Man Presenting Research Articles

Opsoclonus-Myoclonus Syndrome and Acquired Von Willebrand Syndrome As Manifestations of Graft-Versus-Host Disease

Background: Opsoclonus-myoclonus syndrome (OMS), known as dancing eye syndrome, is a rare neurological disorder characterised by a triad of opsoclonus (rapid, involuntary eye movements), myoclonus (uncontrolled muscle twitches) and ataxia. The syndrome is usually seen in children, often associated with neuroblastoma, and is extremely rare in adults. The pathogenesis is thought to be immune in nature and aetiology is variable although most cases are associated with solid tumors or after an infection. Treatment involves a combination of managing the underlying condition and immunosuppression. Acquired von Willebrand disease is a rare acquired bleeding disorder with a range of different aetiologies including lymphoproliferative, myeloproliferative, cardiovascular and autoimmune disorders. The pathogenic mechanism, in most cases is due to increased plasma clearance of von Willebrand factor (vWF) caused by such mechanisms as antibodies, cell adsorption, shear stress or increased proteolysis. Therapeutic approaches focus on prevention of bleeding through supportive treatment, and management of the underlying cause. To the best of our knowledge, this is the first case of opsoclonus-myoclonus syndrome with concurrent acquired von Willebrand disease as manifestations of graft versus host disease. Case: Here we present the case of a 47-year-old man presenting with opsoclonus myoclonus syndrome and concurrent acquired von Willebrand disease as manifestations of graft versus host disease. The patient had a background of relapsed myeloid sarcoma after haploidentical allogeneic haematopoietic stem cell transplant with subsequent chemotherapy to achieve full remission. He received donor lymphocyte infusion as consolidation therapy to enhance the graft-versus leukaemia effect. Six weeks following donor T cell infusion of 1 x 10^6 CD3 cells/kg, he presented with initial features suggestive of graft versus host disease (GVHD) of the digestive tract and subsequently developed neurological manifestations in the form of rapid, repetitive, involuntary and multidirectional eye movements; tremors and ataxia. Further tests prior to planned invasive testing revealed an additional new diagnosis of acquired von Willebrand disease, requiring supportive von Willebrand factor concentrate infusion. Multiple extensive investigations including cerebral MRI imaging, cerebrospinal fluid analysis and paraneoplastic antibodies were all negative for associated malignancy, infection, other autoimmune disorder or disease relapse. Skin, bone marrow examination and cross-sectional imaging confirmed complete remission with complete donor chimerism in all blood cell lineages. The patient commenced steroid immunosuppression for treatment of gastrointestinal GVHD with complete resolution of all symptoms and clinical parameters. Conclusion: We highlight a rare case of central nervous system involvement with graft versus host disease following cellular therapy, manifesting as the rare opsoclonus-myoclonus syndrome with associated acquired von Willebrand disease. The proposed pathological mechanism is the activation of host tissue antigen-specific T and B cells, resulting in autoantibody and cytokine-mediated effects upon neuronal tissue and coagulation proteins. Use of glucocorticoids in this case to suppress auto-antibody formation, block transcription of pro-inflammatory genes and induce lymphocyte depletion was rapidly effective and provided durable remission of symptoms, without recurrence on cessation of immunosuppression. This case highlights the need for close clinical and biochemical monitoring of patients during the risk period following allogeneic cellular therapy, for serious allo-immune manifestations not fitting classical descriptions of GVHD.

Coexistence of Autoimmune Pulmonary Alveolar Proteinosis With Small Cell Lung Cancer in a Man Presenting With Acute Onset Respiratory Failure

Coexistence of Autoimmune Pulmonary Alveolar Proteinosis With Small Cell Lung Cancer in a Man Presenting With Acute Onset Respiratory Failure

Anti-Kv1.4 Antibody-positive Nivolumab-induced Myasthenia Gravis and Myositis Presenting with Bilateral Ptosis and Demonstrating Different Pathophysiologies.

