Tetanus is a severe and potentially life-threatening infection caused by the bacterium Clostridium Tetani. It is a gram-negative anaerobe, often found in soil in spore form and in the gastrointestinal tract of humans and animals. It produces a potent neurotoxin called tetanospasmin. The presence of this toxin on the affected wound contributes to its pathogenesis. In developed countries such as the United Kingdom, tetanus poses a diagnostic challenge as cases are becoming scarce and, therefore, difficult to diagnose in an acute setting following the national immunisation programme in 1961. The prognosis of an acute tetanus can be derived from several risk-stratifying scoring systems such as the Tetanus Severity Score (TSS), with any score above 8 representing a 53% case-fatality rate. Prompt clinical diagnosis, immediate delivery of treatment and strict adherence to the national vaccination programme are paramount to suppress the incidence and the fatality rate from tetanus.

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We describe the case of an 84-year-old woman who presented with right lower chest pain, anaemia and newly deranged liver function which was followed by massive upper gastrointestinal (GI) bleeding with no source of bleeding found on upper GI endoscopy. CT angiography of the GI tract confirmed rupture of a pseudoaneurysm of the right hepatic artery (RHA) that was treated successfully with trans-arterial embolization of the RHA.LEARNING POINTSIf upper gastrointestinal (GI) endoscopy fails to identify the source of upper GI bleeding, CT angiography is required to search for rare causes such as pseudoaneurysm of the right hepatic artery (RHA) with fistula formation with the GI and biliary tract, along with other causes such as aorto-enteric fistula.Pseudoaneurysm of the RHA is commonly secondary to recent surgery or trauma and spontaneous occurrence is very rare.Endovascular repair using transcatheter arterial embolization is the treatment of choice but if it fails, emergency laparotomy should be considered.

Fusobacterium species are gram-negative anaerobic non-spore-forming bacteria, which colonize mucous membranes in humans. Over the recent decade, the significance of these organisms has been increasingly recognized. We describe a rare case of acute hepatitis, which was found to be likely due to Fusobacterium nucleatum, grown on blood culture. In our case, the hepatitis caused by this microorganism resolved completely without any long-term sequelae to the liver, through conservative management namely intravenous antibiotics and supportive therapy only. This case highlights that early detection and prompt treatment in a case of acute hepatitis resulted in a good outcome. In addition, this case also illustrates that the differential diagnosis can be varied in cases of acute hepatitis.