Bilateral Swelling Research Articles

Bilateral optic disc swelling in a man aged 32 years

Bilateral optic disc swelling in a man aged 32 years

Vogt-Koyanagi-Harada Disease after COVID-19 Vaccination

Purpose: To report a case of Vogt-Koyanagi-Harada (VKH) disease after COVID-19 vaccination.Case summary: A 53-year-old female patient with no history of systemic disease or ocular surgery presented with bilateral decreased visual acuity, hyperemia, eye pain, and headache 1 month after COVID-19 vaccination (Pfizer-BioNTech). She initially presented 1 week after symptom onset. Her best-corrected visual acuity was 0.63 in the right eye and 1.0 in the left eye, and she had bilateral grade 2 anterior chamber reactions on slit-lamp examination. Fundus photography, optical coherence tomography, and fluorescein angiography revealed bilateral optic disc swelling, choroidal folds, multiple serous retinal detachments, and fluorescein leakage at posterior poles. She was diagnosed with VKH disease and treated with topical and systemic medications, which completely resolved her symptoms over 2 months.Conclusions: VKH disease can develop after COVID-19 vaccination in patients without any underlying disease. Therefore, possible side effects and treatments should be explained to patients receiving COVID-19 vaccination.

THU009 Subclinical Cushing’s Syndrome In An ACTH-secreting Pituitary Macroadenoma

Abstract Disclosure: N.G. Akabogu: None. D. Kumar: None. N. Sheung: None. A. Akofu: None. A. Uddin: None. S. Dejhansathit: None. F. Marium: None. L.G. Kurukulasuriya: None. Background: Subclinical Cushing’s syndrome (SCS) is characterized by subtle cortisol hypersecretion, which does not result in the typical signs and symptoms of Cushing’s syndrome (CS). While many of the signs and symptoms of CS are common in the general population, there are some that are discriminatory and specific for CS: supraclavicular fat pads, proximal muscle weakness, facial plethora, and violaceous striae. SCS manifests mostly as obesity, type 2 diabetes, and hypertension. Diagnosing SCS is challenging; however, the best screening test to uncover the subtle hypercortisolism is the dexamethasone suppression test (DST). Case presentation: We report a case of SCS in a 62 years old Caucasian postmenopausal patient with a medical history of total thyroidectomy for Graves’ disease, post-surgical hypothyroidism, 7.4cm right pheochromocytoma status post partial right adrenalectomy, incidentally discovered pituitary macroadenoma (during imaging to look for subarachnoid hemorrhage), untreated type 2 diabetes mellitus (A1c 6.6% and stable for 1 year before treatment), hypertension, atrial fibrillation, cerebrovascular accident, and worsening migraines. Patient’s physical exam was mostly unremarkable; she had central obesity and bilateral lower extremity swelling. Pituitary work-up showed evidence of secondary hypogonadism and secondary hypothyroidism with elevated adrenocorticotropic hormone (ACTH) of 130 (AM range: 7.2-63) and cortisol of 12.6, at 11:52AM. Further work-up for hypercortisolism revealed non-suppressed 8AM cortisol (5.83mcg/dL) on the low dose DST and 49% suppression of 8AM cortisol and ACTH on the high dose DST. 24hour urinary cortisol was normal. Patient did not perform the midnight salivary cortisol. Patient subsequently underwent trans-sphenoidal resection of the pituitary macroadenoma. Pathology analysis of the pituitary mass showed weak to moderate immunoreactivity for ACTH. Conclusion: Our patient had abnormal DST but normal 24hour urine cortisol. We may have missed her SCS if we screened her only with a 24hour urine cortisol. This confirms the fact that dexamethasone suppression test should be the first test in the evaluation of subclinical Cushing’s syndrome. Presentation: Thursday, June 15, 2023

Imaging findings of head and neck and intracranial sinus histiocytosis with massive lymphadenopathy (Rosai–dorfman disease): A rare case report

This case report describes a multifocal involvement of Rosai–Dorfman disease (RDD), which is a benign lymphohistiocytosis, with emphasis on imaging findings in a 19 yrs old Ethiopian female patient who was sent to radiology department at Tikur Anbessa Specialized Hospital (TASH) for head and neck and brain imaging evaluations for an indication of bilateral painless neck swelling of 2 years duration. The head and neck computed tomography (CT) and brain magnetic resonance imaging (MRI) revealed numerous enlarged cervical lymph nodes and soft tissue infiltration of paranasal sinuses with associated lytic osseous changes as well as multiple intracranial extraaxial dural-based masses. Smears of fine needle aspiration biopsy from cervical lymph nodes confirmed the diagnosis of Rosai–Dorfman disease (RDD).