Nivolumab blocks inhibitors of T-cell activation and restores antitumor immunity but promotes T-cell activity in host tissues by blocking inhibition of the T-cell function, resulting in immune-related adverse effects. We herein report an 80-year-old man presenting with nivolumab-related myasthenia gravis with anti-muscular voltage-gated potassium channel-complex (Kv1.4) antibodies. On day 29 after nivolumab administration, he simultaneously developed rapidly progressing right ptosis and left facial paralysis. Nivolumab administration was discontinued. He subsequently presented with bulbar paralysis, dyspnea, and muscle weakness and received intravenous immunoglobulin, methylprednisolone, and plasma exchange. The severity of nivolumab-related myasthenia gravis with anti-Kv1.4 antibodies presented with diverse clinical findings.

SAT060 Hyperosmolar Hyperglycemic State Presenting As Seizures

Abstract Disclosure: A. Faber: None. S. Levy: None. Introduction: Hyperosmolar hyperglycemic state (HHS), also known as hyperosmotic hyperglycemic nonketotic state (HHNK), is one of the most severe complications of diabetes mellitus. HHS is a medical emergency defined by high serum osmolality and hyperglycemia as well as the absence of ketoacidosis in most cases. We present an unusual case of a young man presenting with seizures who on further investigation was found to have HHS. Case Description: A 44-year-old man presented to the hospital for a possible seizure at home. His medical history is significant for EBV+ B-cell lymphoma receiving chemotherapy, HIV on HAART therapy, and prior history of cryptococcus meningitis in 2019. He did not have history of seizures or diabetes mellitus. He reported that five days prior to admission, he began experiencing polydipsia and polyuria, which later progressed to lethargy. The day of admission his mother found him on the floor with generalized body shaking with significant shaking of the right arm, urinary incontinence, and blood in his mouth from tongue biting. He was taken to the hospital due to concern for seizure. Workup revealed elevated blood glucose of 972 and elevated serum osmolality of 322. He did not present with overwhelming ketosis; his beta-hydroxybutyrate was 0.57, he did not have an anion gap, and ketones were not present in his urine. His A1c was elevated at 9.9%. The differential diagnosis for this patient’s seizure included chemotherapy side effect, intracranial pathology, infectious etiology in the setting of known HIV, or HHS. Hematology evaluated the chemotherapy regimen and stated it was not likely the cause of his seizures. Neurology assessed the patient with a CT head, MRI brain, EEG, and lumbar puncture, all of which were negative. The CSF from the lumbar puncture underwent intensive testing, which was negative for HSV, VDRL, CMV, EBV, VZV, Lyme disease, and JC virus. Neurology initially started the patient on anti-seizure medication, however later stated his seizure was likely provoked from hyperglycemia and discontinued the medication. Infectious workup included chest X-ray, blood cultures, and urinalysis, all of which were negative. Endocrinology was consulted and recommended initiating basal and bolus insulin as well as testing for GAD antibodies. Unfortunately, the patient left the hospital against medical advice and GAD antibody testing was not completed. Discussion: The most common symptoms of HSS include hyperglycemia, polyuria, and polydipsia. Though neurological symptoms can occur, they are not common. The neurologic symptoms are typically not seen until the serum osmolality reaches 320 - 330 mOs/kg, and this patient’s serum osmolality was elevated at 322 mOs/kg. Though seizure is not well understood in hyperglycemia, treatment for HHS-induced seizures focuses on aggressive management of the underlying hyperglycemic state. Presentation: Saturday, June 17, 2023

TCT-360 Complete Revascularization Strategies in Women and Men Presenting With Acute Coronary Syndrome and Multivessel Disease

TCT-360 Complete Revascularization Strategies in Women and Men Presenting With Acute Coronary Syndrome and Multivessel Disease

Multimodality Appearances of Marginal Zone Lymphoma Masquerading as Cryptogenic Organizing Pneumonia-serial Chest Radiograph and High-resolution Computed Tomography Appearances: (18F) Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography Staging Utility.

