Summary:A 23 year old man presented with a tumour mass in the lung. Subsequent investigation showed ectopic secretion of adrenocorticotrophic hormone (ACTH) and growth hormone releasing hormone (GHRH) from an adenoid cystic carcinoma. The patient progressed to show the clinical effects of long term exposure to high blood levels of both growth hormone and cortisol. The case was complicated by pituitary infarction. The very high blood levels of ACTH, growth hormone (GH) and GHRH proved resistant to treatment with the somatostatin analogue, SMS 201-995, and a possible side effect of the drug is reported. To our knowledge this is the first reported case of ectopic hormone secretion by an adenoid cystic carcinoma.

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Cerebrospinal fluid (CSF) concentrations of C-reactive protein (CRP), tumour necrosis factor α (TNF), interleukin-6 (IL-6), total protein (TP) and white cell count with differential (WCC) have been measured in 24 patients presenting with acute bacterial or viral meningitis and also in a non-infected, non-inflammed control group ( n = 24). In acute viral meningitis, CRP levels were not raised when compared to controls and there was a discordance between high levels of the primary inflammatory mediators (IL-6 and TNF) and the low measured CRP levels. CRP levels were raised in cases of bacterial meningitis. A concentration of 100 ng/mL CRP had a sensitivity of 87% for bacterial meningitis. TNF concentrations in the CSF were significantly raised in cases of acute bacterial meningitis ( P < 0·001). Smaller but variable elevations were seen in the patients with acute viral meningitis. One patient, who succumbed to bacterial infection, showed low CSF levels of CRP, TNF and WCC but an elevated IL-6 concentration. Another, presenting with low CSF WCC, had raised concentrations of CRP, TNF and IL-6 which pointed to the correct diagnosis of acute bacterial meningitis. The development of methods yielding rapid analysis for these cytokines together with a sensitive assay for CRP in CSF would be a useful adjunct to conventional investigation.

The authors present a case of methaemoglobinaemia of acute onset, with an unusually protracted course. The long persistence of this disorder led to a search for the cause which was eventually traced to medication with dapsone. The latter was found to be inappropriately being taken by the patient instead of an antispasmodic that had been prescribed for a spinal condition; this was because the tablets had been incorrectly labelled and dispensed in a pharmacy. The patient took increasing doses of the presumed 'antispasmodic' tablets as they seemed to lack clinical effect, thus further exacerbating the toxic consequences. Moreover, the patient brought his wrongly labelled tablets into hospital and was allowed to use them there, contrary to normal hospital policy. As treatment for the methaemoglobinaemia both bolus and continuous infusions of methylene blue were used, which probably contributed to the severe haemolysis which followed. Furthermore, the development of a rare side effect of dapsone toxicity, namely that of a sensorimotor neuropathy, is reported.

SummaryA case of life-threatening respiratory distress during a Caesarean section under spinal anaesthesia is reported. Possible causes of the event including anaphylactoid reactions and the methods of their diagnosis are discussed. The most likely cause of the episode was felt to be an anaphylactoid reaction to Syntocinon.