FRI249 New Onset Heart Failure In A Patient With Rapidly Progressive Adrenocortical Carcinoma

Abstract Disclosure: J. Peeples: None. S. Shu: None. K.G. Romo: None. J. Tereul: None. B.B. Grissett: None. Background: Adrenocortical carcinomas (ACC) are rare, relatively large (>4cm), lipid-rich, and often aggressive tumors. They may be functional, which typically presents as Cushing’s syndrome and/or virilization, or non-functional, which typically presents as an abdominal mass or incidental finding. They occur in two peak incidences: at the first decade of life and between 40-50 years of age. Over half of adult patients with ACC present with an advanced tumor stage. This case describes a young man with new onset heart failure and adrenal mass with metastases who was found to have biopsy-confirmed ACC. Clinical Case: A 20-year-old man with a history of cigarette smoking and marijuana use, but otherwise in prior good health, presented as a transfer for new onset heart failure in the setting of hypertensive emergency (SBP 260s), and CT findings of left adrenal mass, with multiple lung and liver masses. He noted 2 months of rapidly progressive weight gain, easy fatigability, dyspnea on exertion, and leg swelling. Exam revealed central adiposity with abdominal striae, bilateral clavicular and cervical fat pad, and bilateral lower extremity swelling. Investigations revealed hypercortisolism and ventricular ejection fraction 20-25%. Liver mass biopsy revealed metastatic ACC. Family history was significant for multiple members with early onset hypertension and congestive heart failure, including the death of maternal grandmother at age 40. The patient was initially managed in the ICU with an etomidate drip for adrenal suppression. Cortisol levels appropriately decreased to goal. Additionally, he started IV dexamethasone while inpatient. He was discharged once euvolemic on PO furosemide and follow-up was scheduled with cardiology, oncology, and endocrinology. At discharge, he transitioned to PO hydrocortisone (HC) and was placed on trimethoprim/sulfamethoxazole for PJP prophylaxis, doxazosin, and ketoconazole. He also started mitotane for his cancer treatment, with HC to prevent adrenal insufficiency while on mitotane. Subsequently, he started and failed carboplatin plus etoposide palliative chemotherapy with a continued increase in adrenal mass size. Now, he is on second line pembrolizumab with an ECOG score of 2. Conclusion: ACC is a rare and often aggressive tumor that should be considered in the setting of hypercortisolism and cushingoid features. This is particularly important for patients with a relatively unremarkable history and new onset heart failure with dyspnea on exertion. In these cases, mitotane can be used for hypercortisolism associated with ACC. Unfortunately, these tumors are usually diagnosed when they have already progressed to a late stage, and the prognosis for ACC is poor. Presentation: Friday, June 16, 2023

Case Report: Bilateral optic disc swelling in a patient with tuberculoma

BACKGROUND: In children, tuberculosis of the central nervous system most usually manifests as tubercular meningitis, hydrocephalus post-tubercular meningitis, and, in rare cases, space-occupying lesions known as tuberculoma. We address the diagnostic difficulty in an adult patient with mainly ocular symptoms who was diagnosed with tuberculoma. A 19-year-old young man came with painless bilateral blurring of vision. Bilateral optic disc swelling and bilateral sixth cranial nerve palsy were present. METHODS: Brain imaging revealed ring-enhancing lesions in the cerebellar vermis, left cerebellar hemisphere and left middle cerebral peduncle with surrounding extensive perilesional edema causing effacement of fourth ventricle leading to obstructive hydrocephalus suggestive of tuberculoma. RESULTS: He had a high erythrocyte sedimentation rate and a positive Mantoux test. His Quantiferon-TB Gold test result was positive. The examination of cerebrospinal fluid suggested a high opening pressure. Following anti-tubercular medication along with systemic steroids, his vision improved due to decreased optic disc swelling. CONCLUSION: We wish to highlight that visual loss and grave consequences of tuberculoma can be averted with early recognition and treatment.