Marginal zone lymphoma (MZL) is a group of low-grade, indolent, non-Hodgkin lymphomas rarely manifesting in the lungs. A 46-year-old man presenting with shortness of breath and cough was investigated and treated over 10 months for an atypical pattern of lung disease in keeping with cryptogenic organizing pneumonia (COP). Initial lung biopsies were nondiagnostic - repeat sampling eventually showed MZL. Staging whole-body (18F) fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) demonstrated multisystem stage IV disease with intensely avid widespread pulmonary changes resembling COP. The case elegantly illustrates that pulmonary MZL can present insidiously masquerading as COP and shows the value of (18F) FDG PET/CT to stage extranodal MZL.

Disney boys to men: erotic gaze and masculine gender capital of former Disney boy actors

ABSTRACT This research examines the nature of gender presentation of men who were the stars on Disney Channel shows. Research has already examined how young women who were Disney stars become quickly sexualised and perceived as women under the male gaze. However, there is little corresponding research on boys who are subject to the scrutiny of the public. I engage in a phenomenological content analysis of the social media of three adult male actors who starred on the show Wizards of Waverly Place. The nature of masculine gender capital encourages these men to move towards a masculine ideal while recognising they are under the erotic gaze. These men push to be severed from their youth identities, forming a strategic boundary that nods to the homoeroticism surrounding their identity.

An 86-Year-Old Male with Metastasized Cancer Treated with External Beam Radiation Therapy: A Case Report from Zimbabwe

Prostate cancer is the most common malignancy diagnosed in men and the second most common cause of cancer deaths in men. Incidence increases drastically after the age of 50, however, it is more common in males above the age of 65. Prostatic cancer is asymptomatic in its early stages, i.e., when it is still localized, hence most patients present with late-stage cancers. Patients with late-stage prostate cancer usually present with urethral obstruction, nocturia, narrow stream, and they rarely present with pain or stiffness caused by bony metastases. The common treatment for late-stage prostate cancer is hormonal therapy. We herein present a case of an 86-year-old male who presented with metastasized prostate cancer. The cancer had metastasized to the head of the femur and there was bone fracture in the neck of the femur as well. The patient received external beam radiotherapy as palliative treatment due to the limited resources in Zimbabwe. The patient did not come for follow up review and hence it was not possible to conclude whether the external beam treatment was an effective palliative treatment. The learning points in this case are as follows: stage at presentation of man with cancer of the prostate in comparison with what literature say, management done in comparison to the recommended management guidelines, follow up strategies to minimize patients absconding follow up reviews and how loss of follow up to patients treated affect future evidence-based management of patients.

Collecting duct carcinoma with retroperitoneal mass as initial presentation: a rare case report

BackgroundCollecting duct carcinoma (CDC) is a rare renal tumor, originating from the distal collecting duct. CDC rarely presents as a primary tumor outside the renal system.Case presentationIn this study, we report a rare case of collecting duct carcinoma, with an initial presentation of retroperitoneal lymph node metastasis, and no identifiable primary renal tumor on CT, at the time of diagnosis. The patient was a 64-year-old man presenting with lower back pain. Preoperative CT showed a round, soft tissue mass, measuring 6.7 × 4.4 × 3.3 cm, in the left retroperitoneum with no exact occupying lesion in the left kidney. Clinically, ectopic pheochromocytoma was considered to be a differential diagnosis, and tumor resection was performed. Postoperative pathological results demonstrated that the mass was a fused lymph node, and the tumor cells were destroying the structure. The final diagnosis was lymph node metastatic collecting duct carcinoma, by histology and immunohistochemistry. No further treatment was performed as no space occupying lesion was found in the kidney. Three months later, CT was reexamined, and a mass of 3.6 cm in diameter, was found in the lower left kidney, along with multiple soft tissue masses, in the left renal hilum. Considering recurrence or metastasis, the patient was recommended to undergo surgical treatment, but the patient refused. Four months later, CT was re-examined. The tumor had rapidly progressed but the patient refused treatment again. As per the author’s press release (eleven months after the first discovery), the patient is still alive.ConclusionCDC is a rare malignant renal carcinoma, with a high chance of rapid progress, regional lymph nodes involvement and metastasis. It presents diagnostic challenges to clinicians and pathologists, particularly, in the absence of radiographically detectable intrarenal lesions. Definite diagnosis is based on pathological examination combined with immunohistochemical staining.

