognised Cowden syndrome.

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