Bone and joint disease – Not always a rheumatological diagnosis

Abstract A 17-year-old female presented with a 7-day history of joint pains involving the bilateral knee, ankle and small joints of the hands and feet symmetrically, associated with bilateral knee joint swelling and early morning stiffness and bilateral red eyes. General examination was normal except for pallor. Musculoskeletal system examination revealed bilateral swollen and tender knee joints with restriction of movement along with tenderness in the bilateral shoulder, elbow, ankle joints and spine from T3 to T7 thoracic vertebral levels. Examination of other systems was normal. Investigations showed anaemia, elevated urea and creatinine. Skeletal survey showed multiple lytic lesions. Positron emission tomography revealed multiple punched-out lytic lesions in skull bones, scapulae, sternum, clavicles, ribs on both sides, vertebrae at multiple levels and in pelvic girdle bones. Few lesions showed mild 18fluorodeoxyglucose (18FDG) uptake, metaphyseal moth-eaten lysis in long bones with mild FDG uptake. Bone marrow biopsy and immunohistochemistry confirmed the diagnosis of acute B-cell lymphoblastic leukaemia. The terminology is according to 2016 revision of WHO classification of myeloid neoplasms and acute leukemia.

Bilateral periorbital swelling as the presenting manifestation of recurrent breast carcinoma.

Bilateral periorbital swelling as the presenting manifestation of recurrent breast carcinoma.

OA06 Behçet's associated myositis: an unusual cause of exercise-induced leg pain

Abstract Introduction This case describes a 29-year-old gentleman of Cypriot heritage who presented with exercise-induced bilateral lower leg pain and swelling which made it difficult for him to cycle. Symptoms progressed over months to calf pain at rest accompanied by fatigue. He subsequently presented with central visual loss in the right eye, followed by the left. The second episode of visual loss coincided with development of oro-genital ulceration and, following rheumatology review, a diagnosis of Behçet’s disease was made. The case is significant in terms of the chronicity and nature of presenting symptoms which is not typically described in this disease. Case description A 29-year-old gentleman presented with exercise-induced bilateral lower leg pain and swelling for which he was reviewed in emergency care on four occasions. He received treatment for presumed cellulitis and underwent US-doppler studies, excluding thromboembolic disease. MRI of the lower legs was requested given lack of diagnosis with ongoing symptoms. This demonstrated bilateral muscle oedema in the antero-lateral compartments and lateral gastrocnemius heads, prompting rheumatology referral. Prior to attending rheumatology, the patient developed bilateral sequential visual loss. This was attributed to right acute macular neuroretinopathy, followed by significant left posterior pole choroidal ischaemia 2 months later. Each presentation was associated with transient low-grade anterior uveitis, vitritis, and the presence of a pre-papillary vitreous infiltrate. Initial treatment included a six-week oral prednisolone taper from 60mg daily. He reported a progressive leg pain which initially occurred during cycling but later affecting his walking. He was of Cypriot heritage, with no family history of autoimmune disease. A focused history revealed oral ulceration and an acne-like pustular rash over the back. His gait was antalgic with minimal toe-off phase. Investigations demonstrated raised ESR and CRP, negative autoimmune immunology, negative myositis ENA, normal CK, and positive HLA-B51. Given these features, a provisional diagnosis of Behçet’s was made. Nerve conduction studies were requested to consider whether changes could be secondary to denervation. They displayed non-specific S1 neurogenic changes and small tibial motor amplitudes. Subsequent MRI lumbar spine excluded radiculopathy. Repeat CK remained within normal limits. Muscle biopsy was sought and performed with a clinical suspicion of atypical myositis which has previously been reported in Behçet’s. At the second episode of visual loss, he was admitted under ophthalmology and treated with intravenous methylprednisolone and azathioprine. The case was discussed with our regional centre of excellence for Behçet’s and infliximab at 5mg/kg was commenced. Discussion This case was notable for the complexity and atypical presenting features with calf pain induced by exercise likely due to atypical myositis (biopsy report still awaited at time of submission). More classical Behçet’s disease symptoms including oro-genital ulceration were significantly later. The case highlights the importance of multidisciplinary working and involving specialist centres especially when rapid escalation to biologic treatment is required. Leg symptoms are persistent but improved despite ongoing treatment with prednisolone and azathioprine with the recent addition of infliximab. Visual symptoms have stabilised and skin involvement has settled. Management Rationale At the time of first review in rheumatology clinic, high-dose steroid treatment had already been initiated; therefore, expediting the investigative aspect of his management felt most appropriate, particularly given that myositis seemed to be the predominant feature at that time. In joint consultation with neurophysiology and neurology, putting the EMG and MRI findings in context, MRI of the lumbar spine was felt necessary to exclude discogenic disease causing denervation oedema. Unfortunately, visual symptoms progressed rapidly after this, requiring admission, which precluded an earlier opportunity for biopsy but leading to quick authorisation and organisation of treatment with infliximab. Key learning points This case highlights an atypical presentation of Behçet’s disease including associated likely atypical myositis. Causes of exercise-induced leg pain in a young, fit patient need to be considered: The need for multidisciplinary discussion both across specialties and with regional centres is key in order to progress with diagnostics and treatment In sharing this case for discussion, we wish to highlight possible causes of exercise-induced calf pain and a pathway for investigation of this. Our patient had atypical myositis as the cause for his symptoms in the context of multi-system disease. Both his myositis and ophthalmology presentations were somewhat atypical but multidisciplinary working, along with the development of some further symptoms, were helpful in making the diagnosis.