Osteopoikilosis: a case report

BackgroundOsteopoikilosis, also referred to as disseminated condensing osteopathy, spotted bone disease, or osteopecilia, is a rare bone disorder. The case presented here showcases multiple disc lesions in the spine, extensive multifocal skin lesions, and positive test results for dermatomyositis and multifocal enthesopathy, accompanied by neurological symptoms. This manifestation represents a novel variant of the disease.Case presentationOur patient is a 46-year-old mosque Kurdish servant presenting with complaints of pain in the right leg, lower back, right hand, and neck. Additionally, the patient has been experiencing redness in the right buttock and ipsilateral thigh, as well as gradually expanding and stiffening skin lesions on the left shin for the past 3 weeks. Painful neck movements and a positive Lasegue test were also observed in the right leg. The patient reports pain in the right buttock accompanied by a substantial erythematous area with induration measuring 8 × 15 cm, as well as an erythematous and maculopapular lesion measuring 6 × 18 cm on the left shin.ConclusionsOur patient is a 46-year-old man presenting with complaints of skin lesions and pain in the lower back, pelvis, neck, and limbs. The X-ray reveals shoulder, pelvis, knee, and ankle involvement, while spinal involvement is observed in the neck and lumbar region. Furthermore, the bone scan indicates extensive enthesopathy in various regions, a unique manifestation not previously reported in similar cases.

Elective Endovascular Aneurysm Repair (EVAR) for the Treatment of Infrarenal Abdominal Aortic Aneurysms of 5.0–5.5 cm: Differences between Men and Women

Background: There is significant debate regarding the existence of sex-related differences in the presentation, treatment, and outcomes of men versus women affected by abdominal aortic aneurysm (AAA). The purpose of this study is to compare endovascular aneurysm repair (EVAR) of infrarenal AAAs with the current sex-neutral 5.0–5.5 cm-diameter threshold for intervention between the two sexes. Methods: Retrospective review of consecutive cases from a single teaching institution over a period of five years of patients who had undergone elective EVAR for AAAs between 5.0 and 5.5 cm in diameter. Outcomes of interest were compared according to sex. Results: Ninety-four patients were included in the analysis, with a higher prevalence of men (53%). Females were older at the time of repair, 78 ± 5.1 years, versus 71.7 ± 7 years (p < 0.01), and had higher incidence of underlying comorbidities, namely, arrhythmia, chronic kidney disease, and previous carotid revascularization. Women had higher incidence of immediate systemic complications (p = 0.021), post-operative AMI (p = 0.001), arrhythmia (p = 0.006), pulmonary oedema (p < 0.001), and persistent renal dysfunction (p = 0.029). Multivariate analysis for post-operative factors associated to mortality and adjusted for sex confirmed that AMI (p = 0.015), arrhythmia (p = 0.049), pulmonary oedema (p = 0.015), persistent renal dysfunction (p < 0.001), cerebral ischemia (p < 0.001), arterial embolism of lower limbs (p < 0.001), and deep-vein thrombosis of lower limbs (p < 0.001) were associated to higher EVAR-related mortality; a higher incidence of post-operative AMI (p = 0.014), pulmonary edema (p = 0.034), and arterial embolism of lower limbs (p = 0.046) were associated to higher 30-days mortality. In females there was also a higher rate of suprarenal fixation (p = 0.026), insertion outside the instruction for use (p = 0.035), and a more hostile neck anatomy with different proximal aortic diameter (p < 0.001) and angle (p = 0.003). Conclusions: A similar threshold of size of AAA for elective surgery for both males and females might not be appropriate for surgical intervention, as females tend to have worse outcomes. Further population-based studies are needed to guide on sex-related differences and intervention on AAA.

