To evaluate the association between fragility fracture and interruption of bisphosphonate prescription after three and five years of initial prescription, and to explore the incidence of atypical femoral fracture and osteonecrosis of jaw after three and five years of continued prescription of bisphosphonates. Nested case-control and cohort studies. Clinical Practice Research Datalink Aurum, an anonymised longitudinal database of NHS primary care electronic health records, linked to hospital admission and mortality records from Hospital Episode Statistics and Office for National Statistics databases, respectively, 1 January 1997 to 31 December 2022. Adults aged ≥18 years on the date of the first prescription of alendronate or risedronate, and with primary care data linked to Hospital Episode Statistics and Office for National Statistics databases. Participants with a medication possession ratio of ≥67% in each of the first three and five years were followed up from the three or five year time points to the earliest of fragility fracture, death, end of study, two years, or last data availability. Cases were those who had a fragility fracture and were matched with up to four control participants. Incidence of fragility fracture, atypical femoral fracture, and osteonecrosis of jaw were main outcomes. Data for 26 809 and 13 408 participants prescribed bisphosphonates for three and five years, respectively, were included. Fragility fracture was not associated with interruption of bisphosphonate prescription or intermittent prescription compared with continuous prescription in those previously prescribed bisphosphonates for three years (adjusted odds ratio 1.02, 95% confidence interval (CI) 0.85 to 1.24 and 1.13, 0.93 to 1.38, respectively) or five years (adjusted odds ratio 0.92, 0.75 to 1.13 and 0.87, 0.67 to 1.13, respectively). Time since last prescription was not associated with fragility fracture. After three and five years of bisphosphonate prescription, the incidence of atypical femoral fractures was 1.93 (95% CI 1.55 to 2.41) and 2.50 (1.92 to 3.26) per 1000 person years, respectively, and the incidence of osteonecrosis of jaw was 0.07 (0.02 to 0.21) and 0.00 per 1000 person years, respectively, within two years. Fragility fracture was not associated with interruption of bisphosphonate prescription for up to two years, after either three or five years of prescription. The incidence of atypical femoral fracture or osteonecrosis of jaw was uncommon and rare respectively.
We report a case of granulomatous prostatitis in a young male confirmed on histopathological examination. The case was initially presumed to be a case of prostate adenocarcinoma based on clinical, biochemical and imaging findings. To our knowledge, this is the second such reported case where there is a possible association between psoriasis and the subsequent development of granulomatous prostatitis and the only reported case of a patient on guselkumab immunotherapy.
Colorectal cancer (CRC) recurrence found in the abdominal wall is a rare but devastating event following colorectal adenocarcinoma resection. Desmoid tumours (DTs) are benign, locally invasive tumours which can present clinically and radiologically similar to CRC recurrence in the abdominal wall. Although they have a superior prognosis, they have the potential for significant morbidity. This poses both a diagnostic and treatment dilemma requiring thorough investigation through imaging, histology and multidisciplinary discussion to optimise patient outcomes. We report two cases which involve the identification of abdominal wall masses highly suspicious for recurrence during routine surveillance in the period post-CRC resection. In the first case, the mass was excised, but surveillance was deemed appropriate in the second case following core biopsy. Histology confirmed DTs in both cases. Differentiating between abdominal wall recurrence and DTs represents a significant diagnostic challenge and a dilemma in regard to the decision to resect or not.
Cutaneous tuberculosis (TB) is a chronic granulomatous infection, constituting 1.5-3% of extrapulmonary cases. Disease manifestation is a result of the intricate interplay between host immunity, bacterial virulence and route of inoculation. Orificial TB, a relatively rare manifestation of cutaneous TB, accounts for 2.7% of the cases. We report a case of orificial TB of the perianal region in a man with underlying pulmonary miliary TB. This case highlights the importance of holistic evaluation, strong clinical suspicion and timely investigations, which can lead to swift resolution of lesions.
Donor-funded health programmes strengthen national quality systems in low-income and middle-income countries, but abrupt withdrawal of external support can create institutional gaps and threaten service sustainability. To analyse the impact of sudden donor funding cessation, using the experience of the Health Care Accreditation Council (HCAC) as an illustrative case, and to explore implications for quality infrastructure and health system resilience. This structured case-based policy analysis draws on institutional documentation, administrative records and publicly available reports to examine the effects of funding withdrawal on quality programmes and organisational capacity. Funding cessation led to contraction of technical workforce capacity, scaling back of quality improvement and professional development activities, and disruption of accreditation-related support. The case exposed vulnerabilities associated with donor dependency and insufficient transition planning. Abrupt donor withdrawal can weaken quality systems and patient safety gains. Strengthening resilience requires diversified financing, structured transition frameworks and institutional strategies that embed quality governance within nationally owned systems.