1057 Fournier’s Gangrene Caused by Porphyromonas Asaccharolytica; a New Bug in the Block?

Abstract Introduction Fournier’s gangrene (FG) is a urological emergency characterised by a destructive inflammation of the genital and perineal area typically forming necrotising fasciitis that affects the external genitalia and the perineum resulting in the gangrene of infected tissues as well as generalised systemic deterioration in its severest form. Although FG is typically polymicrobial, we found it can very rarely be mono-microbial and caused by Porphyromonas asaccharolytica, an obligate anaerobic gram-negative rod. Case presentation We present a case of a 44-year-old man seen in the emergency department with bilateral scrotal swelling, redness, and pain. A diagnosis of acute epididymo-orchitis (on a background of chronic severe phimosis) was made. Ultrasound imaging of the testes was consistent with features suggestive of epididymo-orchitis and reactive hydrocoele. The patient also tested positive for the SARS-Cov-2 virus but had no respiratory symptoms. Empirical treatment, as per Trust antimicrobial policy, was initiated with intravenous Flucloxacillin which was changed, following the results of blood culture growth of Porphyromonas asaccharolytica, to Meropenem, Vancomycin and Clindamycin. On day 3 of admission, an ulcer was noticed at the base of the scrotum which progressed rapidly into a fulminant Fournier's gangrene. He was treated radically with urgent debridement and direct closure of the wounds and was discharged after 2 weeks on admission. Conclusions We report a case of Fournier’s gangrene caused by a rare gram-negative organism in an asymptomatic unvaccinated COVID-19 patient. Clinicians need to have a high index of suspicion that this organism can also be a cause of Fournier’s gangrene.

Spheno-Orbital Tuberculosis: A Rare Case.

A 9-year-old girl presented with progressive, painless protrusion of the right eye for 2 months. She also complained of multiple bilateral neck swellings for 2 months. On examination, there was proptosis of the right eye with the eyeball displaced downwards and forwards. The extra ocular movements of the right eye showed limitation of abduction. The vision was normal in both eyes. A detailed clinical evaluation with investigations led to a diagnosis of spheno-orbital tuberculosis. Prompt initiation of anti-tubercular therapy (ATT) led to resolution of the lesion.

E46 Viruses reactivating each other’s!

