A Painless Thoracic Aortic Dissection.

Unlabelled: Thoracic aortic dissection (TAD) has a very high mortality rate and is often missed due to the atypical presentation of patients. We present a case of a man with chronic hypertension, atrial fibrillation (AF) (on regular warfarin) and a previous endovascular aneurysm repair (EVAR), who presented with dyspepsia and was incidentally found to have a ruptured distal thoracic aneurysm on imaging with no obvious clinical signs on examination, nor abnormalities on admission chest x-ray (CXR).

Learning Points: Typical symptoms and signs of thoracic aortic dissection (TAD), such as sudden onset of tearing pain and difference in blood pressure, can be absent in patients.

Lesson of the month 1: A review of a diving emergency.

Physicians should consider barotrauma and decompression illness (DCI) in any patient presenting after a recent scuba dive, even apparently shallow dives. If and when DCI is suspected, clinicians should act without delay to transfer the patient to a recompression facility, even if diagnostic certainty has not been attained. We present a case of hyperbaric injury in an asthmatic woman who had an atypical presentation in view of the depth of dive.

The Use of Denosumab in a Nonagenarian with Primary Hyperparathyroidism.

Denosumab is a monoclonal antibody which is currently licensed in the UK drug market for the prevention of skeletal-related events secondary to malignancy (excluding myeloma). This monoclonal antibody is a 6 monthly subcutaneous injection that works by lowering calcium levels. When used in a 90 year old patient with primary hyperparathyroidism it demonstrated a dramatic reduction in the calcium level which had proven difficult to reduce by bisphosphonates and who was not a candidate for surgical intervention.

Lesson of the month 2: toxic shock syndrome.

Toxic shock syndrome (TSS) represents a fascinating example of immune activation caused by infection resulting in a dramatic and challenging clinical syndrome. TSS is commonly associated with tampon use and still causes significant morbidity and mortality in young healthy women. A misconception is that TSS presents with a skin rash and only occurs in women and children; however, it can occur in males and can present without skin changes.

Exertional syncope as a presenting feature in Guillain-Barré syndrome.

Guillain-Barré syndrome (GBS) is an acute demyelinating disorder of the peripheral nervous system that results in motor weakness, absent reflexes and autonomic nervous system dysfunction. Autonomic failure is reported in approximately 65 % of patients with GBS and usually follows extensive motor involvement. In this case our patient presented with syncope and other signs of autonomic failure before the motor weakness developed.