Mumps encephalitis became a rare complication of mumps virus infection after the vaccination era. However, in immunosuppressed individuals and those with incomplete vaccination history, the virus remains an important differential in cases of infective encephalitis. We present the case of an adult male with Crohn's disease on immunosuppression who developed acute encephalopathy with seizure, abnormal neuroimaging findings, with no initial signs of parotitis. The diagnosis of mumps meningoencephalitis was delayed by subtle, emerging clinical manifestations and incomplete vaccination history. This case provides learning opportunities relating to the clinical timeline of mumps encephalitis, the value of subtle changes in the diagnostic imaging, and important considerations relating to mumps serological investigation.
Glomangiopericytomas (GPCs) are rare spindle cell neoplasms that usually develop in the sinonasal tract and possess a low malignant potential. Although rare, most cases have been found in various areas of otolaryngological importance, notably the deep neck spaces, eyes, larynx, tongue and middle ear. However, no cases of recurrence of infraorbital GPC have been reported in the literature. Total surgical resection is the treatment of choice. Nonetheless this condition recurs in cases of incomplete excision. Because of the rarity of the disease and its prevalence, early detection and care are critical, especially in atypical presentations that necessitate a high level of clinical suspicion. Here we present our first case of recurrence of infraorbital GPC, highlighting management protocols and challenges.
Tuberous sclerosis complex (TSC) is a rare neurocutaneous disorder presenting with growth of hamartomas in various parts of the body. There have been few reported cases of TSC coexisting with hypercoagulable states from protein C and S deficiency and systemic lupus erythematosus, but to the best of our knowledge, this is the first documented case of TSC occurring with primary antiphospholipid syndrome. We report the case of an adolescent female with ash-leaf spots, shagreen patches, cortical tubers and seizures presenting with acute unilateral vision loss from ophthalmic artery thrombosis. Work-up was positive for lupus anticoagulant, and genetic testing confirmed a mutation in the TSC1 gene. She was maintained on aspirin, warfarin and anti-seizure medications. Experimental models suggest possible pathways linking TSC1 deficiency with thrombosis, although this association remains unclear in humans. Podoplanin has been implicated as a candidate gene in both TSC-related epilepsy and thrombosis, potentially linking these two conditions.
Renal malignancy in ectopic fused pelvic kidneys is exceptionally rare, with only a small number of cases described globally. We report a man in his early 50s with bilateral fused pelvic kidneys containing a large renal cell carcinoma extending across both renal moieties. Preoperative CT angiography demonstrated complex aberrant vasculature originating from the aortic bifurcation. Following selective arterial embolisation of the tumour-feeding vessels, the patient underwent radical nephrectomy of the left renal moiety and nephron-sparing partial nephrectomy of the right kidney.Despite the extensive tumour burden and challenging congenital anatomy, renal preservation was successfully achieved. Renal function stabilised during follow-up, with serum creatinine and potassium levels remaining within acceptable limits at 1 year, thereby avoiding the need for dialysis. To our knowledge, this represents one of the extremely few reported cases in which bilateral fused pelvic kidneys with tumour involvement in both components were managed using a combined radical and renal-preserving surgical approach. This case highlights the crucial importance of detailed vascular imaging, multidisciplinary planning and tailored operative strategies in treating malignancy associated with rare congenital renal anomalies.
Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) may cause stress-induced transient acute cardiac dysfunction through myocardial stunning, in the form of exacerbation-triggered Takotsubo syndrome (referred to as Takotsubo stunning). Although prior studies suggest an association between AECOPD and transient cardiac dysfunction, existing evidence is limited to retrospective cohorts, case reports and expert consensus. Therefore, the incidence and clinical impact of Takotsubo stunning with acute heart failure (AHF) during AECOPD remain unknown and may be overlooked due to overlapping clinical symptoms. Cardiac Assessment and Takotsubo-stunning among COPD-exacerbations in-Hospital (CATCH study) aims to determine the incidence of Takotsubo stunning during AECOPD and to evaluate its clinical implication. CATCH is a prospective observational cohort study enrolling adults (≥18 years) admitted for AECOPD at Sahlgrenska University Hospital (Gothenburg, Sweden). Participants with chronic left ventricular systolic dysfunction (left ventricular ejection fraction <50%), pre-existing chronic regional wall motion abnormalities (RWMA) or prior type 1 myocardial infarction are excluded. Following informed consent, participants undergo echocardiographic screening for RWMA and/or systolic left ventricular dysfunction. Screening-positive patients have follow-up echocardiography at 24 hours (±6) and 30 days (±48 hours). Those with reversible dysfunction constitute the CATCH case group, while screening-negative participants serve as controls. Additional assessments include ECG, chest X-ray, N-terminal pro-B-type natriuretic peptide blood analysis and COPD severity. Primary outcomes include the incidence of reversible RWMA or left ventricular dysfunction (proxy for Takotsubo stunning) and in-hospital clinical signs of AHF (Killip class >1). A sample size of 150 patients is required for detecting AHF differences (α=0.05, 80% power). The study received ethical approval from the Swedish Ethical Review Authority. All participants provided written informed consent. Results will be disseminated through peer-reviewed journals and scientific meetings. The CATCH study is registered at ClinicalTrials.gov (NCT06597331). The reference number for ethical approval is 2024-02071-01 (with addenda 2024-05448-02 and 2025-05861-02).