Abstract Introduction COVID-19 is known to cause an immunocompromised state. This condition was associated with reactivation of quiescent viruses. Objectives Describe a case of HHV-6 reactivation in a patient diagnosed with MIS-C syndrome. Methods The diagnosis of MIS-C syndrome associated to SARS-CoV-2 was done by following the criteria established by the World Health Organization (WHO). The reactivation of HHV6 was confirmed by positivity of RT-PCR in blood and presence of IgG in serology. Results A four years old girl, with no medical history who presented to emergency room with high fever associated with conjunctival injection, cheilitis, cervical adenopathy and rash since four days. She developed a generalized tonic-clonic seizure then a vasoplegic shock two days later. Thus, she was admitted in ICU. Clinical examination on admission showed polypnea, a low blood oxygen level, tachycardia, a low blood pressure (28/15mmhg), a hepatomegaly, a maculopapular rash in pelvic region and a bilateral eyelid swelling. Biology showed lymphopenia (660 109/l), hepatic cytolysis, low prothrombin test (19%), an acute renal failure, a biological inflammatory syndrome with an elevated C-reactive protein (274 mg/l), an elevated ferritin, increased d-dimers (1µg/ml) and fibrinogen level which suggest activation of the coagulation cascade with a prothrombotic state and elevated lactatemia (6.4 mmol/l). The chest X-ray was normal. She had a low ejection fraction (39%) showed on echocardiogram. A rapid SARS-CoV-2 test was negative but serology was positive. Since MIS-C syndrome was not known to give severe hepatitis, other diagnoses was proposed. RT-PCR in serum associated to RT-PCR in cutaneous lesion’s biopsy was positive for HHV6. The hepatitis A serology was negative. She has an anterior immunity to varicella-zoster (VZV). She was intubated. She received vasoactive medications, intravenous immunoglobulin (IVIG) and steroids. Course was marked by hemolytic anaemia, which was associated to immunoglobulin (IVIG). Our patient become rapidly afebrile. Vital signs and laboratory parameters of inflammation, CRP, lymphopenia, markers of cardiac injury, transaminases and renal function parameters all normalized. On day 28 of hospital stay, she was discharged with full dose of steroids and low dose of aspirin. Conclusion HHV6 reactivation needs a state of immunosuppression and was reported with acquired immunodeficiency syndrome (AIDS) and a variety of lymphoproliferative disorders. It leads to fever, cutaneous eruption as well as more serious complication such as hepatitis, which is the case with our patient. Ethics No conflicts of interest.

E56 A 16-year diagnosis delay of a patient with Pigmented Villonodular Synovitis

Abstract Introduction Pigmented villonodular synovitis (PVNS), a subtype of tenosynovial giant cell tumours, is a rare non-cancerous proliferative synovial disorder usually affecting the knee in adults(1). The incidence rate is 1.8 patients per million people of the general population, with few reports amongst the paediatric population, hence it is frequently misdiagnosed(2). It has a slow onset of symptoms and has been noted to take ∼18 months to make a definitive diagnosis(3). Objective To describe a case of pigmented villonodular synovitis in a seventeen-year-old African female. Methods A retrospective chart review was done to ascertain the clinical presentation and management of the patient. Case description We present a case of a 17-year-old African female who presented with bilateral knee pain and swelling from 10 months of age. She had been on follow-up at a peripheral facility for 14 years, where she was being managed with methotrexate 12.5 mg weekly and folic acid 5 mg OD for Juvenile Idiopathic Arthritis with no marked improvement in her symptoms. In view of her poor response to therapy, the mother stopped her treatment 3 months prior to presentation in our facility. She initially had intermittent bilateral swelling of the small joints of the hand that were tender which eventually evolved to involve both knee joints. The pain was worse in the morning and was associated with the inability to ambulate and occasional night awakening. The systemic inquiry was otherwise unremarkable. She had an unremarkable birth history, and normal developmental milestones. She was however shorter than her peers and had not attained menarche. The patient had been admitted 8–10 times per year during the span of her illness for similar complaints and had undergone multiple knee joint fluid aspirations to relieve the swelling and several laboratory tests and radiological studies were done. On assessment, she was noted to be of fair general condition with gross asymmetric swelling of both knees and a surgical scar over the right knee with no limitation in the range of movement. There was minimal effusion of bilateral elbows and ankles, and the MCP, ICP and wrist joints weren’t affected. The patient had thoracic scoliosis, a grade 3/6 systolic murmur on the left lower sternal border, no radiation, and hepatomegaly 4 cm below the costal margin. She was prepubertal on sexual maturation rating. There was no central nervous system, abdominal, or respiratory abnormalities. A series of lab investigations to exclude the possibility of juvenile idiopathic arthritis were conducted. This panel included a complete blood count, which showed hypochromic, microcytic anaemia, c-reactive protein was raised at 61 mg/l but normal biochemistry and unremarkable autoantibody profile. Imaging done included a bilateral knee X-Ray followed by a bilateral knee MRI which showed large volume bilateral knee joint effusions associated with synovial-based masses causing extrinsic periarticular bony erosions and intra-articular synovial proliferation forming a villonodular appearance. The patient was referred to orthopaedic surgery and bilateral arthrotomy, drainage and synovectomy of both knees were done. She continues to be followed up in our paediatric rheumatology and orthopaedic clinic with good mobility and no other co-morbidities. She is currently undergoing work up for a delayed puberty. Conclusion Pigmented villonodular synovitis is a rare disease in the paediatric population. In the absence of awareness of its existence and expertise on how to diagnose it, patients may be misdiagnosed and mismanaged over a long duration of time as seen in the presented case.

