Tension chylothorax following blunt thoracic trauma is an extremely rare condition. Here we report such a case and review its management. A 31-year-old man was involved in a road traffic collision. The car rolled over and the patient was ejected from the vehicle. On arrival at the Emergency Department the patient was conscious and haemodynamically stable. Clinical examination of the chest and abdomen was normal. The patient had sustained fractures of the sixth cervical vertebra and the tenth thoracic vertebra, left pleural effusion, haematoma around the descending aorta and fracture of the right clavicle. The left pleural effusion continued to increase in size and caused displacement of the trachea and mediastinum to the opposite side. An intercostal chest tube was inserted on the left side on the second day. It drained 1500 mL of milky, blood-stained fluid. We confirmed the diagnosis of chylothorax by a histopathological examination of a cell block prepared from the left pleural effusion using Oil red O stain. The patient was managed conservatively with chest tube drainage and fat free diet. The chylothorax completely resolved on the eighth day after the injury. The patient was discharged home on day 16.

IntroductionAdjuvants (for example, aluminum salts) are frequently incorporated in licensed vaccines to enhance the host immune response. Such vaccines include the pneumococcal conjugate, combinations of diphtheria–tetanus/acellular pertussis, tetanus– diphtheria/acellular pertussis, hepatitis B, some Haemophilus influenzae type b, hepatitis A, and human papillomavirus. These preparations have been associated with complicated local adverse events, especially if administered subcutaneously or intradermally in comparison to deep intramuscular injection. We describe a severe inflammatory reaction at the site of an injection of 13-valent pneumococcal conjugate vaccine.Case presentationA 4-month-old Arab baby boy developed dermal necrotizing granulomatous giant cell reaction at the injection site (right anterior thigh) of the second dose of 13-valent pneumococcal conjugate vaccine. Ziehl–Neelsen and periodic-acid Schiff were negative. This reaction probably resulted from improper intramuscular administration because the first (at 2 months of age) and third (at 10 months of age) doses were uneventful.ConclusionsDermal necrotizing granulomatous reactions are a serious complication of the 13-valent pneumococcal conjugate vaccine. Health care providers need to administer this preparation deeply into a muscle mass. Completing the vaccine series is an acceptable option. Physicians are encouraged to report their experience with completing vaccine series following adverse events.

Cervical endometriosis should be considered in the differential diagnosis of post-coital bleeding with no obvious ectopy or malignancy.

The presence of ectopic gastric mucosa in the small bowel is usually associated with congenital anomalies such as Meckel's diverticulum, 1 jejunal diverticula 2 or duplication of the small bowel. 3 The presence of ectopic gastric mucosa in the small bowel without these congenital anomalies is extremely rare. Hereby, we report an adult man who presented with mechanical intestinal obstruction caused by an ectopic gastric mucosal ulcer in the jejunum without congenital anomaly.A 39-year-old man was presented to the emergency department of our hospital complaining of central abdominal pain and distension associated with repeated vomiting of 1-day duration. He had no previous abdominal surgery. The patient had milder similar attacks in the last year that subsided with analgesia. On examination, he had blood pressure of 128/69 mmHg, pulse rate of 78 beats per minute and temperature of 36.8°C. The abdomen was mildly distended and tender, but soft and lax. Bowel sounds were exaggerated. There were no abdominal surgical scars or hernia detected. Blood investigations showed leukocytosis of 20.1 × 10 9 /L and high C-reactive protein (28 mg/L).Erect and supine abdominal X-rays showed multiple air fluid levels and dilated proximal jejunal loops. Abdominal ultrasound confirmed the presence of distended small bowel loops without intraperitonealfree fluid. Abdominal computed tomography scan with oral and intravenous contrast showed a dilated segment in the mid-jejunum with sharp transition to normal diameter. There was no intraabdominal mass. The picture was suggestive of mechanical obstruction of the small bowel. A gastrografin meal follow-through study showed dilated jejunal loops without visualization of the ileum or colon 7 h after taking the oral contrast. A decision for laparotomy was made. At laparotomy, there was stenosis in the mid-jejunum (Fig. 1). Interestingly, this narrowing easily gave away when examined between the thumb and index finger of the operating surgeon. There was no evidence for any diverticula or other anomaly of the gastrointestinal tract. Resection of the stenosis and end-to-end anastomosis of the small bowel was performed in two layers using vicryl 3/0.The excised jejunum showed an annular raised mucosa, with superficial erosion on the anti-mesenteric border (Fig. 2). Histopathology of the excised jejunum showed a deep penetrating mucosal ulcer in an area of ectopic gastric mucosa with underlying fibrosis in the submucosa and the muscularis propria (Fig. 3). The postoperative period was smooth and the patient was discharged home 5 days after surgery. Follow-up of the upper gastrointestinal endoscopy 6 weeks later showed mild antral gastritis without duodenal ulcer. Histopathology of biopsies taken showed mild chronic inflammation without Helicobacter pylori. The patient was followed up 3 years after surgery and he was asymptomatic. Fig. 1. Laparotomy revealed a stenosis in the dilated mid-jejunum. Fig. 2. Small intestinal mucosa in which there is slight nodularity and congestion of the surface with f...