Iliac artery occlusion in patients with complex anatomical variations, such as a horseshoe kidney and severe aortic calcification, presents unique challenges to standard revascularisation techniques. In such scenarios, conventional aortobifemoral bypass may carry significant risks due to difficult aortic access and the potential for renal injury. This case describes a man in his early 50s with right common iliac artery occlusion, anterior aortic calcification and a horseshoe kidney, where an extra-anatomic left common iliac to right superficial femoral artery bypass using a polytetrafluoroethylene graft was performed. The approach successfully restored limb perfusion while avoiding high-risk aortic manipulation. Postoperative recovery was uneventful, with improved symptoms and maintained graft patency. This case underscores the importance of individualised surgical planning and highlights extra-anatomic bypass as a safe and effective alternative in anatomically complex patients.
Arthroscopic shoulder surgery is generally associated with a low complication rate. While complications such as neurological injury, stiffness and iatrogenic damage are relatively well recognised, the occurrence of deep vein thrombosis (DVT), particularly of the upper extremity deep vein thrombosis (UEDVT), is exceedingly rare. We report two unusual postoperative cases of UEDVT following arthroscopic rotator cuff repair in two elderly sisters. No additional predisposing factors were identified beyond the perioperative setting; thrombophilia screening was negative. These cases underscore the importance of maintaining a high index of suspicion for thromboembolic events even in low-risk patients and in procedures not typically associated with DVT.
We report a case of a patient in her 50s who first presented with cervical lymphadenopathy and later developed a slowly progressing facial lesion. After an initial lymph node biopsy, a diagnosis of cutaneous sarcoidosis was made and she was treated with immunosuppressive therapy. As the facial lesion continued to progress, a skin biopsy was performed which identified Mycobacterium gordonae In retrospect, this organism had been grown on liquid culture from the first lymph node biopsy but was dismissed as a contaminant. 15 years after the first onset of symptoms, she was commenced on multidrug antibiotic therapy, resulting in a marked improvement. This case underscores the need to interpret isolation of non-tuberculous mycobacteria in the context of clinical findings and to reconsider established diagnoses when the condition of the patient worsens.
Uterine mesenchymal malignancies typically include leiomyosarcoma, carcinosarcoma and endometrial stromal sarcoma, while uterine angiosarcoma is exceptionally rare, with only a few dozen cases reported worldwide. We describe a case of high-grade epithelioid uterine angiosarcoma in a woman in her early 50s, diagnosed via outpatient endometrial pipelle biopsy. MRI and CT demonstrated endometrial and bilateral ovarian masses with multiple cavitating lung nodules, consistent with metastatic disease, stage four B according to the International Federation of Gynaecology and Obstetrics classification (FIGO stage IVB). During oral progesterone therapy for abnormal uterine bleeding, lung metastases initially regressed before subsequently progressing. The patient underwent total abdominal hysterectomy, bilateral removal of fallopian tubes and ovaries and omental biopsy. Histopathology confirmed high-grade epithelioid angiosarcoma with bilateral serous borderline ovarian tumours. Despite surgical management, she experienced rapid disease progression and died 5 months after surgery.