An elderly man presenting with symptoms suggestive of Dhat syndrome

Dhat syndrome is a culture-bound syndrome that has been reported among males in South Asian countries who are generally young, single or recently married, and this condition is known to be associated with prominent anxiety and depressive symptoms. We present an older male who presented with symptoms suggestive of Dhat syndrome with associated significant depressive symptomatology.

BI24 Cutaneous pseudolymphoma secondary to pembrolizumab

Abstract A 35-year-old man presented with a 7-week history of itchy, nontender, indurated erythematous plaques and nodules on his forehead and upper back, with no discriminatory clinical features. He was systemically well. Three months previously, he had completed a 12-month course of adjuvant pembrolizumab for stage IIIC melanoma. The primary melanoma had been excised from his left cheek, with involvement of left parotid and supraclavicular lymph nodes, treated with clearance via superficial parotidectomy and left neck dissection. Clinical and imaging surveillance revealed no evidence of melanoma recurrence. Incisional biopsies of the lesions on his back and forehead both demonstrated a superficial and deep dermal perivascular and periadnexal infiltrate of small- and medium-sized lymphoid cells. There was no epidermotropism and B- and T-cell clonality studies were negative. Morphological appearance and immunophenotype favoured a CD4+-reactive lymphoid process in keeping with cutaneous pseudolymphoma (CPL), secondary to pembrolizumab. The conspicuous forehead lesion was unresponsive to clobetasol propionate under occlusion. A single course of intralesional triamcinolone acetonide 10 mg mL–1 resulted in significant improvement within days, with subsequent complete resolution. The lesion on the back resolved spontaneously. Drug-induced CPL describes an adverse cutaneous drug reaction mimicking B- or T-cell lymphomas clinically and/or histologically. It has been described with anticonvulsants, antidepressants and biologic agents, often with resolution on cessation of the responsible drug (Etesami I, Kalantari Y, Tavakolpour S et al. Drug-induced cutaneous pseudolymphoma: a systematic review of the literature. Australas J Dermatol 2023; 64:41–9). It has been proposed that the drugs affect immune surveillance, leading to an abnormal cutaneous lymphocyte response. A case report (Ayoubi N, Haque A, Vera N et al. Ipilimumab/nivolumab-induced pseudolymphoma in a patient with malignant melanoma. J Cutan Pathol 2020; 47:390–3) has described drug-induced CPL secondary to ipilimumab and nivolumab in a 38-year-old man presenting with erythematous plaques on the hands and face, similar to the presentation of our patient, which responded to prednisolone. As with the other adverse effects of immunotherapy, it is likely that CPL in this cohort is due to an iatrogenic immune dysregulation leading to T-cell overactivity. We present the first reported case of CPL secondary to pembrolizumab and highlight the successful use of intralesional steroid as a treatment option. It is important to recognize CPL as an adverse cutaneous effect of immunotherapy and be aware that it can present after completing treatment due to an ongoing immune response.

