A 56-year-old man underwent radiofrequency ablation for atrial fibrillation. Four weeks later he presented with sepsis and neurological symptoms. Urine analysis demonstrated the presence of blood and protein. A CT scan showed pockets of air in the left atrium. An MRI brain scan revealed multiple cerebral abscesses. The patient developed a third heart sound and splinter haemorrhages. He was subsequently referred to cardiology for transoesophageal echocardiography after starting a course of intravenous meropenem. The cardiology team noted that this individual presented with a triad of infections, neurological sequelae and air in the left atrium after an ablation procedure and diagnosed atrio-oesophageal fistula. A decision to operate was made 9 days after admission. At surgery an area of caseous ulceration was found on the posterior wall of the left atrium overlying the oesophagus. PCR analysis revealed Mycoplasma salivarium, part of the oral flora.

We present a case of piriformis syndrome in a woman in her 30’s following low energy trauma, presenting with unilateral lower limb weakness, altered sensation and urinary retention. CT imaging revealed a bulky piriformis muscle which was further clarified on MRI as an intramuscular haematoma within the left piriformis causing compression of the left lumbosacral plexus. Haematoma formation was exacerbated due to use of an antiplatelet medication the patient was taking for Moyamoya disease, which carries an increased risk of cerebrovascular accident. Surgical exploration of the piriformis and sciatic nerve was undertaken and confirmed a haematoma within the piriformis. A full release of the piriformis tendon was undertaken, and the sciatic nerve was inspected, no further abnormality was found. After review in clinic post-discharge, the patient reported normal sensation and normal muscle power in her feet.

An 88-year-old woman with a background of chronic lymphocytic leukaemia (CLL) and presented with unilateral ptosis and dull facial pains for 1 month. Examination revealed a complete right-sided ptosis and pupillary dilation. Vision in her right eye was limited to light perception. She had total external ophthalmoplegia. Her corneal reflex was not present in her right eye and she had lost sensation on the right side of her forehead. MRI revealed abnormal enhancement in the right orbital apex extending posteriorly to the sphenoid sinus. The mass invaded the superior orbital fissure, optic canal and cavernous sinus. The lumbar puncture was normal. Owing to the proximity of the mass to the cavernous sinus, it was deemed that surgical excision of the tumour was unsafe; however, it was amenable to biopsy. Histology of the biopsies was consistent with CLL. The patient declined to undergo single high-dose radiotherapy followed by dexamethasone.

No abstract

Pulmonary embolism (PE) is a common condition seen regularly by emergency physicians. The authors describe a patient who presented with shortness of breath and syncope. He also experienced drowsy, clammy and sweaty episodes. He was tachycardic, tachypnoeic and saturating at 92% on air. A chest X-ray was normal but an ECG showed S1Q3T3. A CT pulmonary angiography performed showed bilateral pulmonary emboli with a large inferior vena cava (IVC) thrombus. Echocardiography revealed severely dilated right ventricle and atrium, severe right ventricular impairment, pulmonary hypertension, large mobile friable clots seen extending into the tricuspid valve. A multidisciplinary team decided the safest management approach was intravenous heparin. The patient recovered and repeat echocardiography 5 days later showed significantly smaller clots. The extension of an IVC thrombus into the heart and prolapsing into the tricuspid valve is an extremely rare presentation. Furthermore this case demonstrates the importance of echocardiography when diagnosing and generating bespoke management plans for PE.