Small bowel metastasis from colorectal cancer (CRC) is rare and difficult to diagnose, especially in patients with inflammatory bowel disease (IBD). We report two cases with two different presentations. The first, a male in his 80s known to have ulcerative colitis in remission, presented with an elevated CA 19-9 tumour marker one year after laparoscopic anterior resection for CRC. Positron emission tomography and subsequent enteroscopy revealed a duo-jejunal lesion, histologically confirmed as consistent with metastatic CRC. The second patient, a man in his 60s with stricturing Crohn's disease, presented acutely with small bowel obstruction eight months after hemicolectomy for stage IIIc CRC. Imaging and enteroscopy identified a jejunal mass, also confirmed as consistent with metastatic CRC. Both patients underwent resection but later developed peritoneal spread, with both undergoing palliative chemotherapy and immunotherapy. These cases highlight the need to consider small bowel metastasis in IBD patients with previous CRC.
Head and neck carcinoma is the sixth most common cancer worldwide and accounts for approximately 4% of all cancer cases, with incidence varying by subtype and anatomical location . Salivary gland tumours in childhood are rare, with an annual incidence of less than 1 per million, representing fewer than 10% of paediatric head and neck cancers. Although the annual incidence of paediatric salivary gland malignancies is less than 1 per million, a salivary gland neoplasm presenting in a child carries a 50-60% probability of malignancy, with sialoblastoma accounting for approximately 4% of all salivary gland tumours.We report the case of a term newborn who presented with a firm left infra-auricular swelling at birth. Initial ultrasound imaging revealed a well-defined, round lesion with homogeneous internal echogenicity and acoustic enhancement. Subsequent MRI of the neck demonstrated a well-circumscribed, solitary lesion within the left parotid gland. Histopathological examination revealed features consistent with a primary malignant salivary gland tumour, with morphology and immunophenotype suggestive of sialoblastoma. The newborn was treated with complete surgical excision and remained disease-free at 3 months post surgery.
A previously healthy male in his late 40s presented with progressively worsening neurological symptoms-tetraparesis, visual disturbances, aphasia and dysphagia. Brain MRI revealed multiple large contrast-enhancing lesions with mass effect. After extensive investigation, a demyelinating central nervous system (CNS) disease was suspected; however, a differential diagnosis with primary CNS vasculitis was also considered. Despite treatment with high-dose corticosteroids, plasma exchange and immunoglobulins, the patient's neurological condition continued to deteriorate. A brain biopsy confirmed an active demyelinating process. A diagnosis of aggressive multiple sclerosis was established. Immunotherapy with ocrelizumab resulted in clinical stabilisation. This case highlights the diagnostic challenges of atypical demyelinating presentations and the critical role of brain biopsy in guiding early treatment in fulminant cases.
Folliculosebaceous cystic hamartoma (FSCH) is a rare cutaneous hamartoma, composed of follicular, sebaceous and mesenchymal elements, that usually presents as a small papule or nodule on the central face. We report the case of a man in his early 30s with a 10-year history of a large, reddish to violaceous scalp mass measuring 4.5 cm in greatest dimension. The initial clinical impression was a cylindroma. Histological examination revealed a dermal lesion with multiple sebaceous lobules clustered around a central infundibular structure within a fibrovascular stroma separated by cleft-like spaces. This case highlights an unusual clinical presentation and the importance of considering FSCH in the differential diagnosis of scalp masses.
The increased use of imaging has led to more frequent detection of small renal masses (SRMs), often prompting percutaneous renal mass biopsy (RMB) to guide management. While generally safe, RMB carries rare risks, including tumour seeding. We present a case of a 29 mm papillary renal cell carcinoma in a man in his 50s, where tumour seeding into the perinephric fat was identified along the biopsy tract following partial nephrectomy. This was associated with pathological upstaging and contributed to a decision for more intensive postoperative surveillance at the discretion of the multidisciplinary meeting. The case underscores the importance of careful patient selection for RMB, particularly in surgically amenable SRMs, where the risk of tumour seeding should be carefully considered.
Patients with spina bifida (SB) undergoing neuraxial anaesthesia have increased risk of further neurologic injury due to altered spinal anatomy. Meanwhile, scoliosis is associated with concomitant restrictive lung diseases. While research has been focused on managing secondary comorbidities related to SB, limited attention has been given to perioperative anaesthetic care of its increasing adult population. This case presents a woman in her 30s with repaired SB, scoliosis and predicted difficult airway. She was diagnosed with oxygen-requiring pneumonia and bilateral popliteal ulcers for elective debridement. Ultrasound-assisted neuraxial technique was performed to administer isobaric bupivacaine into the L4-L5 intrathecal space. This report highlights the efficient use of ultrasound as an alternative to traditional landmark-based technique in cases of severe scoliosis and SB. A patient-centred anaesthetic plan-emphasising preoperative optimisation, haemodynamic and respiratory stability, immobility and postoperative pain control-is critical for optimal perioperative outcomes in this complex population.