Case Report: Concomitant presence of two STIs in a male patient

Background: The spirochaete Treponema pallidum subsp. pallidum, which causes the infectious disease syphilis, can be spread through sexual contact or perinatal transmission. In recent years, cases of syphilis have increased, especially among individuals engaging in behaviour that makes them more vulnerable (condomless sex and multiple sexual partners) and in men who have sex with men. Condylomata acuminata (external genital warts) is one of the most common viral sexually transmitted infections (STIs). Individuals who are behaviourally vulnerable are also highly prone to be exposed to one or more STIs. Our case exemplifies the occurrence of two STIs in a young man who was behaviourally vulnerable to acquiring STIs. Case: We report a case of a 21-year-old year old heterosexual man presenting with concomitant primary syphilis and genital warts. He presented with a painless genital ulcer and warty growths on his glans penis. Examination showed a painless indurated ulcer and multiple genital warts. Serology was positive for quantitative serological disease research laboratory test (1:16 titre). The patient was diagnosed with two concomitant STIs. He was treated as per the latest Centers for Disease Control and Prevention (CDC) guidelines for primary syphilis and podophyllin resin for genital warts. After four weeks, the genital ulcer showed complete healing and there was a significant reduction of genital warts. Conclusions: Individuals with multiple sexual partners engaging in sexual activity without the use of prevention tools are at a greater chance of acquiring two or more STIs. To reduce concomitant transmission, preventive measures against genital ulcer diseases caused by human papilloma virus, syphilis, herpes, and chancroid, such as early identification and treatment, and condom distribution, must be strengthened as part of national STI prevention. Patients with two or more STIs should be followed regularly to assess the progress of infection and should be offered timely medical treatment.

Diffuse, Adult-Onset Nesidioblastosis/Non-Insulinoma Pancreatogenous Hypoglycemia Syndrome (NIPHS): Review of the Literature of a Rare Cause of Hyperinsulinemic Hypoglycemia.

Differential diagnosis of hypoglycemia in the non-diabetic adult patient is complex and comprises various diseases, including endogenous hyperinsulinism caused by functional β-cell disorders. The latter is also designated as nesidioblastosis or non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS). Clinically, this rare disease presents with unspecific adrenergic and neuroglycopenic symptoms and is, therefore, often overlooked. A combination of careful clinical assessment, oral glucose tolerance testing, 72 h fasting, sectional and functional imaging, and invasive insulin measurements can lead to the correct diagnosis. Due to a lack of a pathophysiological understanding of the condition, conservative treatment options are limited and mostly ineffective. Therefore, nearly all patients currently undergo surgical resection of parts or the entire pancreas. Consequently, apart from faster diagnosis, more elaborate and less invasive treatment options are needed to relieve the patients from the dangerous and devastating symptoms. Based on a case of a 23-year-old man presenting with this disease in our department, we performed an extensive review of the medical literature dealing with this condition and herein presented a comprehensive discussion of this interesting disease, including all aspects from epidemiology to therapy.

Systemic Capillary Leak Syndrome With Cerebral Involvement in a C9orf72 Expansion Carrier: Case Report and Review of the Literature.

Systemic capillary leak syndrome (SCLS) is a rare condition associated with episodes of hypotension, hemoconcentration, hypoalbuminemia, and rhabdomyolysis. We describe a middle-aged man presenting with several distinct SCLS-like episodes, the last being fatal. In addition, in the year before the final event, he developed rapid cognitive decline with contrast-enhancing lesions on MRI and highly elevated neurofilament light protein levels in CSF. Data and imaging were obtained from patient medical records. At the time, the SCLS-like episodes were interpreted as myositis secondary to viral infection. A thorough workup for other causes, including genetic testing, was negative. As for the rapid cognitive decline, despite an extensive workup for infectious and inflammatory causes, no definitive diagnosis was made. Whole genome sequencing however identified a C9orf72 hexanucleotide expansion. The C9orf72 expansion is associated with frontotemporal dementia and amyotrophic lateral sclerosis but has also been shown to increase susceptibility to neuroinflammation. Recent findings also suggest C9orf72 to exert functions in the immune system, in particular regulation of type I interferon responses, in turn shown to be associated with SCLS. This case suggests a possible link between SCLS, cerebral inflammation, dysregulated type I interferon signaling, and expansions in C9orf72.