Neonatal giant mastauxe: a case report.

A 13-day-term male neonate presented with bilateral breast enlargement and milky nipple discharge, which worsened upon breast massage. The mother had an uneventful pregnancy, and neither the mother nor the baby had a history of drug intake. The examination revealed soft, non-tender, non-erythematous bilateral breast swellings measuring 3.6×3.8cm on the right side and 3.2×3.4cm on the left side. Ultrasonography confirmed their hypoechoic nature with minimum vascularization. The white blood cell count, C-reactive protein levels, and culture of nipple discharge yielded normal results. The baby was discharged, and upon follow-up after 2 weeks, it was observed that breast swellings had spontaneously reduced in size. Neonatal breast enlargement can occur as a result of either the transplacental transfer of maternal estrogens or declining levels of estrogens toward the end of pregnancy, leading to hyperprolactinemia. However, the exact reasons behind the occurrence of giant mastauxe in some newborns remain incompletely understood. It may be due to increased sensitivity of the breast tissue to estrogens. Proper clinical examination, along with the use of ultrasonography and/or laboratory investigations if required, is essential to differentiate giant mastauxe from neonatal mastitis or breast abscess. Treatment primarily involves observation and providing reassurance to parents.

Primary Sjögren’s syndrome misdiagnosed as Mikulicz’s disease: a case report

BackgroundSjögren’s Syndrome (SS) is an inflammatory autoimmune disease, and Mikulicz’s disease (MD) is a lymphoproliferative disorder. Both MD and SS are more common in middle-aged female, and the dry eyes could be presented in both of them with different degree. The MD patients are characterized by symmetrical swelling of the lacrimal glands which also can occur in the early stage of SS. And the imaging findings between early stage of SS and MD are lack of specificity. Therefore, SS and MD have similarities in the clinical manifestations, imaging and pathological findings and are confused in diagnosis.Case presentationA 51-year-old female patient presented with bilateral swelling of the upper eyelids for 2 years. She also reported having dry mouth and dry eyes which could be tolerated. The Schirmer’s test result is positive and the laboratory tests indicate serum total IgG increased. In the bilateral lacrimal gland area could palpate soft masses. The orbital magnetic resonance imaging (MRI) examination showed bilateral lacrimal gland prolapse. While the histopathological result was considered as MD. The immunohistochemical (IHC) staining results were positive for IgG and negative for IgG4. To clarify the diagnosis, SS-related laboratory tests were performed: anti-SSA antibody (+++), anti-SSB antibody (+++), anti-Ro-52 antibody (+++). With a comprehensive consideration, the final diagnosis was SS.ConclusionWhen the clinical manifestations are atypical, it is necessary to pay attention to the differential diagnosis of SS and MD.

A single, episodic event of unilateral/bilateral scrotal swelling in a group of adult boars at an Austrian boar stud

