A 39-year-old right-handed man presented to his family physician with sudden-onset weakness in his right arm and leg that had lasted 10 minutes and resolved completely. In the year before presentation, he had an episode of weakness on the right side of his face and difficulty comprehending that had lasted for 5 minutes. The patient reported having an unexplained collapse 4 years before presentation that had not been investigated.The patient did not smoke, and he did not use drugs or alcohol. He had no history of hypertension, diabetes, coronary artery disease or hyperlipidemia. There was no history of hemoptysis, dyspnea or fatigue. The patient reported having recurrent nosebleeds since early childhood, and his mother also had nosebleeds regularly and "low blood oxygen levels." His maternal grandmother had experienced numerous "mini-strokes."On examination, the patient was not in distress. He had a regular pulse rate, his blood pressure was 116/65 mm Hg, and his respiratory rate was 15 breaths per minute. He had finger and toe clubbing and several telangiectasias on his lips, tongue, gums and conjunctiva (Figure 1). The results of the rest of the clinical examination were normal. Initial investigation showed that the patient had a normal hemoglobin level (151 [normal 120-160] g/L) and reduced oxygen saturation (90% [normal ≥ 95%] on room air). The levels of his electrolytes, glucose, lipids and inflammatory markers were normal, as were the results of a hypercoagulable screen. Because we suspected pulmonary arteriovenous malformations, we measured the patient's arterial blood gases in the supine and standing positions. The patient had a supine pH of 7.4, a partial pressure oxygen of 60.2 (normal 80-100) mm Hg, a partial pressure carbon dioxide of 34.2 (normal 35-45) mm Hg and an oxygen saturation of 91%. When standing, his pH level was 7.4, his partial pressure oxygen was 56.8 mm Hg and his carbon dioxide level was 32 mm Hg with oxygen saturation of 89%. A shunt fraction of 21% was calculated by use of the 100% inspired oxygen breathing method (upper end of physiological shunt 5%-8%). Pulmonary arteriovenous malformations can lead to unexplained hypoxemia with further desaturation occurring when standing (orthodeoxia), as occurred in our patient. This finding is because of greater gravityinduced blood flow through basally situated pulmonary arteriovenous malformations which thereby increases the right-toleft shunt and hypoxemia. 1 The results of cardiography and chest radiography were normal.

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We are reporting a case of a 10 year old boy admitted in Dhaka Shishu (Children) hospital with the complaints of -swelling of both side of inguinal region for 2 months, tenderness of the same area for 1 month and low grade fever for 2 months. With the history and physical examination of the patients our differential diagnosis was Tuberculosis/Lymphoma/Cat scratch disease (CSD). He had only a history of contact with a kitten for 1 week 3 months back but no history of cat scratch or bite. Lymph node biopsy revealed that it was a case of Cat scratch disease. Introduction Cat scratch disease (CSD) also known as "Cat scratch fever" or "Subacute regional lymphadenitis" 1 is a usually benign infectious disease caused by the intracellular bacterium Bartonella henselae. It is most commonly found in children following a scratch or bite of a cat by about one to two weeks. It was first discovered in 1889 by Henri Parinaud.2 It oc curs worldwide with no racial or sex predilection.Kittens are more likely to carry the bacteria in their blood, and may therefore be more likely to transmit the disease than are adult cats. However, the results of experimental studies showed that fleas serve as a vector for transmission of B. henselae among cats. 3Although this disorder is strongly associated with cats, other animals have also been implicated. Reports also be found of transmission by dogs, rabbits, and monkeys. A few anecdotal cases have also been described involving transmission by porcupine quills and fish bones. Transmission occurs by scratching, biting or possibly even licking. Kittens seem to be particularly common as vectors. Case HistoryA 10 year old previously healthy boy from a slam area admitted in Dhaka Shishu (Children) hospital with the complaints of -swelling of both side of inguinal region for 2 m onths, tenderness of the same area for 1 month and low grade fever for 2 months.Two months back he first noticed bilateral swelling of his both ingunal region and initialy it was hard and nontender. He also complaints of low grade intermittent fever for the same duration. Ultimately the size of swelling increased and its consistency changed to soft and it became tender as an abcess for the last 1 month. He did not get any treatment for these problems. The boy was fully immunized and BCG m a rk was present. There was no history of contact with TB patient, gradual weight loss, night sweating; no abdominal pain and abdominal fullness.He did not notice similar swelling anywhere of his body and recalled a history of contact with a kitten 3 months back. At that time he was circumcized and cofined to home for 7 days and used to play with a kitten on his bed. But there is no history of cat scratch or bite on his lower limbs. After that, he never went to any contact with any cat or kitten. On physical examinationThe boy was cachetic (anthropometric measurements were-hight-120 cm, weight-17 kg, OFC-48 cm) and febrile. He was mildly pale and vital signs were within normal limit. Abdomen was soft and nontender without organomeg...

The Case: A 46-year-old nurse was admitted to the Neurology Department after 6 weeks of recurrent and transient neurologic episodes. She described several episodes of disorientation, language abnormalities and motor weakness, all resolving within an hour. She thought the episodes likely related to long hours of work and decreased sleep; however, she had begun noticing problems with memory and concentration, which prompted her to seek medical attention.She reported no cardiac, rheumatologic or constitutional symptoms, and her medical and family histories were unremarkable. A nonsmoker and nondrinker, she denied any drug use.Upon examination, she was afebrile and her vital signs were normal. She was alert and oriented. Head and neck results were normal, including fundoscopy. Cardiac examination revealed a grade 4/6 pansystolic murmur, loudest at the apex. Pulmonary and abdominal exam results were normal. Splinter hemorrhages were noted in both hands. Initial neurologic exam results were normal except for her cognitive tests, which showed some difficulty with naming, concentration and short-term memory. The results of laboratory investigations, including a range of hematologic and rheumatologic tests and a full septic workup, were normal.MRIs of the head showed several scattered cortical and subcortical infarcts, including a recent left frontal infarct (Fig. 1). Cerebral angiography did not find evidence of vasculitis.Chest radiography showed a small density in the right lung. Augmented CT of the chest confirmed a 2.1 × 1.9 cm