Avelumab in metastatic collecting duct carcinoma of the kidney: a case report

BackgroundCollecting duct carcinoma (CDC) of the kidney is associated with an aggressive course, limited response to treatment, and poor prognosis. Platinum-based chemotherapy is currently recommended as the first-line treatment in patients with metastatic CDC. Accumulating evidence supports the use of immunotherapy with checkpoint inhibitors as second-line therapy.Case presentationIn this case report, we describe the first case of avelumab administration due to disease progression during chemotherapy with gemcitabine and cisplatin in a Caucasian, 71-year-old man presenting with multiple metastases due to CDC of the kidney. The patient initially responded well to four cycles of chemotherapy and his performance status improved. After two additional chemotherapy cycles, the patient presented with new bone and liver metastases (mixed response to chemotherapy with an overall 6-month progression-free survival). We offered him avelumab as a second-line treatment in this setting. The patient received a total of three cycles of avelumab. The disease remained stable (no new metastases during treatment with avelumab), and the patient developed no complications. To alleviate his symptoms, radiation therapy for the bone metastases was decided. Despite successful radiation of the bone lesions and further improvement of symptoms, the patient developed hospital-acquired pneumonia and died approximately ten months after the initial diagnosis of CDC.ConclusionsOur findings suggest that the applied treatment modality with gemcitabine and cisplatin chemotherapy followed by avelumab was effective in terms of both progression-free survival and quality of life. Still, further studies assessing the use of avelumab in this setting are mandatory.

A Rare Case of Complete Sequestration of the Patella: an Unusual Presentation of Patellar Tuberculosis

Abstract Osteoarticular tuberculosis affecting the knee with isolated involvement of the patella is rare, accounting for less than 0.09% to 0.15% of cases. We present a case of 48-year-old man presenting with chronic knee swelling, pain, and stiffness. Radiographs revealed a completely sclerotic patella with erosions and irregular margins. Magnetic resonance imaging revealed chronic synovitis, joint effusion, and bony erosions with full-thickness cartilage defects in the patella. He underwent surgical debridement with extensive synovectomy, and a total patellectomy was performed. Intraoperative samples conclusively diagnosed it as a tubercular infection of the patella and synovium. The patient was started on antitubercular chemotherapy. A 2-year follow-up revealed good knee function with an extensor lag of 100. There has been no recurrence of infection. This report is a rare case of complete patellar sequestration secondary to tuberculosis patella, which was successfully treated with radical debridement and patellectomy.

Bywaters Lesions: A Rare Cutaneous Vasculitis in Rheumatoid Arthritis.

Bywaters' lesion is a cutaneous vasculitis seen in rheumatoid arthritis.1 A 70-year-old man presenting with polyarthritis and finger papules visited our hospital.

ABDOMINAL TUBERCULOSIS PRESENTING AS INTUSSUSCEPTION

Intestinal obstruction is a rare adult entity that behaves differently from its paediatric counterpart because of underlying pathological landmarks, most commonly neoplasms. The main clinical manifestation of chronic intussusception in adults remains dull abdominal pain. Computed tomography remains the diagnostic method of choice and surgical resection is the treatment of choice. Here is one such case of chronic intussusception of a 59 year old man presenting with abdominal distension and vomiting for 20 days. Evaluation revealed an intestinal obstruction and the patient was admitted for an emergency laparotomy. Intra-operatively ileo-ileal intussusception was noted with lymph node as the lead point. Since the intestine was gangrenous and the haemodynamics of the patient was unstable during the operation, and there was a strong suspicion of abdominal tuberculosis, so the small bowel was resected and a stoma was created. Postoperatively the patient were started on anti tuberculous drugs based on histopathological reports. Only about 5% of all cases of intussusception are believed to occur in adults. Adults often present with a vague history of symptoms such as diarrhoea, constipation, and weight loss, in contrast to typical childhood symptoms such as acute onset, episodic abdominal pain, currant-jelly stools, and vomiting. In one study, 30% of his adults had intussusception. The most common benign cause of intussusception was postoperative adhesions. Limited resection with intestinal anastomosis was often performed in benign intussusception. Abdominal tuberculosis as a cause of ileo-ileal intussusception is poorly described in the scientic literature