BackgroundScrotal swelling is a clinical situation which can be caused by different aetiologies. In this case report, we describe a multi-week episode of unilateral and bilateral scrotal swelling in boars at an Austrian boar stud and its diagnostic work-up.Case presentationIn the summer of 2020, the herd veterinarian of an Austrian boar stud reported that over a period of six weeks, five out of 70 boars presented with unilateral severe swelling of the left scrotum and three out of 70 boars with bilateral severe swelling of the left and moderate swelling of the right scrotum, respectively. A complete history was obtained and an on-site evaluation of the facility was done. Five boars were necropsied, and a variety of samples harvested for further diagnostic investigations. Infectious differential diagnoses associated with unilateral swelling of the scrotum or the testis were excluded through serological and tissue testing. In three of the five boars, histopathology revealed complete acute haemorrhagic necrosis of the left testis concurrent with strongly congested blood vessels. Review of the collected information with a group of experts in the field of boar stud management resulted with consensus that, most likely, trauma was the etiologic event causing the clinical signs and pathology. Coincident with discussion of implementing video recording cameras in the boar housing area, no further clinical cases followed. As this case occurred during the first lockdown of the COVID-19 pandemic, we propose that the distress and travelling restrictions may have contributed to frustration among boar stud workers, which was consequently expressed as misbehaviour against boars.ConclusionsOnce all known infectious causes of unilateral swelling of the scrotum were excluded, a critical diagnostic work-up focused on non-infectious causes. Non-infectious causes, such as trauma, need to be carefully evaluated, as it may also include human misbehaviour against boars. Summarizing all findings of this case report, the authors hypothesize that a blunt trauma was the reason for the series of mainly unilateral swelling of the scrota of boars.

Oral surgery under general anesthesia in a patient with catecholaminergic polymorphic ventricular tachycardia: A case report

AbstractBackgroundCatecholaminergic polymorphic ventricular tachycardia (CPVT) is a fatal arrhythmic disease. Herein, we report a case of third molar extraction performed under general anesthesia to avoid ventricular tachycardia.Case PresentationA 28‐year‐old woman presented with constant pain and bilateral mandibular gingival swelling. The patient had a history of CPVT diagnosis at 5 years of age, which had been managed with beta‐blockers and sodium channel blockers. Due to the contraindication of using epinephrine and the risk of CPVT induction due to pain, the extraction was conducted under general anesthesia.ConclusionOral surgery in CPVT patients requires appropriate anesthetic agent selection.

Henoch-Schönlein purpura with antecedent allergic diseases in a 4-year-old child: a case report.

Here the authors present a 4-year-old girl with antecedent allergic history associated HSP. She presented with non-blanchable purpuric rashes, abdominal pain with bilateral ankle swelling. She had been treated for atopic dermatitis and acute urticaria without angioedema and acute tonsillitis. The potential association of HSP and these condition should be kept in mind in order not to miss the impediment complications of HSP. HSP usually presents with rash, abdominal pain and vomiting, joint pain especially involving knees and ankles, subcutaneous oedema but in severe cases there could be renal involvement leading to nephritis, neurological manifestation involving neuropathies, altered mental status and many others. This case highlights the rarity of disease, presentation, association with allergic diseases and availability of treatment modality.

Bilateral Infectious Extensor Tenosynovitis: A Case Report.

Infectious extensor tenosynovitis is a rare infection spreading along the extensor tendons of the extremities. It presents a diagnostic challenge in the emergency department (ED) given the nonspecific signs and symptoms, as opposed to the more common flexor tenosynovitis that is diagnosed by the classic Kanavel signs on physical exam. Here we present a case of bilateral extensor tenosynovitis in a 52-year-old female denying past medical history who presented to the ED with two days of bilateral dorsal hand swelling and pain. She denied any risk factors such as direct trauma to the hands or intravenous drug use. The rare diagnosis was suspected in the ED due to a very high complement reactive protein level and a concerning point-of-care ultrasound. Extensor tenosynovitis was ultimately confirmed on computed tomography and by operative irrigation and drainage of the tendon sheaths. This case demonstrates the importance of keeping extensor tenosynovitis on the differential when seeing a patient with dorsal extremity edema and pain, even if the findings occur bilaterally.

RED EARS, RED EYES AND HEARING LOSS: A DIAGNOSTIC DILEMMA

Relapsing polychondritis (RP) is a disease that confounds clinicians worldwide due to the difficulty in confirming its diagnosis and determining the best treatment plan. We report a case of a 34-year-old lady who presented with bilateral inflamed auricular swelling and red eyes, which turned out to be relapsing polychondritis. The patient was successfully treated with long-term oral steroids and is on regular follow-up. This report highlights how the subtle signs of her condition were picked up, leading to her diagnosis of RP and the treatment regime that successfully reversed her symptoms. The challenge of picking up subtle signs of the disease is best met by working as a team in a multidisciplinary setting. A literature study shows that RP is a rare disease that can present with many symptoms.