DESCRIPTIONA 35-year-old woman, apparently normal, who had participated in traditional Devithullal (a religious dance form involving violent head banging for hours at a time) on the evening of the following day developed vomiting, urinary incontinence, altered sensorium and quadriplegia. All blood investigations including thrombophilia workup were normal. CT scanning of the brain was normal. MRI diffusion-weighted image showed the characteristic bilateral ventral pontine hyper intensities ( figure 1A) and the apparent diffusion coeffient (ADC) map images showed bilateral ventral pontine hypointensities diagnostic of acute infarction (figure 1B). MR angiogram revealed basilar artery thrombosis ( figure 2A,B).'Head banging' denotes vigorous, rhythmical, rapid flexion and extension of the neck in time to music.1 It can cause vertebrobasilar ischaemia because the vertebral arteries are fixed in the

IntroductionAcute pulmonary embolism has varied presentations ranging from asymptomatic, incidentally discovered emboli to massive embolism, causing immediate death. Tumor embolism is a rare but unique complication of malignancies. This uncommon catastrophe of a malignant tumor in a young patient, culminating as a pulmonary embolism, is being reported for the first time.Case presentationA 19-year-old Asian man presented to the emergency service at our hospital with acute onset dyspnea. His clinical examination led to the suspicion of an acute pulmonary embolism with a lower lumbosacral radiculopathy. A magnetic resonance imaging scan of the pelvis demonstrated a chondrosarcoma arising from the right iliac wing, eroding into the common iliac vein and creeping up the inferior vena cava to lodge in the pulmonary artery, thus producing a saddle embolus.ConclusionThe importance of exploring for malignancies in the event of an idiopathic pulmonary embolism is highlighted. Early detection of such malignancies can substantially affect the outcome in young patients.

SUMMARYA 14-year-old girl was referred for evaluation of headache with episodes of transient blurring of vision, and intermittent fever for 4 weeks. On examination she was conscious and febrile, with multiple annular purpuric skin lesions present over the face and back. Neurological examination revealed a bilaterally extensor plantar response, with bilateral papilloedema. Lumbar puncture yielded clear spinal fluid with a very high opening pressure with a normal biochemistry and cytology. Neuroimaging showed evidence of raised intracranial tension. She was provisionally diagnosed to have idiopathic intracranial hypertension (IIH) and started on anticerebral oedema measures. Despite medication, she continued to be symptomatic. On the sixth day of admission, her antinuclear antibody and antidoublestranded DNA registered positively in high titres. She was diagnosed with systemic lupus erythematosus (SLE) with IIH and was started on corticosteroids, with dramatic recovery of her symptoms and clinical signs. Reports of SLE, the maiden presentation of which is IIH, are rare in the literature. BACKGROUND

A 14-year-old boy was referred to us with a history of progressive painless massive symmetrical cervical lymphadenopathy, provisionally diagnosed as lymphoma. Multiple biopsies were needed, and confirmed the diagnosis of Rosai Dorfman disease (RDD), which is a very rare benign condition. Sinus histiocytosis with massive lymphadenopathy, also known as RDD, manifests as bulky lymphadenopathy in children and young adults. Extranodal sites such as the skin, upper airways, gastrointestinal tract and central nervous system can be involved. There is a characteristic pattern of lymphoid proliferation with a thick fibrous capsule, distention of lymphoid sinuses, accumulation of plasma cells and proliferation of large, often atypical, histiocytes showing emperipolesis is characteristic. The disease is considered to be benign and usually self-limited. We emphasise the need for doing a repeat lymphnode biopsy even if the prior histopathology is suggestive of reactive lypmhnode hyperplasia in every case of persisting lymphadenopathy.

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